hi I'm Naidu from great online training are you looking for career in medical coding you want to know what is medical coding and roles and responsibilities of medical coder job opportunities in medical coding career growth in medical coding and what are the salary packages of medical coder how to apply for a medical coding jobs and what type of training do you need to become a medical coder so so let's get started with this particular video I'm going to explain in detail in this our comprehensive medical coding training course is designed to equip students with necessary skills and acknowledge to pursue a successful career in medical coding this course aims to provide students with understanding of medical terminologies like anatomy and physiology as well as different coding system systems used in healthcare industry including ICD 10cm CPT and hspcs our expert instructor will provide Hands-On training on practical exercises and real case studies to ensure thorough understanding of medical coding principles and practices so here our course OB to mainly understanding the fundamentals of medical coding developing and accurate coding skills to various medical specialities gain Proficiency in ICD 10 cm CPT and hspc coding systems interpret medical documentation and assign a appropriate codes applying a coding guidelines and regulations preparing for professional coding certification exam let's talk about our course structure the training course will consist of live interactive sessions practical exercises coding practices and periodic assessments to evaluate the progress we offer the course in two modules 45 days basic medical coding training is one module another one is 90 days medical coding we offer the course with a different batches and we accommodate various schedules each batch will consist of limited number number of students to ensure personalized attention to effective learning if you interested on live training with Nikita so please log on to our website great onlinetraining tocom and enroll yourself for a free demo session please attend the demo session see how our training is if you are liking then you can proceed further if you don't like it that's fine so at least try our demo session before you enroll if you are interested in this video please hit hit like And subscribe to our Channel and click on the Bell icon for latest updates in our channel so let's get started hello everyone uh how are you all I hope you are doing well uh i' like to welcome you all for great online training Dev medical coding introduction okay before starting I like to introduce myself myself Nikita I'm medical coding trainer in great online training I'm a CPC certified medical coding trainer with uh around 6 years of medical coding experience okay fine then uh we'll move forward and see what are the what are the topics we going to cover in this class and so we'll see what is medical coding the roles and responsibilities of medical coder job opportunities in medical coding career growth in medical coding we'll see uh how much salary package you can expect as a medical coder also we'll see what types of training do you need to become a specialize in medical coding and lastly question and answers okay so the first point what is medical coding this is very common question most of the students ask to me what do you know about medical coding anyone anything do you know about medical coding please feel free to share one it's okay so by the definition medical coding is the process of converting descriptions of medical diagnosis procedures and other services into standardize numeric alpha numeric codes numeric or alpha numeric codes and these codes are universally accepted means the these medical codes are same all over the world okay this is the definition of medical coding I'll explain you in the simple manner it is medical coding is the process of taking patients Healthcare information which can be any diagnosis any symptom or illness from patient report okay or any medical procedure patient undergone or any medical necessity or medical equipment or any other Medical Services the patient took that we have to take from The Physician or patient's report okay and then we have to convert that information into medical code that is called Medical iCal coding okay and these are Universal alpha or alpha numeric CES we have to assign these codes to the medical diagnosis procedures and services right we have to assign these medical CES to the medical diagnosis procedure and services the patient undergo okay so uh this is the transformation of complex Medical Rep okay complex medical reports into the simple medical coures which are accepted worldwide all the medical CES are same in now we'll see what is revenue cycle management okay revenue cycle management also known as RCM what is importance of this cycle or uh why do you need to understand this cycle reason is medical coding is one of the step involved in revenue cycle Management in simple language revenue cycle management is nothing but as the name suggest it is cycle of management of Revenue whose Revenue as this medical coding is the is happen in US healthcare industry so management of us Healthcare organization's revenue is called revenue cycle management see each year healthcare provider perform millions of procedures services on patient right from simple checkups to complex surgeries and this is the process of Revenue collection for those Services given by Healthcare organization okay so revenue cycle management is the process of collection of revenue for healthcare organization right this is the diagrammatic representation of revenue cycle management basically this is the cycle between patient provider and pair patient provider and paay now first let me make you understand what is patient what is provider and what is pair okay so the provider means any doctor any doctor whoever is going to treat the patient okay provider is any doctor whoever is going to treat the patient whether it can be uh he mbbs MD do okay or whether he's radiologist pathologist anesthesiologist whoever it can be whoever it it can be a provider okay and provider is the blanket term used to describe anybody who provides Medical Care and certified to give Medical Care okay who is provider means the one who is certified to give medical care right now we'll see who is the patient patient is the one who receives medical care who suffering from any health issue uh any diseases okay we going to receive medical care we can call them as patient okay then the pair is the insurance provider right pair is the insurance provider so let me help you figure out how Healthcare Works in India versus how Healthcare Works in us okay once you understand difference you will uh you will get clear idea about what we do right so in India most of us we are not covered under Insurance even if we are covered under insurance we what happen is you need to get admitted in hospital right to Avail the insurance benefits we need to get admitted in the hospital at least for 24 hours right otherwise you will not going to receive any insurance benefits and most of the outpatient services are not covered much in India right but in us that is not the case in US almost everyone even including children they are all covered under some form of insurance why is it like this because cost of care the level of care in India is very High the cost of care in US is way too high all the process are very costly in us as compared to that of in India so there are almost everyone is covered under some form of insurance either it can be government insurance or it can be private insurance so what will be patient doing all his or her life they will pay some amount as a premium to the insurance company okay they uh they will pay some amount of insurance as a premium to the insurance company and that is where payer comes in picture okay so now we learn three pieces the patient means the one who who will going to receive the uh service from provider okay the provider means the doctor whoever it can be it can be mbbs MD do anyone okay who is certified to give Medical Care and the pairer is insurance company now we'll see how RCM cycle happens in between these three peoples where do medical coder comes in picture okay uh you can see from this uh diagram this cycle starts with appointment scheduling then Insurance verification then in this uh third step medical billing and medical coding happens okay then the claim submission then AR and denial management and lastly reporting okay but uh in the actually this revenue cycle management consists so many steps but to make it simple I have included few steps here okay now we'll try to learn this cycle in simple manner okay so now when you have any health issue what happened in India you will call your doctor right you'll call your doctor uh for appointment or or else you just walk into the doctor's clinic or Hospital right which is uh which is outpatient visit where you pay him then and there right he will give you your report and prescription he will write your Vital Signs symptoms reason reason for encounter what was your chip complaint diagnosis and all right and and finally he will wrote treatment and drugs you received or you you have to take okay he will hand over your report to you and you you will pay him then and there so the cycle ends here in India correct in India you you will you pay your doctor then and there only right when it uh when you are not going to get your insurance benefit means uh you are going to the doctor for simp checkups like uh if you have fever or cve and cold like that which is outpatient visit you see your doctor and come back to your home without any Hospital uh means you are not going to admit in the hospital at that time you pay your doctor then and there and come to your home so uh that's how cycle ends here in India okay so the patient uh sorry so the provider getting paid on the same day okay but in us this is not the case right in US Healthcare Works in different manner their process is entirely different from our process so what happen in us even if it is a small outpatient encounter means even if you have small means cold and cup normal or some pain back pain or something right first you need to schedule your appointment then the uh Healthcare Staff Check uh your insurance eligibility and verify your insurance for insurance benefits and all okay then you go to the doctor okay and then the doctor check uh check you okay he did checkups treatment he'll ask you uh your medical history she he'll ask you about your current complaints okay what what issues what health issues you are facing sorry so he'll going to ask you and uh he'll give you treatment accordingly okay and at this time the conversation between the doctor and the patient conversation between doctor and patient is being recorded either by Audio either by audio record or entire video is recorded and this recording are going to send to the medical transcriptor okay medical transcriptor to translate that audio or video recording into word format okay the medical transcriptor translate that video or audio recording into word format and now medical coder comes in picture medical coder translate those complex reports what sorry medical coder collect information important important information from that reports like diagnosis the procedure the services patient receive and uh he will convert he or she will convert those complex information to the simple Medical CES according to guidelines and policies okay these CES now these CES consist certain bill amount or certain charges on it okay so medical biller prepare medical bill and submit the claim and that's how insurance compan is going to understand how much amount they need to pay to the doctor right likewise in US doctor or Pro provider receive their payment for their service or care do you understand hello understand this revenue cycle management it is okay yes ma'am yeah it is okay if you doesn't understand much because we're going to explain this in each and every step in further sessions right now we'll move ahead to the roles of medical coders okay as of you know the main uh this medical coder play crucial role in healthcare industry okay how medical coder play crucial role by translating complex medical information into standard standardize numeric or alpha numeric C right they assign numeric or alpha numeric code to the diagnosis procedures and services based on medical records these codes are used for various purposes including billing reimbursement research and Healthcare data analysis okay so the main role of medical coder is to ensure that he will he or she will going uh choose proper diagnosis and procedure from the patient's report and assign the correct code correct medical code following guidelines and policies of medical coding okay so that provider so that healthcare provider receive appropriate payment for their services and maintaining the Integrity of patient record okay so now we'll see the responsibilities of a medical coder the main responsibility is to review and verify documentation of diagnosis procedures and treatment results means uh when you get as a medical coder you get any report you you know how to collect the proper information because the med you can see the medical reports are sometimes in India we'll get medical reports of one to two pages right but in us they they report each and everything means uh your medical history your chip complaint your uh previous diagnosis your if you have any procedure okay if patient physician perform any procedure on you previously or in the current uh scenario that is also mentioned in that report but as a medical coder it is your responsibility to choose the correct diagnosis for that current encounter okay uh to choose corre correct procedure and treat M for that particular encounter and then you have to assign the proper diagnostic uh and procedure that code to the that Diagnostic and procedural information right so medical coder is responsible for coding and extracting patients incounters and they need to make sure that codes are assigned and sequence correctly following the guidelines and policies right so these are roles and responsibility L is of medical coder now we'll see what are the different job opportunities in this medical coding the main part of this uh industry this us healthcare industry is you can enter into this industry as soon as you completed your graduation because minimum educational qualification requirement is graduation whether you are from Science Background or Commerce background or Arts anyone anyone can enter into this industry because there are many roles present in this or many job opportunities in this us healthcare industry but if you want to be a medical coder uh most of the companies prefer candidates from Science Background because as a medical coder you sorry you need a knowledge about human anatomy medical terminologies right but even if you are not from Science Background you can join this uh industry but one thing is important that you uh you have to be ready to learn about human anatomy and medical terminologies and it will going to difficult for the Commerce or Arts means non-science background students right that's why most of the companies prefer science graduated candidates only so once you have graduated and ear your certification you can start applying for medical coder jobs at different locations like hospitals doctor offices and other Healthcare facilities cor and other option is work from home or you can work remotely for US Direct directly for us companies now we'll see role wise what are the different job opportunities in this field first one is obvious medical coder who is responsible for uh extracting correct diagnosis and diagnostic procedural information from the patient record and assign proper Diagnostic and diagnosis and procedure code to that to that medical information okay following the guidelines and regulations next role can be coding auditor next rle is coding auditor or you can say as a QA quality analyst as name suggest quality analyst he is responsible he or she the quality or analyst responsible for conducting audits on coded medical records to verify accuracy and compliance with coding standards right so to become a coding auditor you need at least few years of medical coding experience you can start your career as a coding auditor if you uh want to be in this field if you want to become a coding auditor first you have to start your job as a medical coder because uh as a auditor you have to conduct audits on the coded charts by medical coders also coding Auditors offer feedback and education to coders for enhancing their accuracy okay that's why QA requires at least few years of medical coding experience next one can be medical coding manager or supervisor or you can say uh PL or team leader okay who manages a team of coders supervises coding processes and ensure the acement of departmental gos for this role also you need few years of experience as a medical coder okay uh this is this medical coding manager also collaborates with Healthcare professionals to improve coding and documentation practices next one is uh Clinic documentation specialist who collaborates closely with Healthcare Providers to guarantee accuracy and comprehensive documentation in medical records so the clinical documentation Specialists serve as Legion between clinical language and coding requirements basically clinical documentation specialist is uh responsible for uh what you can say documentation okay next role can be complient specialist who ensures that coding practices aligned with Healthcare regulations and guidelines and next role is medical coding instructor educator or you can call it as the medical coding trainer who trains uh individuals aspiring to enter the field of medical coding okay who give education uh to such peoples about medical coding you also maintain and uh updated curriculum reflecting latest coding guidance and Industry developments okay again to become a medical coding trainer first you need few years of medical coding experience right next role can be health information manager or director who oversees the entire health information management department of medical coding and insur uh ensures confidentiality and security of Patients health information okay the next one is remote coding opportunities many coding positions offer flexibility of remote working right since uh this uh Corona thing happens the companies most of the companies uh start providing remote working or work from home opportunities or you can become uh freelance or contract uh coder okay so that uh you'll get more flexibility while working right now we'll see career growth in medical coding as I told you to go on higher position you need few years of experience mostly uh to grow up your career in medical coding when you start your career you get hired as a junior medical coder or uh as a medical coding traine where If you hired as a medical coding traine uh they will give you the patient sorry the company will going to give you few months of training and then they will join you as a junior medical coder after completion of your training but at that time uh few companies uh ask you for money or few companies give you uh that training free of cost okay but there are very less companies who provide training nowadays okay when I join this this industry I got trained from my company itself because at the time there are very less resources of medical coding training so company s provide training and then uh confirm us as a junior medical coder after completion of their exam okay so the first step is uh either medical coding training or Junior medical coder if you already nowadays uh there are many options of medical coding training we also provide medical coding training okay so if you took training from companies like us and already trained in medical coding then you can join that company as a junior medical coder or directly the Second Step which is senior medical coder because you already know about medical coding you already uh completed your medical coding training right you are certified correct so if if you are uh yeah that is also one point uh you can get either just a medical coding training or medical coding certification training also and complete your certification before joining this field so that you directly come to the step two senior medical code okay you can become a certified Senor medical coder if you pass medical coding certification exams okay what are those certifications what kinds of training you need to become a coder that we'll discuss in further slides so the first step is Junior medical coder Next Step means second step is senior medical coder and uh third step is you can become a quality assurance or QA as I have told told you before also to become a medical coding QA you need at least few years of experience as a medical coder and after that depending on your quality your productivity your knowledge you will be promoted as a QA where you have your responsibility is to uh conduct audits of coded charts by medical code and if necessary uh give feedback to them to improve their quality okay because quality is very important in medical coding because if you uh put wrong or select put or select wrong medical code the entire cycle will collapse and the result of that the provider will not going to receive their payment on time it will be delayed because that report then have to goes through different different steps right so quality in this medical coding is very important part right so the next step after QA you can become a team leader if you have Team leading capacity capacity of handling team if you're senior manager and others capacity in you that you can lead the team they can promote you as a team leader okay then you can become assistant manager then manager and Senior manager also as you gain more and more experience next we'll see what qualities you need to become a successful medical coder okay to become a successful medical coder first you need need proper knowledge or good knowledge about medical terminologies human anatomy physiology human diseases pharmacology right because ultimately you have to read the report of the patient and select proper diagnosis and after that you have to select proper code for that diagnosis or that procedure so uh knowledge of medical terminology human anatomy physiology diseases science symptoms pharmacology is very important to become a medical coder that's why most of the companies prefer only science graduate but if you are from different uh graduation background you can start your and you want to become a medical coder you have to prove your knowledge and for that you can go through different coding certification if you are or if you clear that certification no going to stop you correct because all they need is knowledge of the human anatomy physiology and all correct next is uh you you you must know how to read medical records you must be aware about regulations rules and regulations of your sare industry you must know about process of physician query if any discrepancy or missing information in the patient health record you need to query The Physician so you need to know about that process other qualities are or skills you required are you should be uh detail oriented you should be a critical thinker you must possess good computer skills as you have to work on the computer you must be aware about different uh key key shorts C shortcuts and all right how to use different different softwares you need good analytical skills good communication skill and all so these all the different qualities you required to become a successful medical coder right next the main part the salary expectation am I right because everyone needs salary so when you start this career as a medical coder whether if you start your career as a fresher just after completion of your graduation you want to start your career you can join as a fresher non-certified but there are very less opportunities present nowadays as I told you nowadays there are many medical coding training programs are going on medical coding uh training institutes are started most of the companies prefer certified or trained medical coder okay so uh my uh suggestion for for you if you want to be in this field don't make a hurry uh first get trained in medical coding okay or try to complete your medical coding certification before starting your job the reason is here you can see here because if you join this industry as a fresher non-certified you'll get salary between 10,000 to 20,000 only you will not get more than that okay but see here the difference directly 10,000 increment cor even though you you are fresher but you are certified you will get salary ranges between 20,000 to 30,000 good right to start your career if you get uh 20 to 30,000 salary at the starting of your career this is this can this much you can get in your future correct again where uh as of uh as you gain more and more experience you can get more salary up to 4 years of experience you can expect up to 50 to 60,000 also it again it depends on your experience credentials geographic location and work settings right credentials means how many certification you have earned because uh each and every certification have uh means companies provide you extra certification allows okay so if you have many certification you'll get that much of uh what I can tell you uh you'll get that much of certification allows right again it depends on geographic location mostly the companies based in South area they will provide you more salary than as of now from Mumbai and Pune okay again it depends on work setting if you uh work in night shift you will get night allowance right so the salary again depend on the experience your experience credential geographic location and work setting but this much is starting salary 10 to 20,000 but if you are certified you can expect 20 to 30,000 as certified coders command High salary due to their specialized Knowledge and Skills correct so now we'll see what types of training do you need to become a medical coder first one is educational requirement it is important to complete your graduation because minimum graduation is required for most of the positions okay then and postgraduation is not mandatory but if you complete any Healthcare Information Management program or any as I told you medical coding training program or any related field can provide valuable knowledge and enhance your job prospects like if you have any healthcare related information sorry education like nursing or uh B Pharmacy and all then then it will be good but not mandatory next is specialized medical coding training like I I have told you enroll in dedicated medical coding training program will through vocational schools community colleges or online institutions okay you can go through those or complete those medical coding training programs so that uh it will be easy for you to uh clear the interview rounds because while interview most of the companies prefer to take your aptitude test to check your knowledge okay and then they proceed with other rounds right so comprehensive training covers essential topics like Anatomy medical terminology Healthcare Pro procedure and key coding systems including ICD 10 cm CPT and hcbcs level two course also we also going to uh see what are the scores in forur the sessions okay next one is professional certifications these are the certifications I have told you before sorry attend professional certification is highly recommended and may be prerequisite for employment as I told you nowadays uh there are many medical coding training institutes are started most of the companies only prefer C even the candidate is fresher they required certified candidates non-certified candidates are not in demand okay so uh it is very important if you want to be a medical coder you my request or my advice for you to complete your training and go for this certification the certifications include certified medical coder which is also known as CPC offered which offered by American Academy of professional coders also known as APC second certification is is a certified coding specialist also known as CCS which is provided by Aima means American health information management assoc association okay or you can go for certified coding associate which is also known as CCA this is also offered by Aima and these three any one of these three you can complete before joining any organization okay so you can uh you will command more salary right next is practical experience again hands-on experience through internships externships or interlevel positions in healthcare settings practical application of coding knowledge is real world scenario is invaluable and lastly soft skill development obviously uh you you must possess good analytical thinking uh effective communication skills attention to details okay you must consist essential soft skill right so these skills are crucial for accurately interpreting medical records and translating them into course so that's all for today if you have any question feel free to ask me and if you if you find this session interesting I request you all to uh go on this site we have given below which is www.great online training.com and register yourself for our medical coding training program and start your career in medical coding any question okay then we'll meet tomorrow again on the same time okay if you have any question you can ask me I'll try to okay give you answer okay thank you for your attention have a great day welcome to grade online training uh this is day two first step in medical coding okay and I'm Nikita CBC certified medical coding trainer in grade online training as you can see uh today we're going to discuss about first step in medical coding right so in this session we going to discuss about if you you uh choose medical coding as your career okay so what kind of codes what kind of different CES you have to use in medical coding what is structure of those CES that we going to discuss in this session in our previous session we uh I just give you information sorry introduction about medical coding right uh about what is medical coding what is uh revenue cycle management uh what are the different career opportunities uh in medical coding how to apply for a job and uh what types of uh certifications qualifications required for medical coding salary expectations everything we discuss in our previous session right but then then to if you have any doubt about medical coding if you have any question feel free to ask me okay today we're going to discuss discuss about the first step in medical coding so we'll see what are the topics we going to cover in this class we'll see uh again I know what is medical coding because you have you must have good knowledge about what isical coding what is RCA that I will going to discuss in more detail in this session okay what are the different steps involved in RCM uh then what is ICD codes what is CPT codes what is hcpcs codes okay what is modifiers and lastly we'll see few examples of medical coding okay and see how to find out the course right so starting with I'm starting with uh what is medical coding as you know medical coding is the process of converting description of medical diagnosis procedures and other services into standardized numeric or alpha numeric codes right means uh roles and responsibilities of medical coder is to convert the diagnostic and procedural and service Services provided by uh to the patient convert this all these information into medical codes is called medical coding right now we'll discuss more about revenue cycle management revenue cycle management is nothing but RCL you uh if you want to be uh in this field if you want to start career in this field you must have knowledge about at least basic knowledge about Med uh revenue cycle management okay because when uh you will going for interview the interviewer surely going to ask you at least one question about this cycle okay or at least he'll going to ask you uh what is meaning of RCM so you must be able to uh discuss or give answer about this right that's why I have again included this point in this session so uh this is the diagrammatic representation of revenue cycle management which starts with appointment scheduling then Insurance verification then Med billing medical coding then claim submission then AR and denial management and lastly reporting okay that you know as of now but today we're going to discuss more about each and every state okay so basically revenue cycle management is the process used by healthcare system in the US and all over the world to track the revenue from patients from their initial appointment or encounter with the healthcare system to their final payment so basically Reven cycle management is uh cycle between patient provider and payer so uh provider means any doctor whoever is going to treat the patient whether he is MD mbbs do anyone okay who who is certifi to provide medical care to the patient and then patient is the one who is going to receive the medical care who suffering from any disease or having any symptoms or illness right uh then the uh what we can say payer is insurance provider okay because uh obviously patient is uh throughout their life patient will going to pay uh certain amount as a what can say as a premium to insurance provider right that's why here payer is the insurance provider okay to make you understand is better uh I'll explain you in uh in simple way how health system works in India versus how healthare system work in us okay uh in India most of us we are not covered under any ins uh any insurance okay few of us are covered under Insurance either uh it will be provided by our company or that that will be private insurance okay but to aail that insurance benefit we need to get admitted into the hospital Hospital okay that insurance in India mostly applicable for inpatients only inpatient means one uh who is get admitted for at least 24 hours in the hospital who get service uh medical service from the hospital at least for 24 hours then and then only you you are eligible to get insurance uh what you can say benefits right and most of the outpatient services like uh if you just have any back pain or something and you are going to doctor doctor prescrib you some medicine and you came back to your home at the same time uh same day that service will not going to cover by insurance company you pay the doctor then and there only so in case of outpatient in India doctor get paid on the same day right but in US condition is different the healthare system uh goes in different manner in US almost everyone even including children they are all covered under same form of or some form of insurance right why is it so because cost of care cost of uh uh the procedure Services level of care in US is very high than India so uh there almost everyone is covered under some form of insurance either it can be private insurance or it can be government insurance what kind of insurance are there uh they using that we going to discuss in uh next sessions okay so what will be the patient doing all his or her life they will pay they will be paying some amount as a premium to insurance company that's the reason why here paay is insurance provider okay now I hope you have clear idea about who is payer who is provider and who is patient correct now we'll try to learn in this session just a minute H okay now we'll see how RCM cycle happen in between three people okay where do medical coder comes in picture and what are different steps involved in this RCM cycle okay that is what we will try to learn in this session so now when you have any health issue what happen in India as I discussed earlier in India you will call your doctor and schedule for appointment right or you just uh walking into the doctor's clinic or Hospital which is then outpatient visit right where you paid him there only okay on the same day but in in us that is not the case their process is entirely different from our places our process so what happen in us even if it is a small outpatient encounter patient need to schedule their appointment and then their Healthcare staff will check their insurance eligibility then actual encounter happen then the conversation between doctor and patient is being recorded and then that recording is sent to Medical transcriptor then medical transcriptor convert that uh what that recording into word format and uh prepare medical report and then medical coder convert that medical report into course medical coder uh choose the proper diagnosis procedure from that report and choose correct medical code for that particular diagnosis and procedure and then send that codes to the medical bill biller team right because those medical CES consist some charges or bill amount on it so medical biller prepare medical bill and submit declaim and that's how insur insurance compan is going to understand how much amount they need to pay to the doctor right likewise in US doctor or provider receed their payment for the service or care correct now we'll see what are the different stepes involved in RCM the first step is uh patient registration when patient call for appointment the health Care staff collect patients demographic information like patient name patient say patient address uh their date of service uh their uh date of birth everything including insurance information okay so this is the first step in revenue cycle management then Insurance verification then the medical billing team verifies sorry for disturbance okay okay there now uh the second step is Insurance verification where medical billing team verifies the patient Insurance strictly end to end means they check for insurance uh eligibility what are the benefits patient is eligible for and all okay then third step is encounter where patient consults healthcare provider the details of condition and service performed is recorded either by Audio or video correct so this is about encounter next step is medical transcription where that recorded audio or video is transferred into a medical transcript okay the process of transferring voice recorded or video recorded medical reports by Healthcare Providers is termed as medical transcription this is the definition of medical transcriptor what is uh role of medical transcriptor he convert that audio or video recorded medical information into health record uh or Health Report okay he prepared Health Report uh in word format and send that report to medical coder so the next step is medical coding where medical coder transform that patients condition medical services medical prescription into universally accepted alpha or alpha numeric codes medical codes okay that is called medical coding so the next step is charge entry charge entry is the process by which charges of medical services are submitted to the appropriate payers for billing me medical biller team is going to submit the charges to the appropriate payer means insurance provider okay so the next step is the accounts receivable follow in this process this is process uh in the medical billing which is responsible for looking after denied or rejected claims and refiling them with correct diagnosis or procedure CES actually uh what is meaning of denied or rejected claim means uh denied means uh the claim is going to denied by insurance provider the denied claims has to go through whole RCM cycle and last lastly it will be denied by insurance provider due to some uh discrepancy or some error mostly it is related to coding okay so it is medical coder job it is medical coders responsibility to choose correct diagnosis and procedure code up and correct modifier on that code if necessary and submit the claim right so that less denied claims are generate okay next is uh rejected claims are those which are rejected uh in some step in any step of the revenue cycle management and get back to the uh another step another previous step okay so that uh we can correct that claim and refile again okay but denial step uh denial claim has to go through all the revenue cycle corre and get denied after going to the insurance provider so this is also uh you can uh play role or you can say this is also one kind of job in this us healthcare industry okay where medical coder works as a denial denial coder okay they work on denied claims only their job is to uh see what is the error what is the reason for denial okay so as you can see here the next step is Deni management the Deni code coder has to work on denial claims and uh identify and resolve problems that lead to claim denial okay and lastly uh patients followup and payment the last step in the process is getting paid by insurer and the patient okay this is all about revenue cycle management I explain you I have explain you in very basic manner okay I hope you understand if you have any doubt feel free to ask me can we go forward okay okay so again next is the medical coding now we're going to discuss more about medical coding and what kind of CES we going to uh use in medical coding their structure where can we find it code who is going to update and maintain those scores okay that we going to discuss in uh this slide so what is medical coding again medical coding happens every time you see a healthcare provider okay uh the healthcare provider review your complaint medical history makes an expert assessment of what's wrong and how to treat you and documents or record your visit then the medical coder uh coders translate that documentation into standardized course okay now where there is the use of this codes why we are converting these things into medical coding right you might have thinking why there is use of this code why to convert this course uh means this information into course correct the reason behind is is uh the insurance provider is mostly not from Science Background so he not going to understand any medical term or procedure or any this is he doesn't have mostly he doesn't have he or she doesn't have any knowledge about this medical terms right so to make them understand exactly how much amount they have to pay to the doctor we help them okay so basically as a medical coder you get chance to work for us uh us healthcare industry you get chance to work for us insurance provider isn't it exciting this is very good opportunity for you and even you can join this uh field this medical coding field just after completion of your graduation but my suggestion is before joining try to complete your medical coding certification okay or at least medical coding training program so that it will uh increase your chances of getting highest paid job like I uh told you in previous session correct okay then we'll see uh what are the different kinds of code we'll going to use these codes are uh means medical coding we we are using medical codes to code the report this codes tells the payer what is patient diagnosis what are the treatment services supplies provided to the patient again any unusual circumstances or medical condition that affected those treatments or Services okay uh again uh so this all information the payer get understand using by seeing those medical codes okay so medical coding's primary use is to ensure medical billing and insurance carriers uh pay and process claims correctly right but these codes are also valuable for research purposes and basic medical recordkeeping for patients okay because mostly patients information is kept digitally so we can track patients information medical record uh digitally right also uh these codes are been used for for research purposes and uh this medical coding standardizes this language and presentation of all these elements so they can be more easily understand tracked and modified and this common language mandated by the health information portability and accountability act which is also known as Hippa if you want to start career in medical coding please note down the points which I have uh I will going to tell you this is important that is important because I have gone through many interview rounds okay so I have a good idea about uh what exactly interviewer are going to ask you in your interview whether you are fresher or experience anyone so this is also the main point the interview are going to ask you what Isa okay at least they will ask you what is full form OFA right so you must have understanding of it so please note down it Hippa is health information portability and accountability act which allows hospitals providers and payers to communicate easily and consistently okay so uh there are three types of codes inside medical coding first one is ICD course right ICD is nothing but International classification of diseases okay I is international classification of diseases as its name suggest it is used for this course or this course set is used for diseases to code diseases and medical conditions okay uh any condition like uh symtoms illness or any disease disorder or cause of death we can code from these cours sets Okay which are known as ICD course then uh next one is CPT course CPT is nothing but current procedural terminology which describes Medical proced procures and services okay we use this course to code Physician Services surgical or diagnostic procedures or tests into alpha or mostly numeric course okay and uh lastly third type of codes or Cod set we use is hcpcs course also known as hipic course right the uh this code means hcpcs means Healthcare common procedure coding system Healthcare common procedure coding system is nothing but hcpcs or hipic course this cour describes non- Physician Services like uh means if wheelchair is used for the patient mostly uh these services are used for impatients right uh like ambulance if you use if any patient use ambulance or any syringe or saline anything which needs non-physician Services means uh nurses provide the care nurses use the supplies to provide your care okay so those supplies which are used for patient pent care okay whatever supplies is required for patient care when patient is in the hospital all those products and supplies we code with hcpcs clear this thing is it clear we're going to discuss this all the sets in further sessions okay so we'll start with International classification of diseases which is nothing but ICD course okay ICD CES are a set of designations used by Healthcare staff to communicate diseases symtoms abnormal findings and other elements of a patient's diagnosis in a way that is universally accepted by those in the medical or Insurance fields okay so the codes used for coding diagnosis and symptoms abnormal findings are same worldwide okay and those are called as called as ICD CS the ICD is maintained by World Health Organization this is also important Point ICD is maintained by World Health Organization wh wh maintain ICD course okay wh is responsible for maintenance and update uh updating the ICD codes and use across the globe with some country specific modification okay the 10th and the most recent Edition is known as ICD 10 which we are using currently okay ICD 10 cm International classification of this is 10th clinical modification CM means clinical modification and as it is 10th clinical modification it is named as ICD 10 cm when I started my medical coding Journey uh at the starting we are using we were using ICD9 course at that time we were using ICD9 course now it is ICD 10 course okay uh those ICD9 course uh which which were will be using are of 3 to five character codes which are numeric codes with few expect uh exceptions then transition happen and then ICD9 replaced by uh ICD 10 course in around I think in 2015 so uh in 2015 it changed to ICD 10 cm course okay though these codes have three to seven characters which are alpha numeric where every code begins with an alpha character which is indicative of chapter okay to which code is classified and then second and third character are numbers okay first character is alphabetic character which is representative representative of chapter and second and third character are numeric again four 5ifth 6 and seven can be number or letters that is this this is the structure of ICD 10cm course we'll going to see that also so the ICD course will be updated every year via ICD 10 cm or PCS coordination and maintenance committee okay these CES are updated ICD CES are updated each year every year in October month remember this this is also important Point ASD codes are updated each year by October months okay from uh the reports of the October date of Service 1st October you have to use the updated ICD 10 course okay because if you enter the previous or non-updated code this uh obviously the system will not accept that code okay so now uh ICD has two types in the ICD also there are two types ICD 10 uh sorry ICD International classification of disease 10th clinical modification known as ICD 10c which include diagnosis CES for reason for encounter okay means any uh symptom any illness abnormal finding or any uh disease which is the reason for encounter okay or impression you can say which is confirmed diagnosis okay and the nature of these codes are 3 to7 Alpha and numeric codes or digits sorry and the second type of ICD is ICD 10 procedure coding system this is known as ICD 10 PCS course these CES include procedure CES for inpatient treatments and services and the nature of this course are seven alpha alpha numeric uh course okay seven digit you might have confused right now am I right because in the previous slide I have told you CPT and hcpcs CES are used for uh procedures right but don't get confused I will going to discuss more and explain you where we have to use what kind of course okay don't worry about it this is just basic knowledge this acd1 procedure coding system we use only for coding inpatient treatment and services not for outpatient okay I I have told you that uh there are different kinds of specialities in medical coding like uh as the we have many kinds of patient categories of patient like outpatient inpatient and different kind of services they they are getting the coding system also different mean Specialties is also different okay so uh when you are going for medical coding uh we when you are going to work in medical coding you are working in any one speciality either you can be outpatient coder you can be uh inpatient coder you can be enm coder uh or as I told you denial coder or you can be anesthesia coder surgery coder or Interventional Radiology coder or just Radiology pathology uh and so on there are many specialities present in medical coding and depend on your specialty s also uh changes salary package nowadays mostly inpatient coder commands High salary because they have to code they have to choose more diagnosis from the patients report okay they have to assign many codes for one patient or one encounter right obviously as he is admitted in patient admitted in the hospital he will he going to receive most of the care okay that's why he uh and for uh their care uh most of the supplies are also being in use and you have to code all those Services all those diagnosis and all that's why inpatient coder command higher salary than others okay so don't worry about it if you don't understand difference between ICD 10 PCS and CPT code don't get confused okay we'll see one example see here uh one patient having coronary artery disease which is nothing but C okay it is the diagnosis and to cure C enoplastic procedure is per perform okay uh this is obviously if angioplasty is perform on any patient that patient is impatient okay he or she is admitted in the hospital so you have to use the ICD 10 PCS course for coding this the angioplasty procedure right so code used for CAD is i25.10 okay which is from icd1 CM which is cor set for used for diagnosis coding right whereas code used for angioplasty is 047 K 042 which is uh description of this code is dilation of right femoral artery with drug eluting intraluminal device open approach see how difficult it is so generally ICD 10 PCS coding is uh somewhat different and way too much different but difficult than normal CPD coding that's the reason why inpatient coder or also known as ipdg coders command High salary okay now we'll see I hope you have now clear idea or at least basic idea about what is ICD and what is the structure of ICD I hope okay now we'll start with current procedural terminology which is nothing but CPT course CPT course consist a wide range of services performed by physicians such as surgeries test and evaluations okay CPT was adopted as a part of centers of Medicare and Medicare Services Medicare center for Medicare and Medicare Services also known as CMS please note down this part CPT is maintained by CMS CMS is centers for Medicare and Medicaid services and it's Healthcare common procedure coding system also known as hcpcs or hitp this hcpcs C set is divided into two principal subsystems okay so basically the CPT is one part or one set which is included in hpcs coding system okay so the level one of cpcs is comprise the CPT course which we are used for Physicians uh services or surgeries performed by physician surgeries uh which are diagnostic or any service surgical Services any okay uh test and evaluation those we have to code using CPT and level two codes are h C PCS course which are used for non- Physician Services like Ambulance Service wheelchair syringes and all okay so level one codes are also known as CPT and level two codes are also known as hpcs okay the CPD codes are also known as level one course okay this is also main important point you may get question on it that what types of code are or what is the another name of level one code or what is the another name of CPD code either way okay so level one CES are nothing but CPT course okay and these are maintained by American Association American Medical Association okay m a American American Medical Association CBT codes are maintained by American Medical Association and these are five digit numeric CES that are assigned for the following services and procedures so these are the classifications of or chapter wise you can say classification of this course okay for evaluation and management we have course which are started with 99 series 99201 to 99499 these course are also known as 99 series okay then Anastasia course we just started with 001 0 to1 triple9 okay then surgery course which are started with uh this is the last session of section of the CPT course okay because it again depends or divided according to your body system okay that's why it has wide range of codes uh which starts with 1 212 uh 1690 okay then Radiology codes which are used for xray CT MRI ultrasound and all uh these codes are comes under 7102 2 7 4 * 9 okay which also known as 7,000 series then pathology and laboratory course which are 848 289 356 okay and lastly medicine codes which are starts with 90281 to 991 99 okay so these are different Cod sets use in CPT okay you can find this course in CPT book which is maintained by American Medical Association so these are few examples of CPT and a uh 7145 uh which is code used for radiological examination which is nothing but x-ray chest single view you can see here SL ly difference in between uh in last digit the fifth digit right 7104 is common in this all this three what can I say these three CS but just as the views changes the last character is also change right 7145 is for single view chest xray 71046 is for two view chest xray whereas 710 0 47 is for 3 VI Che 6 right so you have to uh properly assign the code you have to choose your code properly H then another example is CT thorx without contrast is coded with 71250 CT thorx with contrast 71 to 60 C CT thorx with or without contrast is coded as 1 71270 okay again uh 90716 which is for administration of verella or chicken fox vacine so this kind of course comes under CPT okay which are used for outpatient procedure coding okay and and ICD 10 PCS CES which are also used for procedure coding but those Cod are used for in patient coding okay now we'll see what are the hcpcs force hcpcs is nothing but Healthcare common procedure coding Healthcare common procedure coding also known as hcpc or hit Peak or they also known as level two CES level one CES are CPD CES whereas level two CES are hcpcs CES and it's these hcpcs CES are alpha numeric medical procedure CES which are nonphysician Services okay uh this code are used for non- Physician Services supplies provided to the patient okay use for as I told you now use for non- physician services such as ambulance services and prosthetic devices and all they represent items supplies and non-physician services not covered by CPT course which are level one course the course which are not included or the services not covered by CPT codes are included in hpcs course okay level two CES are composed of a single letter in the range a2v followed by four digits okay then level two CES are maintained by us centers for Medicare and Medicaid services again this hcpcs CES are maintained by CMS please note it down hpcs course are maintained by CMS we'll see one example as I told you it composed of single letter in the range of uh a to V followed by four characters like in this example a 0021 this is this code is used for ambulance service outside the State per mile transport okay so this code is for ambulance service then j0290 which is used for injection meline sodium 500 mg okay so this is all about Healthcare common procedure coding system okay now we'll see exact difference between uh I know you have confused now between all these courses but I try to make it easier for you see here ICD 10 cm which is international classification of disease okay which describes diagnosis and medical conditions okay icd1 CM describes diagnosis okay I 10 PCS which are used for procedure coding system describes inpatient procedure inpatient is more important in this uh uh description okay because ICD 10 PCS CES are used only for inpatient procedure Services these course said are not going to use uh in outpatient coding okay if you want to go for inpatient coding if you want to start your career in inpatient coding ipdg then and then only uh you'll get education about this courses okay for that you need to get separate training okay because in normal medical coding training you will not going any information more information about or training about this ICD 10 PC PCS course because these course sets are used only in ipdg coding okay but CPD codes ICD codes hpcs code these are common codes which are used in most of the medical coding specialities okay that's why uh the when you attend any basic medical coding training uh training at that time you'll get knowledge only of ICD 10 P ICD 10 cm codes CPT codes and hcpcs codes okay so now again ICD 10 cm CES are for diagnosis ICD 10 PCS CES are for in inpatient procedure and CPT codes which are also known as level one CES are used for out pression procedures and services okay and hcpcs course are also known as level two course and they describes non- Physician Services and supplies as provided to the patient also ICD 10 cm course maintained by you can note down whole information on this slide okay because this is very much important information okay ICD 10 cm course are maintained by World Health Organization wh again ICD 10 PCS course are also maintained by wh CBT coures are maintained by American Medical Association and hcpcs coures are maintained by centers for Medicare and Medicare Services CMS can we move forward hello ma'am can we move forward all right so the next point is modifiers modifier in medical coding modifier is two characters two characters either it can be numbers or two letters okay these modifiers are appended to a CPT or hcpcs course these are not going to open we have we no need to or we can't use these modifiers on diagnosis coding means uh I ICD course okay we have to use or append this course on CPT or hpcs course okay why uh why we have to openend this modifier in which cases in which scenario and what are the structure what kind of modifiers are there that everything will going to discuss in further sessions okay I will give you proper information and one dedicated session for this modifier okay don't worry about it if you don't understand anything during this session just uh try to understand the basic things basic use of this modifier basic uh uh what can I say basic definition of these modifiers okay so the modifier provides additional information about the medical procedure service or Supply involved without changing the meaning of the code okay medical coders use modifier to tell the story of a particular encounter in other word I'm sorry just a minute okay so in other words many medical and surgical procedures and services are complex and modifiers indicate a service did not occur exactly as described by its CPT or hcpcs code descriptor okay because each and every code has its own descriptor okay and we have to uh match that descriptor with our uh patient's condition okay which is mention whatever is mentioned is p in patient report we have to match that condition in CPT or hcpcs course descriptor but the situation did not change the code that applies okay because uh like uh if something happen during any medical procedure and patient has to terminate that procedure before completion okay or sometimes uh physician has to to uh repeat the procedure okay Pro provide same service more than once in uh in the same encounter like in this scenarios we have to open modifier to that CPT particular CPT code because if we enter any CPT more than once on the same patient same date of service same encounter okay the system will show error okay for that reason we have to open modify if you open modifier on that CPT the the system will not going to show you error okay so modifiers explain why the physician or other qualified Healthcare professional provide that service or procedure right when to use modify [Music] uh I'll give you some examples to provide additional information about services that were provided unusually okay or to denote uh when not to not all the services in the bundle are not performed okay or more than one provider perform the service or procedure okay at that time also obviously if two two or three surgeons performing the same surgery you have to uh explain that in coding manner right you because everyone needs their payment correct for that reason you uh you have to code that the same CPT three times but if you enter the same CPT three times the system will going to show you error as duplicate CPT correct but if you open the proper modifier for more than one physician okay the system will not going to show you any error then again if uh uh procedure was bilateral then also you have to open the code if you have if sometimes what happen few procedures have bil code also okay but few procedures are unilateral codes okay so in that case you have to use code for bilateral procedure okay 50 modifier is used for bilateral procedure if you open 50 modifier on any CPT the medical biller going to understand okay this CPT is performed twice or perform on both the letter take left and right side okay so this is the use of modifier we going to discuss more deeply don't worry about it these are few examples of modifiers CPT modifiers are generally two digit scores okay like 53 modifier which is used for discontinuous procedure discontinuous procedure means uh physician is performing procedure but uh any any health issue is happen means either sometimes you know uh patients BP goes increase or down at that time physician has to terminate that procedure okay in that cases we have to open 53 modifier right whereas 76 modifier which is used for repeat process procedure performed by same physician on same date of service okay if any cases physician has to repeat the procedure on the same patient same date of service like uh if any like you can say if one patient has two Legions on the abdomen okay and code for abdominal procedure on abdominal Legion is same and what you will going to do you will append you will give that CPT code twice right but to not get error you have to open 76 modifier on the second SHP right so that uh the system and ultimately the medical biller also understand the reason behind assigning that same CBD code twice okay now hcpcs means level two code modifiers are alpha numeric codes CPD modifiers are generally two digit codes whereas hcpcs or level two modifiers are alpha numeric CES or they have two letters only like E1 is used for upper left eyelid okay if any service provided for upper left eyelid or any Supply provide for upper left eyelid then to to mention that we have to use even oh even sorry modifier okay TC modifier which is nothing but technical component technical component means if uh suppose I'm having pain in my chest okay so I'll go to the the doctor one physician but uh he ordered chest x-ray to find out the reason behind it reason of that chest pin he need need uh need to see my chest x-ray but he doesn't have check x-ray machine so he'll uh he refer me to another physician or another hospital for just checks the chest x-ray I'll I'll do chest x-ray and took that report and get back to that previous physician and show him that report chest xray report and then uh that first physician interpret that chest xray okay here you can see the two physician provide services to me right one is just interpreting that and Order and then interpret that chest xray and one physician or you can say radiologist uh perform that actual X-ray and both need their payment right and for that reason you need to assign the CPT code suppose it is what I can say single view chest xray 7101 0 you have to uh use 7101 0 two times on the same patient right but to make medical biller understand how much amount they have to pay to The Physician how much amount they have to pay to the radiologist we have to open TC modifier on one CP okay so that is how we will going to use modifier I hope this is clear clear to you now we'll see few examples uh and see how we can search ICD icds okay and for that you need to go to icd10 data.com if it is possible for you right now to go ond1 data.com please go on it other wise I'll also share with you you can see my screen here okay this is icd10 data.com you can see somewhat like this okay we'll see the first first we'll see uh we'll find out the code for chess PR okay here here again wait okay now we have to find code for chest uh chest pin right so we'll have to go on first we need to go into the pain session okay course for pain pain category pain starts with p so we have to open click here on P okay and we have to type it down pin can see here uh they highlight all the pins in yellow color okay we need this one because we have only chest pain there is nothing if it is pain full chest we have to openend on pain only okay so I'll click on this pin now here this CES are depend on different sites okay our site is chest pin for that I press crl F and find chest okay this is the shortcut we might have aware about it control F to find out about any uh any anything from the document okay so I got the chest here here in front of this chest we'll see one code r07.9 but you can see here there are so many codes present under this chest okay anterior wall a typical ischemic muscular skeleton do we know anything about it we have uh we have to find only chest pen we have not we don't know any specification of this pin so we can't append on this course okay we have to choose this code only okay I click here and see here it says chest pen unspecified because we don't know don't have any specification right so we have to openend on this unspecified code which is nothing but r0 7.9 we'll see is it correct or not correct r07.9 next one is abdominal colic wa to search another code again we have to go on this here in index you can see icd1 CM index external cause index table out drugs table out neoplasm okay but we have to use icd1 CM index only okay and what is our condition now colic we can we can go by abdomen we can start with abdomen we have to start with the condition okay or the symptom particular so we go into C terms and here we have to find for colic okay okay see here how many colleages are there they get highlighted in yellow okay so we have to go for this one col I click here and I reached see now we'll go by site our site is abdomen okay so colic abdominal colic I'll choose this four see col and here also if you go down you can see applicable to colic not otherwise specifi okay or you can see here approximate synonyms abdominal colag colag child again course are depend on uh patient age and everything everything we will going to discuss more we going to learn more about this in for the sessions okay don't worry if you doesn't understand so right now this is our code R 10.83 we'll see is it correct or not R 10.83 right next one we'll have to see G Stones okay again again we have to go on to the index G Stone here we have only one one word g Stone so we have to go by G only and type it here Stone okay so now see here G Stone doesn't give me any code now what to do but he guided me that c also calculus look for calculus and then in the calculus see here there is comma between calculus and gallbladder it means you have to first go for calculus and then under calculus you have to go on to this site means gallbladder if you click on this blue term directly it will lead you to the calculus gallbladder see here you are under calculus term it is you can say it as a shortcut okay if you click on this uh blue color term it will directly lead you to that term as here calculus and we are under it is highlighted here in yellow color calculus gallbladder okay you have to carefully look for these lines okay on the first line there is a gallbladder so we have to choose this code and if there is any uh condition with gallbladder like col cystitis is present or if you know that this gallbladder uh with each chony or something then you have to choose accordingly but right now we have just we have to find code for G Stone okay so we'll click here and see calculus of G bladder without colis statis without obstruction right when you doesn't have any specification about the specific information about that uh condition in report you have to assign unspecified code okay here you have to go down if you go down you can see approxim approximate synonyms are bilary calculus kisis or gall stone or gallbladder stones like this okay so our code is correct which is nothing but K 80.20 you see is it correct or not k80.20 so the next we'll see is cron disase cron disease of small intestine with Pista see here here we need to find more specific code okay because we have information more information we have to go by these specifications what is that Cron's disease so we have to first go on to disease okay because disease is the condition okay all the diseases are get highlighted here but we have to go for this one only disease okay when I go on to the disease first I have to find whether it is the what is that disase Cron's disas right okay so we'll see is it Chrome is present here or not okay it is there so cron thises is present here but it it tell us that c enteri is regional so we have to go like this we have to click here ENT is orinal see here it leads us on yeah the main term is antis and the sub session under the enteritis is regional directly lead us on this code but again see here we have further specification Cron's disase of small intestine the part is small intestine and plus with fista right so we have to see whether we have the specific code small intestine where is the small intestine we have to search for it and now you have to search it in this second line okay you have to go by this second line mhm see here the small intestine okay we got here the small intestine here right judum mum junam everything here is also one code given K 50. but again we have further specification small intestine with fistula so we can't append on this K 50. code if you assign this code it will be wrong because we have more specification and we have more specific code for this condition so now we are on the second line okay then again under the small intestine we have to go with and on this third line okay in third line we'll find fistula so we have to choose this code this is our code which is nothing but k50 013 we'll see this code see here can see the same description cron this is of small intestine with fistula right if you go down it shows the path how we reach to this code first we we go on antis then Regional then into Regional we'll find uh small intestine then with complication fistula okay K .013 correct code now lastly last example is pressure ulcer of right hip stage three okay pressure aler right hip stage three again we have to go on and this index okay now our term is Ulcer right we have to go on ulcer okay we to click on this aler and here we have we need to find for hip control F hip see we have stage also right we have specific uh stage which is stage three okay so we have to look for hip right oh we have see here now we are under uler and the second row it is stage three okay or you can directly go by stage three stages okay stage two stage three under the stage three you will find this hip okay H see here pressure alcer of hip now the first code is pressure aler of unspecified Hep then look for this triangle shape symbol red color first one is for unspecified hip second one is for pressure aler of right hip our hip is Right correct right hip we need to search for right hip stage three so right hip stage three pressure Al of right H stage three L 89. 213 we see correct so this is how you have to search for icds I hope it is interesting you enjoy finding out this medical course how to uh find out the medical code is most uh enjoying part to find out this course are you enjoying okay uh so now we'll see one more example as you can see in actually report okay in report I'm sorry you can find indication okay okay I'm sorry for disturbance H so in report there is an indication indication States about uh patient's problem okay what illness what symptoms patient facing okay so here a 40 year old male with rectal pain rectal bleeding and some left sided lower abdominal pin this is the indication of this patient okay or reason why this patient came into the hospital okay I have highlighted these terms the main terms or which are diagnosis procedure again what is the impression what what are the main terms we have to find the code for that those we have we are sorry I have highlighted and like the same manner you have to also highlight the terms if you are going for any medical coding certification exam okay so that you can uh easily find out your code you no need to read your report again and again okay so here on our patient doctor perform procedure which is known as colonoscopy then next uh so we have to code or search code for procedure colonoscopy okay that is clear then the description of the procedure where they describe everything what kind of instrument they use and what are the findings they find out while the procedure everything then postop diagnosis or impression these are the confirmed diagnosis these are the result of that procedure outcome you can see that is confirmed diagnosis which is given by the physician also known as impression so it states uh first diagnosis is moderate size in internal hemorrhoids and second is mild diverticulosis so this is the reason behind this patients rectal pain rectal bleeding and abdominal pain okay see here here patient having left sided lower abdominal pain again if you find if you if any cases if you have to assign this code okay to Left sided lower abdominal pain you have to go by pain then you have to search for abdomen then under the abdomen you have to search for Left sided or sorry left lower sided okay so you can assign proper specific code now we'll see what are the codes so CPT code for this colonoscopy is 45378 okay that you will find on uh in the CPT book itself or if you are in the medical coding field if you when you start your mod coding job the either client or your company will provide you the software to find CPT CES okay now we'll find out ICD 10 course internal hemorrhoid okay we'll just find out code for internal hemorrhoids we have to go by the term hemorrhoid sorry okay here here is the term hemoroid here also we have internal we have to find for internal okay so this is our code is it correct let us check K 64.8 is it correct what is the description we again have to check see here so many synonyms are there bleeding internal hemorrhoid bleeding internal hemoroids whether it it will be one or two we have to assign the same code okay so we can assign this code for this these many terms okay now we'll go for another one next one is diverticulos I'm sorry diverticulosis of large intestine with bleeding because patient also having bleeding right we have to go by diverticulosis now again index then find D then type it here diverticulosis see here diverticulitis is also there diverticulum is also there diverticulosis is also there diverticulosis dulum diverticula all comes under same uh category but diverticulitis is different condition so be careful while choosing your code okay again here the verticulitis with bleeding okay dictis of large intestine without perforation or absess with bleeding K 57. 31 is it correct or not we'll check yes it is correct K 57. 31 okay so this is how you have to find out different kinds of icds okay CPT how to find out CPT code that I can't show you right now but I just show you how to find out ICD course okay and I hope you enjoy finding this ICD course and also I hope uh you now have have at least basic idea about medical coding what kinds of code we are using in medical coding and uh what are the different structure their maintenance Committees of those course okay and at least you have now few knowledge about how to find out different icds okay we'll discuss more discuss it more in detail in our further session each and every topic don't worry about it okay so lastly thank you for your [Music] attention welcome to Great online training it's a day three human anatomy and physiology myself Nikita I am CPC certified medical coding trainer in great online training as you can see my screen uh today uh we're going to discuss about human anatomy and phys iology you might have thinking that we already know human anatomy and physiology why it is necessary to again study the human anatomy and physiology right you might have thinking but as a medical coder you must have knowledge of anatomy because Anatomy knowledge is very crucial part in medical coding and uh as we are human being we have tendency to forget some things right in daily routine also we forget some things where I keep that particular object or uh someone's name also we going to forget if we uh not using that the same item or same name in Daily manner right likewise uh it is possibilities are there that uh you might have forget some terms or some body parts or working of some body part right that's why uh it is need to study human anatomy again okay just a minute now we'll see what are the different topics we going to cover in this class so uh today we'll see first introduction what are the importance of human anatomy in in related to medical coding okay then we'll go by different body systems like circulatory system then respiratory system then digestive system nervous system endocrine system we'll also see reproductive system anomet system muscular skeletal system then we'll also see Universal terms to describe the body parts placements okay then body cavities then you'll see quadrants and regions of the abdomen okay and lastly question and answer okay so let's start with the introduction to the human anatomy okay why human anatomy is or why to study human anatomy to be in this field in US healthare field and work as a if you work as a if you want to work as a medical coder why why human anatomy knowledge is mandatory okay because uh medical coders knowledge of for medical coders knowledge of anatomy is crucial in assigning codes for procedures and diagnosis Right medical coders must understand body structure and organs to assign course accurately you can assign codes accurately only when you have correct knowledge of human anatomy right so knowing basic human anatomy is a fundamental part of being a successful medical coder knowledge of basic medical terminology and human anatomy helps you assign a more accurate diagnosis and procedure CES because procedure CES are more specific to certain parts of the body in many cases okay so if you have proper human anatomy knowledge if you if you know which organ found in or which bone or which muscle found in which part of body okay or organ then you can assign or I can say you can search the medical code very accurately and quickly okay again medical coders need to know the names of body parts organ and system to assign the correct code for example uh a medical coder must know difference between various bones in the body to assign the fracture code okay if you know about each and every bones in your body which bone located in which area then and then only you can assign correct fracture code easily very easily and fast because uh as a medical coder you have your quality should be at least 95% okay and your productivity is at least 100% or above than that okay so to be a productive you must possess good human anatomy knowledge to find your your medical CES quickly okay and accurately also again uh the medical coder must also understand relationship between organs and system to assign CES accurately for example uh understanding the relationship between Heart and Lung is crucial in assigning CES for Heart and Lung conditions because uh most of the CES are correlated with each other or or you can see uh combination CES are present in uh most of the ICD or disease CES okay like diabetes is related with CKD chronic kidney disease or hypertension and diabetes is related with each other so you can find combination code if you have proper knowledge of anatomy diseases then and then only you can assign proper code easily and quickly right because medical coding most of the people says that medical coding is like a different language I also agree with it medical coding is like a different language because we know what doctor doctor know right and that to without going into Medical School medical coder know what doctor is saying we have to read as a medical coder we have to read and understand the Health Report of the patient if we don't understand any part of the report that or some part of the report or any term mention in the report then it is potential that we choose wrong medical code so that's why understanding your body your Anatomy your physiology different body systems different medical terminologies if is important it will all goes together these all understanding these all is key for being successful medical coder okay you can't neglect Anatomy terminology and directly start studying medical coding because if you didn't study uh Anatomy how will you going to understand coding right so the anatomy of the human body is made up of a number of different body body systems that work together to perform more complex bodily functions and you need knowledge of all of those okay so now we'll start with circulatory system okay here circulatory system is uh means our heart is the main part or main organ of circulatory system okay uh or heart is situated in in the middle of chest cavity which is also known as mediastinum okay and it is enclosed in pericardium you must uh you may uh I I suggest you to note down these things because if you are going for medical coding interview or even for medical coding certificate test uh exams okay there you will expect this kind of questions the simple simple questions straight having straightforward answer but you must have knowledge about it so that you uh these medical coding uh exams are open book exams you will find everything in your book medical coding book you will find everything about DC es in ICD book plus you will find CES also obviously but then two if you already know about uh diseases and all this human anatomy uh you will not going to it will not going to waste your time in searching the that term into the book right because uh ultimately you have to cover your paper complete your paper within a Time okay so uh please note down the uh the points which I'm going to tell you this is important that is important okay because I have gone through many interviews because I think that even though you didn't need any job even though if you don't want to change your job okay then also you have to go through it interviews if you get chance to get interviewed by any anyone go through it so that you uh it will build your confidence right you'll get to understand uh how much knowledge you have uh what are the new things you need to learn okay and how interviewer going to ask you questions okay and uh this circulatory system is more important of working of the heart is very important because uh I have I remember that when I go on for went for my uh interview at the first time at my first job when I'm fresher in this field I don't know anything about medical coding and I go for interview at that time the that interviewer asked me tell me the function about function of circulatory system okay and even after a few years of medical coding experience the another interviewer also asked me to explain anyone system anyone body system so again I tell them about circulatory system only because circulatory system is easiest system to explain that my opinion so be ready for this okay so about circulatory system there are two parts of this system the cardiovascular system it is composed of heart blood vessels and blood whereas uh second system is the lymphatic system it is made up of lymph node lymphatic vessels lymphatic vessels are are those vessels which carry link fluid then the thymus and the splen and as well as other parts thymus is the gland located in the chest that helps produce t- cells which are a type of wbcs okay white blood cells now we'll see functions of circulatory system circulatory system provides a means of transportation of nutrients water oxygen hormones and body salts body salts to the cell this everything means nutrient water oxygen hormones and body salts to the uh body cells and take away waste from the body cells okay it also serves as protective role by dis uh dispatching specialized def uh defensive cells through the lymphatic system okay now the main part which is very important please make a note of it working of heart okay where is the heart situated heart situated in mediastinum cavity okay and enclos in pericardium okay so our heart is uh consisting or divided into four chambers upper chambers are called Atrium so we have right atrium and left atrium and lower Chambers are called ventricles so we have right ventricle and left ventricle again these Chambers are separated this right atrium and uh right ventricles are separated by what is this wall this is called tricuspid wall okay this is tricuspid wall whereas left side of the heart means left atrium and left ventricles these are separated by biker speed wall or it also known as metal wall please make a note of it metal wall is also known as Bas speed wall okay not the triped wall okay metal wall means bped wall so uh Superior vwa collects deoxygenated blood from upper part of the body whereas inferior venacava collect deoxygenated blood from lower part of the body okay then uh from left atrium it goes into the right ventricle via tricuspid World okay and then the right ventricle pumps that deoxygenated blood collected from all over the body to the lungs via pulmonary artery pulmonary artery is the only one artery in our body which carries deoxygenated blood please make a note pulmonary artery is the only one artery which carry deoxygenated blood other arteries carry oxygenated blood okay this is an exception then that blood goes into the lung and where oxygenated blood from lungs via pulmonary veins the oxygenated blood uh come back into the left left atrium okay and again here pulmonary vents which carry oxygenated blood this is also one exception of when pulmonary vein is the only one vein which carry oxygenated blood other veins carry deoxygenated blood please make note okay so pulmonary vein gives oxygenated blood to left atrium then via B speed or materal wall it goes into the left ventricle and where uh left ventricle pump this oxygenated blood for all pump the blood oxygenated blood to all over the body via aorta okay this aorta aorta is the largest artery in our body this is important Point aorta is the largest artery in our body which carry oxygenated blood from heart to all over the body okay so this is the uh function of our heart there are two types of circulation okay pulmonary circulation and systemic circulation pulmonary as name suggest pulmonary means related to lungs okay so pulmonary circulation begins with the right side of the heart sending blood to the lungs to absorb oxygen and to release carbon dioxide okay CO2 then the systemic circulation means uh the systemic circulation carries blood from the heart to the cells of the body where nutrients and waste exchange takes place okay this is clear please make sure that uh you going to learn more about this circulatory system and the working and how circulation happens in or how circulation takes place in heart before you going for any uh medical coding interview okay now we'll move toward our next system which is respiratory system so respiratory system main organ is obviously lungs okay lungs have two loes right uh right L and left L right side uh on the right side uh lung have three loopes okay right Superior lobe right middle lob and right inferior l L whereas left side have only two loopes up left Superior L and left inferior L okay then larynx then tra tra is also known as wind pipe because it carries wind we have uh breathe in and breathe out okay then the diaphragm diaphragm present between lungs and abdomen okay then these are branches these branches are called as broni okay so main function of respiratory system the respiratory system provides oxygen to all cells of the body by performing gas gas exchange between air and blood gases correct it is made up of nose tra lungs and broni broni is the main uh passage of trachea that leads to the lungs okay as well as other parts so now we'll see different functions of respiratory system as uh besides helping you in inhale or breathe in and exhale or you can say breathe out respiratory system has many other functions also like it allows you to talk and to smell it warms air to match your body temperature and moisture moisturizes it to the uh humidity level your body needs also it delivers oxygen to the cells in your body it removes waste gases including carbon dioxide from the body when you exhale and also protect your air West from harmful substances and irritants right now we'll see working of respiratory system so here you can see the Bron bronchioles are ended up with this sack like structure which is known as lvol Sac so when we breathe in the air goes into the alola sa right every few seconds and with each inhalation air fills in Alvi it is structural and functional unit of the respiratory system what is that lvi make a note okay LV lvi is structural and functional unit of the respiratory system in the process called diffusion oxygen moves from Alvi to to the blood through the alol wall via small capillaries okay the oxygen is in the air which filled in alol set right so via alv wall it goes into the bloodstream okay you can see here here in this diagram oxygen is going into the uh blood while uh carbon dioxide is exchanged going again into the carbon dioxide going in and oxygen going out from the Alvi okay and this process is called diffusion what is diffusion oxygen moves from Alvi to the blood through alol wall is called diffusion okay this oxygen reach blood then flows back to the heart which pumps it through the arteries to oxygen hungry tissues throughout the body the carbon dioxide made by the cells as they do their work moves out out moves out of the cell into the plasma of the blood and the blood reach in carbon dioxide then returns back to uh to the heart via the via the veins okay okay and from the heart the blood is pumped to the lungs where carbon dioxide passes into the LV to be exit this is clear this is about the functioning of uh function and working of respiratory system and different parts okay now we'll move ahead towards our third body system which is nothing but digestive system digestive system there are uh different parts or organs involved in digestive system like mouth liver stomach pancreas gallbladder dudum dudum jum these are the parts of small intestine large intestine is there again anal Canal is there rectum appendix everything comes under digestive system the digestive system convert food into nutrients that the body can use right this is the main function of digestive system to convert food into nutrients that body can use the G GI track consist of or oral cavity fing esophagus stomach small intestine large intestine and anal Canal mostly these are all organs because these car flu oh sorry food okay so the GI tract consist oral cavity fings this is also one question you may expect G TR consist oral cavity fings esophagus stomach small intestine large intestine and anal Canal whereas the accessory organs include the teeth tongue gland and glandular organs such as salivary gland liver gallbladder and pancrea okay because they assist in digestion they secret some uh hormones that secret some enzymes and help in digestion okay now we'll see how digestive system works working of different part of the or organ of the digestive system first come is mouth okay mouth breaks up the food particles and also assist in producing spoken languages okay then the salivary gland secretes saliva who which moist and lubricates food which also consist amage enzyme which digest polysaccharides okay then comes fings okay here this is the fings parents help in swallowing then comes in esophagus who helps in transport of food then the stomach then food goes into the stomach who uh whose job is to store and churn food which also consist pepsin enzyme who digest which digest protein then HCL activates enzymes then breaks up the food heals germs and it also has mucus which protect stomach wall limited absorption okay then we have liver here liver breakdowns and build up many biological molecules okay and stores vitamins and ion liver also destroyed uh destroys old blood cells and poisons okay and uh make B to add in digestion next one is this is green organ is gallbladder gallbladder helps in storage stores and concentrates by okay then comes in is pancreas okay pancrea Secret hormones which regulates blood glucose level okay bicarbonates neutralizes stomach acid dpin and chemot triin digest proteins amyes digest polysaccharides and lipas digest lipid lipas digest lipids okay then comes uh small intestine here the pink one Okay small intestine completes the digestion process okay the mucus Pro mucus in the small intestine protects gut wall in small intestine absorption of nutrients and water is also get absorbed in small intestine then peptides digest protein then sucas digest sugars Ames digest polycrates okay then food goes into the large intestine okay yeah then large intestine reabsorbs some remaining water okay and irons and also forms and stores fishes then rectum stores and expel faces faces okay and the anus is the opening of for elimination of faces okay so the that's all about digestive system this is clear okay so we'll move forward on our next system which is nervous system okay the brain cervical nerves Thor IC nerves all the nerves in our body just a minute sorry the nervous system consist brain cervical nose thoracic nerves lumbar nerves sacral nerves setic nerves peripheral leg nerves all the nerves present in our body make nervous system okay so the nervous system is a complex network of nerves and nerve cells nerve cells are also known as neurons that carry signals or messages to and from the brain and spinal cord to different part of the body okay the job is to carry the signals or messages from brain and spinal cord to the different parts of the body correct it is made up of central nervous system and peripheral nervous system the central nervous system also known as CNS central nervous system CNS is made up of brain and spinal cord okay the brain controls most of the body functions including awareness Ms sensation thoughts speech and memory okay so this is about central nervous system whereas the second nervous system is peripheral nervous system also known as pns peripheral nervous system pns is the part of the nervous system outside of the nervous central nervous system okay it is made up of nerves and ganglia that send signal to and receive signal from the central nervous system the nerves present outside of the central nervous system or comes under peripheral nervous system whose job is to send signals to and receive signals from the central nervous system this is clear okay now we'll see what are the functions of nervous systems okay so the central nervous system CNS consist of brain and spinal cord okay brain and spinal cord makes central nervous system which is respons ible for sensory activities storing memories and emotions right then comes peripheral nervous system okay pns which consist cranial and spinal nerves okay which brings messages to and from the central nervous system to the rest of the body then uh the peripheral nervous system again divided into two part somatic nervous system and autonomic nervous system okay somatic nervous system is responsible for voluntary movements voluntary muscle movements whereas autonomic nervous system is responsible for involuntary action such as uh heartbeat pupil dilation Etc involuntary and voluntary what is difference between involuntary and voluntary so voluntary actions are those actions which are uh under you can control under a conscious mind okay when you are conscious you can control those actions okay but involuntary uh actions are those actions that are not under conscious controls all right so next this autonomic nervous system again divided into sympath sympathetic nervous system and parasympathetic nervous system okay sympathetic nervous systems responsible for fight or fight response whereas parasympathetic nervous system responsible for rest and relax actions like digestion and other things okay this is clear now next system is endocrine system endocrine system is made up of hormone secreting organs okay those are like hypothalamus pituitary gland parathyroid gland thyroid gland thymus adrenal gland pancreas if you are male you have testes if you are female you have ovaries so these all are hormone secreting glands okay and parts of endocrine system okay the hormones created and released by the glands in your body's endocrine system who control nearly all the processes in your body these chemicals help coordinate your body's function from metabolism to growth and development emotion mood sexual functions and even sleep right if you have hormonal balance you are not able to sleep you can see most of the old peoples have complaints that they are not able to sleep right because they have hormonal balance okay so balance in hormones is very important in our body many glands make the endocrine system like the hypothalamus pitutary gland and pineal glands are present in here in brain hypo thus pitutary gland and pineal gland are present in brain okay then uh parathyroid gland present in your uh neck neck region okay then thymus is between your lungs here okay then the adrenal glands are present on the top of your kidneys here the yellow one these are called adrenal glands okay then the pancrea is behind your stomach it's present behind your stomach and if you are woman you have ories and if you are men you have testes those are present in pelvic region right so these are different organs of endocrine system now we'll see their functions okay gland and their functions the adrenal gland these are attached to kidney surface on the top of the kidneys okay their position is on the top of the kidney keep it in mind that adrenal glands are present on the top of the kidney you may have question on this also their hormones control growth sugar metabolism kidney function and stress okay then uh hypothalamus hypothalamus find found at the base of the brain the main controlling gland it is called as main controlling gland okay hypothalamus controls all the other glands its hormones the hormones secreted by hypothalamus control most of the body functions and all other glands okay then uh pitutary gland pit gland found at the base of the brain okay and hormones secret hormones that controls growth reproduction lactation and stress then we have uh ovaries to produce female hormones estrogen and progesterone then we have testes which are helped to produce male hormones testosterone then thyroid gland which control metabolism and growth then parathyroid gland which are located near thyroid gland in the neck which control calcium and phosphorus deposition okay then we have pancreas the pancreas located in a fold of a deum behind the stomach which produces insulin to control sugar metabolism okay if you have any uh problem with pancrea you may have sugar means thisas related to Sugar metabolism okay or related to insulin then uh we have placenta also placenta also secretes some hormones after birth membrane that covers the fetus is called placenta which maintains pregnancy and produce female hormones Okay so these are different glands and their function There Are all uh many other glands also present so uh please make sure you're going to study all the glands and their function before going for medical coding interview or going for any medical coding related exam okay now next one is the reproductive system the female we have two types of reproductive system if you're a female you have a vagina uterus Fallopian tubes ovaries cervix like this but if you you are male you have pennies testes W difference uh seminal vesicle like that okay or prostrate gland the reproductive system enables the production of offscreen okay this is the main function of reproductive system that enables production of offscreen the male reproductive system is made up of testes scrotum penis vast difference which is known as the passage way for sperms and prostate gr then the female reproductive system is made up of the ories hopan tube uterus and vagina the memory glands are considered accessory organs okay now we'll see what are the functions of different reproductive systems female reproductive system perform the following functions like uh they produce eggs necessary for reproduction called OA oom is the singular for 1 a and o is for Mania EXs okay or us sites okay female reproductive system incubate and nourish a fertilized egg until it is fully developed they also also produce female sex hormones that maintain the reproductive cycle okay now we'll see functions of male reproductive system male reproductive system produces and maintain and transports SP sperms sperm is the male reproductive cell and protective fluid also which is known as Cen then uh it is also responsible for discharges sperm within the female reproductive tract during intercourse and uh also produces and secretes male hormones responsible for maintaining male reproductive systems like testosterone okay then the next system is integrety system inget system means made it is made up of skin okay the skin is the largest organ of the body please make a note of it skin is the largest organ of the body okay the intercat system includes epidermis dermis hypodermis hypodermis is also known as subcutanous tissue and other Associated glands hair and nails here you can see in this diagram it is made up of our skin is made up of epidermis this is the outermost layer of the skin which is protective in nature if anything happen with our skin first it has to deal with epidermis okay then we have dermis below this epidermis okay which consist lots of glands you can see hair follicle is also grown from dermis only sweat glands okay blood vessels cous glands okay all the glands are present in EP sorry dermis okay which is middle middle layer of the skin then we have uh hypodermis which is also known as subcutanous tissue it is the innermost layer of the skin which connects skin to the other body organs or muscles okay so now we'll see functions of integrety system so it its main function is protection the skin and hair provides a barrier against harmful substances uvite or U radiation from the Sun okay and from the temperature extremes okay then second function is sensation the skin contains nerve endings that detect touch pressure pain heat and cold okay then uh temperature regulation the skin can sweat and widen blood blood vessels to regulate body temperature then next one is West excretion the skin eliminates some West through sweat right then vitamin D production skin helps in vitamin D production also when skin exposed to UV light from the sun sun the skin produces vitamin D which is important for B bone health okay if you have any bone related disease means if you have some pain in joint or in any bone area doctor may suggest you to check your calcium level and with calcium level they also suggest you to uh do vitamin D deficiency test because vitamin D is very important in absorption of calcium if you though even though your body have enough calcium even though you are taking enough calcium in your body if you have vitamin D deficiency there is no use of that calcium because vitamin D is very important to absorb that calcium okay now we'll move towards our next system that is the muscular skeletal system obviously as name suggest muscular skeletal system so it is made up of skeletal system and muscular system okay so skeletal system main function is to protect the blood body and body organs right to protect body organs and give body its shape and form it is the main function of skeletal system it is made up of bones joints ligaments tendons and cartilage ligaments are the fibers that connects bone to another bone okay ligaments are the fibers that connect bone to another bone bone to bone connected with ligaments whereas tendons are the fibers that connect muscles to bones okay muscle to bones are connected with tendons please make a note you may get confused between these two okay because what happened during interview even though if you know each and everything at the time of interview you will not going to recollect it it happens many time right so please make a note of each and every point which are important so that uh you can go through it while you're interview okay and not get confused then uh there are total 270 bones are present when we born or you can say 270 bones are present in new Bor okay but in adults only 206 bones are present why is it so can anyone tell me anyone where are the other bone gone then all right uh those bones many bones get fused while we grow okay so uh in adults we have only 206 bones but when we Bor we have 270 bones okay please make note newborn baby have 270 bones while adults have 206 bones okay the must then we have this is about skeletal system then the next system is muscular system which enables the body to move okay it is made up of muscles tendons ligaments and cartilage okay tendons are connection between muscles and bones okay whereas ligaments are connection between bones to bones okay now see what what are the different types of muscles and Joints present in body our human body okay so we have three types of muscles cardiac muscle skill skeletal muscle and smooth muscles okay these are divided uh on the basis of their structure okay so the skeletal muscles are voluntary in function they are mostly present in our Limbs and all over the body okay but uh voluntary means they contract and relax under con ious control as I said earlier voluntary means they contract and relax under conscious control okay you can control them uh their movement the skeletal muscles are voluntary in function but cardiac muscle and smooth muscles these are not under conscious control so these are called as invol muscles what are those cardiac and smooth muscle okay so this is we have this three types of muscles we'll see what are the different uh different types of joints we have in our body first one is fixed joints okay fixed joints do not allow any movement the joints between the bones of our skull are example of f joints fixed joints are fixed they are not allow any movement okay the bones present in skull are called uh sorry joints present in skull are called Fix joints okay sorry uh next one are slightly movable joints which allows very little movement okay very little movement like the joints present in between our vertebra okay then we have freely movable joints which can move quite freely and allow a variety of movements examples include bone bone joint knee joint foot joint or sorry ankle joint and our shoulder joint okay these are examples of freely movable joint so we have three types of joints fixed joints which are not allowed any moment slightly movable joint which allows little movement and freely movable joints which can move quite freely okay and allow variety of moments so uh this is all about different types of body systems okay I know this is uh not enough knowledge regarding medical coding you need more knowledge more and more knowledge about human anatomy but it is not possible for anyone to cover uh that entire chapter in few sessions right obviously because you you you have took too many too many years to learn human anatomy right so again go back uh and check your uh 11 12th books for human anatomy and go through it okay make each and note of important notes okay so that's that is about different body system now we'll move ahead towards Universal terms to describe the body part placements okay so these are different body planes which is sagital plane coronal plane transverse plane okay what are those uh plan are going to discuss ples of the body are anatomical Concepts often used by health professional to describe how your body moves during exercise or other activities okay it is depend on your body movement there are three type of three types of plane of body first one is coronal or frontal plane then next uh second one is Sagal or longitudinal plane here sagital plane this one okay the transverse coronal plane is here and the transverse plane is here okay transfers plane is also known as exal plane coronal plane separates front and anterior back of the the body front means anterior and back means posterior okay so here the coronal plane which separates our body into front and back okay means anterior and posterior whereas sagital means this one which separates the left and right side of the body okay then third one is transverse plane which is also known as exal plane which separates upper and lower holes of the body upper means Superior while lower is inferior okay so first plane is coronal plane it is often referred as frontal plane okay often referred as frontal plane please make a note coronal plane is also referred as frontal plane okay as it divides the body into front means anterior and back means posterior session okay posterior and uh anterior sections okay the movements that occur in the coronal plane are lateral or side to side movements okay this includes abduction abduction means moving your limbs laterally away from the middle line of the body okay moving your limbs laterally away from the middle line of your body if you raise your hands uh in sleeping L like okay that is called abduction for example lifting your legs to the side or lifting your hands to the side and then uh second is adduction adduction mean moving your limbs medially towards the midline of the body for example lowering your arms down to the side of the of your body okay if you sorry if you lift your hands to the side it is called abduction whereas if you lowering lowering your arms down it is called adoption please don't get confuse between this ter okay next plane is sagital plane which divide our body left and right okay Sagal plane also known as longitudinal plane okay which divides body into left and right Wes okay or you can say left and right side movements that occur in the sagital plane or longitudinal plane are involve forward and backward movements okay our day-to-day activities usually occur in this plane since we usually move by swinging or our arms and legs in front of us right so sagital plane divides Us in left and right then third is transverse plane it is also known as aial plane okay aial plane divides body into upper means Superior and lower means inferior walls okay Superior and inferior walls then the movements that occur in this plane involve rotation or horizontal movement okay so this is all about the different planes of the body now we'll uh now these are the few terms which you have to keep it in mind okay it is very easy to understand because I kept it in differentiate manner okay I have differentiate them so that it will easy to digest interior means see situated before or at the front of whereas posterior means situated after or at the back of middle oh sorry medial means pertaining to middle or near to the middle of the body whereas lateral means far from center of the body part away from middle okay then superficial means on the surface not too deep okay on the surface surface means superficial deep means away from the surface or further into the body Superior cranial or seic means above over top okay whereas inferior means codal pelic or towards the fit proximal means towards the beginning the nearer of two items distal means more distant far from the origin inversion means to turn inward to turn upside down to reverse in position or order and ersion means to turn outward okay ipsilateral means on the same side and contralateral means on the other side IFC means same Contra means different or other Okay so supine means with back or dorsal side downwards okay prone means lying face downward means if you uh sleep on your stomach laying your face down it is called prone position whereas if you sleep on your back okay then that position is called supine it is more most important question H this question I got in during my CPC exam also and one of my interviewer also asked me this question when I am pressure uh also and when I uh given interview as a experience also so this is important very very much important suin means when you sleep on your back whereas prone means when you sleep on your stomach or laying face downwards then dorsal means relating to back or posterior whereas ventral means relating to front or anterior these are few uh terms related to medical coding which you need to know now we'll see different body cavities okay our body is made up of different cavities okay different body cavities so dorsal body cavity consist cranial cavity here and ventral cavity made up of these two or comes under dorsal body cavity whereas we also have thoracic cavity abdominal cavity pelvic cavity okay the human body is divided into number of body cavities which are FL fluid fill spaces in the body that hold and protects internal organ okay these are fluid field spaces in the body that hold and protect internal organs the two largest human body cavities are ventral cavity and dorsal cavity dorsal cavity and these three cavities are comes under vental cavities okay these two body cavities are subdivided into smaller body cavities like dorsal body cavity divided into cranial cavity and vental cavity whereas ventral cavity is divided into thoracic cavity abdominal cavity and pelvic cavity okay first first one is vental cavity it is at the anterior or front of the trunk okay the organs origin uh contained within this body cavity include lungs heart stomach intestines and reproductive organs okay and it is subdivided into thoracic abdomen or you can and pelvic or you can say abdomino pelvic cavities then next one is dorsal cavity it is at the posterior or back of the body including both the head and the back of the trunk means spinal cavity okay the dorsal cavity is subdivided into cranial and spinal cavity okay so these are few again these are the organs included in each cavity cranial cavity consist or consist brain and pitutary gland whereas vental cavity consist spinal cord thoracic cavity consist lungs thymus uh then heart which is situated in mediastinal cavity then abdominal cavity which consist stomach liver pancreas gallbladder spleen large and small intestine okay and lastly p cavity which consist urinary system and reproductive system clear is this clear about uh body cavities I hope you are understanding this yes ma' okay now we'll see different quadrants of the abdomen okay so as you know this is our abdomen it consist liver gallbladder large intestine small intestine stomach pancrea rectum anal Canal everything okay but to make it easier our medical system divided it uh this our abdomen in four quadrants okay like right upper quadrants right lower quadrant left upper quadrant and left lower quadrant into four quadrant quadrant wies if you see our abdomen is divided into four quadrant light right upper right lower left upper and left lower quadrant and you have to keep it in mind that what are the organs comes under which quadr okay because uh if you remember yesterday we uh in our previous session we have one report right in that report that patient has some uh specific pain I think left lower quadrant pin right and we have specific code for that pin okay so uh you have to be able to uh connect the connection between that pain and related disease okay that's why you need to understand what are the different organs present in which quadrant okay so right upper quadrant consist uh most of the part of the liver gallbladder is comes under right upper quadrant only then dud denum mean some part of small intestin okay then D J uh Junction then ascending colon mean some part of uh you can say large intestine okay then uh most of the part of stomach pancreas left colic uh flexure then transverse colon junam this comes under left upper quadrant okay whereas left lower quadrant consists descending colon Sigma colon rectum andal canal and the right lower quadrant consist appendix appendix is main part because most of the people have problems related to appendix so if you have a right lower quadrant pen then it is possibilties are there that you may have something related with appendix or or ilium okay and again few part of rectum and anal Canal this is clear now we'll see regions of the abdomen if you divide your abdomen into regions we have nine different regions first one is uh this is here right hypochondria region then uh this side left hypochondria region okay then in the middle upper middle we we have epigastric region I'm sorry then we have in the middle right lumbar region then exactly in the middle umbilical region then uh in the middle left side we have left lumbar region then in in the Lower Side we have right ilc region then hypogastric region then left ilc region okay and these are the different organs come under these regions right hypochondria consists liver gallbladder right kidney and small intestine epigastric region consist stomach liver pancreas dudum spleen adrenal gland left hypochondria region consist plen colon left kidney pancreas okay then left lumbar region consist gallbladder liver and right colon whereas umbilical region is umbilical or nville region then parts of some small intestine Dum okay then left lumbar region consist uh descending colon and left kidney then uh seventh is Right ilc region which consist appendix or appendix and seeum sorry then we have hypogastric region which consist of urinary bladder uh sigmoid colon female reproductive organs or male reproductive organs okay then we have left ilc region which consists descending colon and sigmoid colons okay so if you divide your abdomen as in different region we get nine regions and if you uh divide your abdomen in quadrants we have four quadrants okay please make note of it it is also very important so that's all about human anatomy now we'll move towards our question part okay I expect answer from you so uh unmute your mic and give me answer please it is okay if you give wrong answer don't worry about it ready hello hello M yes so the first question is how many bones does an adult human skeleton have we going to answer your options are uh 205 207 209 or 206 which is correct one 206 ma'am yes correct okay then so the correct answer is option D 206 okay please make note of it this is very important question and in uh newborn we have two how many [Music] anyone adult have 206 bones whereas newborn have 270 ma'am very good 270 bones so the next question is second question which of the following structures keep blood flowing unidirectionally in humans the options are bronchol neurons septum or walls we going to answer yes well ma'am what option D yes yes you're right correct option D is walse just a minute sorry sorry so uh walls are the structure which keeps blood flowing unidirectionally in humans okay next question is which of the following type of cartilage I'm sorry which of the following type of cartilage is present at the Joint of long bones in humans fibrous Highline elastic or calcified we going to answer it's okay if you give wrong answer option b Highline right so Highline is correct answer Highline cartilage is present at the joints of long bones in humans okay so the next question is which of the following hormones help in secretion of HCL from stomach gastrin secretin pepsin or Rainin gastrin ma'am very good so the option is a gastrin gastrin hormones helps in secretion of H CL from stomach and the last question is which of the following is in innermost layer of the human eye retina choid Scara or cornea m' option D cornea mhm no anyone man what come again option a re yes correct so retina is the innermost layer of human eye that is correct very very good girls very nice so this is the uh end of this session these are the answers okay so again thank you for your attention and thank you for atten in this session and making this session very interactive and giving answer to my questions okay I hope you enjoying learning this medical coding right if you have any doubts you can ask me anytime okay and if you find this session this medical coding session interesting and if you want to learn more about medical coding if you want to enroll in our medical coding training sessions you can go through this uh link we have given below which is nothing but www.r onlin training.com and register yourself okay so again thank you bye-bye take care so hello everyone how are you hello I hope ma'am okay good uh so welcome to grade online training myself Nikita ycbc certified medical coding trainer in great online training uh this is all about this sessions are all about medical coding and this is day four and today we're going to learn about medical terminology before starting I'd like to hear from you what do you know about terminology or medical termin ology or why it is important to learn medical terminology please tell me whatever you think hello fine so the terminology ma'am yeah please please go ahead no idea about that but why there is need to learn medical terminology what do you think about it see terminology means study of specialized Concepts and linguistic destination or terms right so medical terminology means uh study of words and languages used specifically in medical or health field so why there is need to learn why can't directly we go and study medical coding fine okay uh we'll see it before that we'll see uh what are the different topics we going to covered in this class so we'll see objectives that's the question I uh ask you okay then we'll see introduction then basic word Parts okay then we'll see medical root words medical prefixes suffixes then we'll uh see some word analysis and medical terms medical abbreviations and acronyms okay so first let us starts with objectives okay for learning if you want to be a professional medical coder and meet your productivity goals remember I told you this medical coding jobs are uh focus on your productivity these jobs are productivity based okay and with productivity you have to uh give your quality at least 95% quality also so to meet your productivity goals and quality goals you need to know medical terminologies right if you want to work with medical or Healthcare professionals nurses you must have understanding about different medical terminal Tech ology Anatomy synonyms different types of prefixes suffixes then and then only you can do your coding job perfectly am I right so learning more about medical care and treatment is the main objective of learning medical terminologies right then we can also find our mistakes more easily uh working quick L and accurately uh and hit our daily productivity Target and quality Target quality Benchmark also sorry then ensuring accurate coding and billing if you know about most of the medical terminology if you have good knowledge of medical terminology anatomy and all then and then only you can choose uh correct diagnosis also and uh choose correct code right and lastly enabling healthcare service providers to receive payments on time obviously if you uh as a medical coder do your job properly if you maintain your 95% quality then uh there will be no rejections happen or less rejections happen and uh less denial claims happen and so that the service provider get their payment on time correct that's why we have to learn medical terminologies we can't go directly and start learning medical coding because if you do do so you'll not going to understand many terms involved in medical terminology okay now we'll see introduction what is medical terminology what are the different components of medical terminology medical terminology is the language used in healthcare to describe Anatomy structures condition diagnosis procedure treatments and much more okay it is nothing but medical language which are used in healthcare medical terms usually use a combination of prefixes root words and suffixes to define the meaning okay the word of medical terminology is quite vast so we organize them by category to make it a little easier to digest the categories are like medical root word medical prefixes medical suffixes medical terms medical abbreviations and acronyms right and uh I want to clear one thing that uh we are going going to cover this all these topics in this session but it is not possible for anyone to cover all the medical terminologies in one hour session okay so it is ongoing process of learning medical terminology you have to learn more and more about it here in in this session I'll give you few examples few uh import or daily use uh medical terminologies examples but eventually you have to go through and study your own own style studying your own style uh in this medical terminology okay and ultimately when you start working in as a medical coder you going to learn new new medical terminologies right so my suggestion is uh go through simply go through Google or any medical related book or medical dictionary where you can find medical terminologies and if possible took print out of it and daily read few medical terminologies uh read few prefixes suffixes okay so that uh you'll go through it and you'll know most of the medical terminal ologies right I'll going to give you many examples which are commonly used okay let's start with the basic word Parts okay you might have thinking that we can use Google for medical terminology to find meaning of any word if you didn't didn't understand the meaning of it right am I right yes that that we can do but ultimately you can't re can't search for each and every term on Google because it will take much time to search each and every term and while working as a medical coder your uh you can't waste your time because medical coding jobs are productivity based you must complete your daily Target if you if you go and look up for many terms each and every time it will slow down your productivity correct so that's the reason why you need to know at least basic medical terminologies which are commonly used in Health Report okay so the foundation of medical terminology is rooted in learning the basic four basic World Parts okay which are prefixes root words suffixes and combination uh or combining forms the most medical words have a beginning middle and an end okay the beginning is the prefix whereas the middle is the root word and the end is the suffix beginning is called prefix middle is called root world and end is called suffix right the com the combining Vel those are mostly used combining vels are o or i Etc it uh is used between two word roots or between a word root and a suffix to ease the pronunciation okay the Vel combining vels mostly use combining vels are o or I these are either present between two root words or between one root word and suffix to ease the pronunciation so that you pronounce that medical terminology easily for example for example you can see this word Earth oathy Here Earth Earth is one word whereas o is combining W again pathy is another word okay if there is no o how will you going to pronounce this word orthopathy sounds weird right so orthopathy you can uh pronounce it easily because of this combining Vel o again here you can see hepatic word here hipat is one word mean or root word whereas I see is at the end which is suffix okay but IC is begin with w i that's why here uh there is no requirement of any other V because I is already there in I suffix okay then the understanding terminology in involves breaking words down into their separate components of prefixes suffix and root word and possesses a good working knowledge of those words if you uh don't know about any or if you come across any uh new word or new medical terminology then what you have to do you have to know how to break up those word in prefix seix and root word okay and also you have good working knowledge of those parts you know you must understand there you must have knowledge about their meaning also then and then only you can understand meaning of that whole medical term you can see one example hypothermia here hypo is prefix THM is root word whereas I is suffix if you if you don't know even if you even don't know meaning of this word this medical term hypothermia after after you break this uh term into hypo and EA you can easily understand the meaning because hypo is because hypo is below normal and THM means heat whereas I means condition so the meaning of this term is the condition where uh in which body temperature goes below normal range correct so likewise you have to break your medical term now we'll see root words root means subject the main subject of that word okay the main part or Foundation of a word is called root word all words have at least one root word correct because that is the main subject without root word there is no any medical terminology a word root may be used alone or combined with other elements to form a complete word the root the root word root usually refers to a body part some root words are derived from Latin or Greek language okay that's the reason why you uh you have to understand the meaning of those word you have to go through different different medical terminology okay because also if you are going to take this taking this medical coding certification exams for uh medical coding they will not allow you any medical dictionary or use of Google even though these exams are uh open book exams right so to be able to pass this examination you must possess good working knowledge of medical terminology which are present in those 150 questions because this mostly this certification exam uh I have given CPC certification exam so I know that uh CPC uh certification exam consist 150 questions which we have to complete within 4 hours though it is open book exam you have to uh manage your time to complete your paper okay because uh if you have good working knowledge of for this medical terminology Anatomy then and then you can cover your paper because most of the question they ask are based on medical terminology only means uh they included Medical terminologies in question okay so that uh they test your medical terminology knowledge in order to lead you to the right medical code okay so we'll see one example again hyper hyper thyroidism okay if you break down this word into hyper thyroid and ISM here you can see thyroid is the root word okay thyroid means thyroid gland then hyper is prefix okay and the meaning of hyper is higher than normal hypo means higher lower than normal where as hyper means higher than normal okay and eam is suffix which is used for condition okay so the meaning of hyperthyroidism is thyroid gland makes more thyroid hormones okay now we'll see combining forms a combining form is simply a root that includes one or more vels tracked onto the end of it to make a root suffix combination pronunciation uh pronunciation okay so the combining form is simply a root that include one or more Vel at the end of it to make root suffix combination pronunciation okay for example psychology the main root is in Psychology the main root is psych means mind and the suffix is logic means study of okay but if here this o is not present okay this Vel o is not present then this world will be uh psychology doesn't flow as well as psychology right does we insert the o to create a more English sounding word right this is the use of combining form or use of Vel to make it more more easy to pronounce so as the example shown the comb combining form concept is all about vels consonants and pronunciation okay now we'll see few example examples of root words these are uh few root words used for organs different organs like uh here we'll use safe word for head okay whereas NF is used for brain okay inside the head what present brain so infe okay then ocul or oculo you can see o is written inside the bracket because it is used in few terms okay few terms consist only ocul so a few terms consist oculo also so ocul means I cardi or cardio means heart again uh Gast or gastro means stomach whereas Rhino means nose hipat or Hipp means liver whereas po means large intestine like this there are so many root words present in this medical word okay now we'll see few root words for heart and blood vessels which are commonly used at least you have to by heart this few root words which are commonly used okay so the him or himo or Sango sorry sangu is used for blood aort is used for aort then card or cardio means heart artery or arterio means arteries NGO or NG means blood vessels then when or Veno or pleb or pleo means V now we'll see few important root words regarding head head means safe whereas brain means infe okay okay Rhino means nose tan or meringo used for eard drum okay odont or dento is used for tooth lingu is used for tongue okay then Oto is used for ear whereas opthalm or oculo is used for eyes these are few uh root words for digestive organs hpet or Hipp means liver poosy means gallbladder then Colo means large intestine whereas ILO means small intestine Gast or gastro means stomach ESOP or esopha means esophagus these are few root words which are important in digestive system now we'll see root words for bone and muscle area Okay mayo means muscles okay mayo means muscles whereas OST or osto means bones dorsa is used for back cost or Costo is used for rib scapo is used for shoulder whereas brei or brachio means arms carp or carpo means wrist again these are few more root words root word we'll see few examples also using this root word where it goes just a minute okay so abdomino means meaning of the abdomino is abdomen so abdominal Gia means abdominal pain arterio means artery so arteriosclerosis means hardening of arteries because SC osis means hardening so hardening of arteries is called arterio sclerosis sorry hello any doubt no ma'am okay uh then cardi or cardio means heart so cardi megali is nothing but enlarge heart or enlargement of heart because meali meaning enlarge okay so next is Derm Derma or dermo or dermat or dermat mean Skin So dermatitis means irritation of skin because itis is irritation okay then inel or inel low means related to brain right if it is it is related to head remember this okay intis is the example of uh uh enal word root word so entis is nothing but inflammation of the brain because itis means inflammation Gast or gastro means related to stomach or digestive okay so gastritis means again inflammation itis is inflammation so inflammation of stomach is gastritis hemat or hemato means blood related to blood so hematemesis means vomiting of blood because emesis means vomiting so vomiting of blood is called hematemesis again my or mayo means muscle so myocarditis means inflammation of heart muscles okay myocarditis here you can see two root words my means muscles and card means heart that is why myocarditis means inflammation of heart muscle okay then oste or Osteo means related to Bone so osteoblastoma means nothing but benign bone forming neoplasm okay Auto means related to to ear so Auto micosis means infection of outer ear okay then pulmon or pulmono means related to lungs so pneumonia is nothing but infection that affects lungs the next one is rhin or Rhino meaning Rel related to nose so roria means runny nose this is common symptom right so runny nose is also known as roria do you know about it okay even if you don't know right now you get understand runny nose is also known as roria okay so sclerosis is the next word sclerosis is nothing nothing but hardening or heart so Scleroderma means hardening of skin because Derma means Skin So Scleroderma means hardening of skin next is therm or Thermo means indicates heat so thermop plagia means heat stroke okay so that was a few examples of root words apart from that they are many too many root words present in this medical uh sector you have to ultimately go through daily you have to go through few root words okay next we'll see prefixes prefixes or prefix is descriptive part of the medical term okay a prefix word a prefix is a word element attached to the beginning of a word or word rule okay it is attached to attached at the beginning of the word or word root adding or changing a prefix changes meaning of the word if you change prefix it will changes meaning of the word the prefix usually indicates a number time position or Direction like uh just we see one example uh hyper thyroidism or uh hypothyroidism here hyper hypo are prefixes okay so if you change uh if you add hyper in in the word thyroidism it is what do it mean increase thyroid okay whereas hypo means decrease or low level so it will change if you change the prefix it will change meaning of the medical term right many of the same prefixes found in medical terminology and are also found in English language okay now we'll see few examples of prefixes alphabetically we going to see few examples a or N means without or lacking so anemia is nothing but blood does not have enough RBS if you have less rbcs or not enough having rbcs in your blood it will call as anemia okay and or Andro means related to male so Androgen is male sex organ okay then anti anti means against okay so antibiotics means the medicines that fight bacterial infection it's called antibiotics because biotics is Rel uh biotics meaning bacteria or bacterial infection then next word is Auto auto means self so autonomy means nothing but self governed then bio bio means life so biology means study of life because logic is study study of something is called logic so biology means study of life then next word is Kim K or chemo so chemistry Kimo means or Kim means chemistry so chemo therapy is the one drug treatment that uses powerful chemic chicals is called chemotherapy okay next one is Contra Contra means against so contraception means device or technique that prevents conception okay then next one is site or cyto meaning cell okay cell is known as cyto so cytotoxic means a substance or process can damage cells okay cytology also cytology means study of sales called cytology likewise these are few more examples this means difficult or abnormal so disia means abnormal breathing because Pia means breathing then U EU u u means good or well soia means healthy breathing breathing disia is abnormal breathing whereas upia means healthy breathing then next word is fiber or fibro this this is mean fiber or fibrous tissue example of it is fibrosis meaning thickening or scaring of tissue then gluco or glyco means related to glucose or sugar so glycogen means stored form of simple sugar then gy or gyo or GIC is related to female so Gynecology is study and treatment of the diseases of woman right then Hydro or Hydro means water so hydris means fluid or uh CSF builds up within the brain okay then Ideo means self or one's own ideopathic means a disease of its own then lice or liis means breakdown or destruction mean uh example is Lis the breaking down of the membrane of the cell is called Lis because lice is breakdown next Mal Mal means bad or abnormal okay this means also abnormal and Mal is also abnormal so m means abnormal an example of M is Mal formed means badly shaped next one is M or Miko so sorry mic or M meaning fungus so Moto Mota means I'm so sorry Moma means disease caused by bacteria or fungi then NEC or necro means death the necrosis mean death of body tissue is called necrosis Neo means new so neonate meaning a newborn child then next one is pan or pant or panto means all or everywhere so pens Petopia means having low level of red blood cells white blood cells and platlets okay then next one is re means against or backward so re Rejuvenation means make fresh or New Again these are few examples of uh prefixes okay you can go through search on Google and you will going to find more prefixes also if you need my help if you need any suggestion from me I'm there to help you okay now we'll see suffixes a suffix is meaning suffix represent meaning of that word okay a suffix is a word element placed at the end of a word or word root that changes the meaning of the word again either you change prefix or you change suffix the meaning of the world is going to change okay changing the suffix change meaning of the word in medical terminology a suffix use usually indicates a procedure condition disease or part of speech okay many suffixes are div derived from Greek or Latin words mostly this uh you can see in this medical terminologies uh most of the words are derived from Greek or Latin words that's the reason why you have to go through different different medical terminology right so three important suffixes are commonly used are algia or logi and itis okay algia means pain okay logi means study of and itis means inflammation okay so these are these three suffixes occur in many medical terms for example when you learn Le a new rout such as the neur or neuro which means null you will know meaning of neurologia Neurology and neuritis so directly you you going to understand three new medical terms if you know the meaning of this algia log and itis because these are commonly used suffixes okay and neurologia means pain in a nerve neurology means the study of nervous system also the speciality dealing with diagnosis and treatment of nervous system disorders and neuritis means itis means inflammation so neuritis means inflammation of a nerve so remember these three suffixes these are very much important suffixes okay now we'll see few examples of suffixes alphabetically if there is a suffix a c AC meaning pertaining to for the example cardiac card means heart related to heart so cardiac means related to Heart then brachial means related to arm so anti brachial means related to to forarm okay then uh site or stic means related to cell so thrombos site means blood cells okay then daa means pain or swelling so thrombos throda means pain in the chest then e or eel means pertaining to esophagal means esophagal is the example meaning related to esophagus then ectomy this is the this is also commonly used suffix ectomy ectomy means cutting out or exision okay cutting out means or exision means ectomy okay oygen and ectomy both having e into it so you can remember it like this because you will find most of the term with this suffixes okay ectomy means cutting out or exision means uh for example the hysterctomy hysterctomy means exision of uterus then Imes means vomiting so colesis means presence of bile in Vitus hamis means present of blood in the next one is isation isation means result or condition or state so cathet catheterization means being fitted with a catheter is called catheterization then ISM means condition so hypothyroid m is the condition when lower level of H thyroid hormones present in your body ites or itis means inflammation arthritis example is arthritis means inflammation or joint because Earth means joint Oro means bone where Earth means joints please remember these differences okay because these These are the points where you can do mistake or you can jumble or means joint Oro means bone okay and itis is just as I say itis is commonly used suffix in many terms okay so itis means nothing but inflammation it means it by it means quality or state so immunity meaning the quality or state of being immune is called immunity em ium em means structure or tissue so epithelium means layer of the cell that line hollow organs and glands okay it's called epithelium then lysis or litic means breakdown or destruction or dissolving so osteolytic means condition where bone tissue is destroyed here you can see Earth means joint and osty means bone okay so please remember these terms osteolytic means condition where bone tissue is destroyed then malaia means softening not Malaysia right it's m a l a c i Malaysia so it is softening so osteomalacia means soft bone disease okay then megali means enlargement so hip means enlargement of liver next is om om o m a means tumor related to tumor so saroma means cancer or muscle or connective tissues okay it's called Sara then otic otic oot t i c otic meaning relating to the ear so diotic means affecting or pertaining to both here because d means both or two right so diotic means pertaining to both ears next is OS o u s means pertaining to example is filamentous means bearing or covered with thread like structure is called filamentous then next word is pathy pathy means disease so neoy means disease of kidney the next one is pania pania means deficiency or lack of so leucopenia means a decrease in number of lucos sites in the body is called licop then fagia or fagi means eating or swallowing example is dysphasia dysphasia is difficulty in swallowing okay because fasia means swall swallowing and this means difficulty so dpia is difficulty in swallowing this is how you have to break down the medical term and uh learn the their meaning okay the next word is or next suffix is FIA that is FIA first one is fagia p h a GI I p a gii means swallowing okay or eating whereas p a si uh a means p h a s i a meaning speech related to speech I'm sorry aasia aasia is the example of FIA so fasia is nothing but difficulty in speaking okay then plaia plaia means related to growth so hyperplasia means enlargement of bodily organ or part it's called hyperplasia now we'll see how we can do word analysis just give me one minute so now we'll do uh and we see how we can do word analysis if you don't know uh meaning of that word okay first example is lucco cytopenia okay we'll have to divide this word like this the word root one is here we have two root words first one is Luke which is meaning White Luke means White and the second root word is site means sail so Luke site means white cell that is confirm okay then the here combining W is O there that's the reason why lucos cyto okay then we have suffix which is nothing but Pia Pia means decrease decrease in amount okay so here we uh break down this term as Luke o site o Pia so the meaning of this Lucy cytopenia term is decrease in number of white cell is it like this you have to break down the word or the medical term into different parts different word Parts like prefix suffix root word combining W and then you will easily understand meaning of that medical term okay now it's your turn I'll give you one this uh this medical term you going to tell me I want answer from you right it is okay if you are wrong don't worry just try to tell me how will you going to analyze this word how will you going to break this word hello yes ma'am yeah try it this is very easy word and right now we go through this both words try to break this medical term is the prefix ma'am mhm correct andma dma is the suffix okay and what is the meaning of this word rather than than just breaking you need their meaning meaning of those words scare meaning or at least you can say what is meaning of Derma skin skin diseases correct so Derma is skin related to skin uh sorry skin and scare means hardening okay and here combining Vel is O that's the reason why it we can pronounce it properly SC Scleroderma right so here root word is Clare okay scare means hardening and combining Vel is O whereas suffix is derma means skin okay so the term we divided as scare o Derma okay so the meaning of this medical term is hardening of the skin okay next word is electrocardiogram belongs to the heart ma'am yes correct because of which word AO correct then how many vels present in this term first look look out for vels so that you will going to easily break down this term the common W will which will use for medic using medical terminology W that is O right so we have only two o here elect o card o gr we have two two WS so our word is divided as elect o cardr here first root word is electri means related to Electric whereas the second word is cardi as you say cardi means heart and next lastly suffix is gram gram means a written record so the term divided as elect cardiogram so the meaning of this electrocardiogram word is or medical term is record of heart's electric activity is called electrocardiogram okay this is how you have to analyze the word so that it is easy to understand meaning of that medical term understand try practicing try to go through different different uh medical terminology so that it will be easy for you okay and try to first uh look for combining W okay so this is all about how we have to do word analysis the key to learning medical terminology is to learn prefix suffix and root words again abbreviations and when you learn this you combine them together to figure out all of the different terms knowing the prefix suffix will really going to help you to make strong Foundation that you can pretty much piece your any term together okay if you have good knowledge of medical terminology or prefixes suffixes root words different abbreviations human anatomy you can divide any word any medical term easily okay now we'll see few medical terms which are commonly used in uh Healthcare System okay what is medical terms these are the words that are frequently used among practitioners or nurses or you can say doctors okay so ultimately doctor are using means you have to go through these terms while you you are uh reading the patient Health Report correct that is why you need to learn the medical terms the commonly used medical terms are acute acute means uh signifies a condition that begins abruptly and it is sometimes severe but the duration is short is called acute Okay means any any condition begins abruptly or it is sometimes severe also and duration is short that condition is called acute condition then benign benign means non-cancerous if the tumor or that tumor is non-cancerous uh doctor will say benign tumor okay meaning of it is that tumor is non-cancerous then next word is biopsy there there are see there are many words start with a or medical term starts with a here I can't uh I'm not able to collect all of them okay I just give one example okay okay you have to go through Google and different medical books to learn these things okay then biopsy biopsy means a small sample of tissue that's taken for testing okay generally in case of uh cancer of or if doctor doubts that any case is cancer related they will suggest for biopsy where a small sample of tissue taken from your skin for for testing okay then next one is chronic chronic signifies is a recurring persistent condition like heart diseases okay chronic conditions are recurring and persistent conditions right then next one is defibrillator defibrillator it is an apparatus used to control heart fibrillation by application of an electric current to the chest wall or heart mostly we have seen this type of this defibrillator in TV mostly in movies or in Cals right that is that instrument is called defi relat then edema edema is swelling caused by fluid accumulation okay if fluid cause due to fluid accumulation it is called edema edema edema is not edema and uh soft tissue swelling is are both are different terms okay and we have uh different codes for those conditions okay we have different code for anema we have different code for soft tissue swelling okay so keep it in mind that this thing edema is caused by fluid accumulation it is type of swelling but it is caused by fluid accumulation right then embolism means and arterial blockage often caused by blood clot is called embolism okay then fatig is a feeling of weariness uh tiredness or lack of energy is called fatic then we have impatient impatient means a patient who requires hospitalization or who is admitted in the hospital for at least 24 hours a day that patient is called impatient okay then we have intravenous intravenous indicates medication or fluid that's delivered by V then we have malignant which indicates presence of cancerous cells malignant means presence of cancerous cell whereas benign means non-cancerous if the cancer is or if the tumor is benine that tumor is non-cancerous if the tumor is malignant that means that is that consist cancerous cells okay then Medicare Medicare means uh refers to a government health insurance plan for adults older than 65 or individuals with a disability okay whereas Medicaid it is another type of government health insurance that helps low or limited income families with the cost of health insurance okay we're going to discuss about this Medicare and Medicare Medicaid Insurance in further sessions also because this whole us Healthcare System goes around this terms only because we are working for Medicare and Medicare patient that's why you need more understanding about these terms okay then outpatient outpatient is a patient who receives care without being admitted to a hospital okay then relapse relapse means return of disease or symptoms after a patient has recovered that is called relapse so these are uh some medical terms which are commonly used okay now we'll see some medical abbreviations and acronyms what is meaning of abbreviations and acronyms can you tell me hello headings ma'am yeah acronyms and uh abbreviations means shorthand version of common medical terminologies okay or you can say short forms like this these are few examples of abbreviations commonly used in medical coding so ALS means Advanced life support is called ALS then BMI BMI means body mass index then we have BP BP means blood pressure then CRF CRF means chronic renal failure or uh we have also CKD chronic kidney disease okay then DM means diabetes mtis then Ed or ER meaning emergency department or emergency room it's called EDR ER the coder uh who is working in means coded charts from uh emergency department are called Ed in Ed coder okay then EKG EKG means electrocardiogram then we have HR HR means heart rate then ICCU ICCU is nothing but intensive coronary Care Unit intensive coronary Care Unit means ICCU whereas ICU means Intensive Care Unit right lbw lbw means low birth rate it's called lbw MVA means motor vehicle accident or we also have MVC MVC means motor vehicle crash okay then we have NICU NICU means neetal Intensive Care Unit it's called ncu then we have preop preop means preoperative so these are few uh abbreviations used in medical terminologies okay so my uh I want to one request to you please go if you want to be a medical coder if you want to be in this field us Healthcare field and work as a medical coder please go through these different different medical terminologies by using uh Google or any medical related books or dictionary okay if you need my help if you need my suggestion uh which site it is good for referring this terminologies and all I am there to help you ask me I will tell you okay but go through it and try to recollect recollect it okay try to uh bring take out the print out of those pages so that you can go through them daily okay so lastly thank you for your attention and making this uh session very interactive okay if you find this uh session uh my teaching interesting if you want to learn more about medical coding if you want to join our medical coding uh course then please go to the given link below which is www.great onlinetraining tocom and register yourself bye-bye take care so hello everyone welcome to grade online training myself Nikita I'm a CPC certified medical coding trainer in grade online training this is day five today we're going to discuss about business of medicine what do you think what will be going to discuss in this session what do you think what is meaning of business of medicine anyone all right uh business of medicine is nothing but you can say it is the administrative side of medicine or uh healthcare industry okay here we're going to discuss about uh future scope or career opportunities in medical coding if you see medical coding as your professional career then what are different possibilities okay uh then we'll see uh different kinds of payers different kinds of uh providers okay and other rules and regulation regarding coding okay uh different kinds of insurance provider that we going to discuss in this session okay so we'll see what are the different topics we'll going to cover in this class today we'll see uh coding as a profession then we'll see hierarchy of providers then the different types of payers then we'll uh understand RB RVs then medical necessity then the advanced benefit in notice it is also known as ABN then the need for privacy and security then we'll see covered entities of HIPPA remember I uh told you about Hippa hia regulation that we going to discuss in today's session uh then Hightech and its impact on Hippa then we'll see Fraud and Abuse and their examples and lastly we'll see some acronyms okay so first coding as a profession as of now I hope you get better understanding of uh what is medical coding and what are the different career opportunities in medical coding so can you please uh can someone tell me what is medical coding anyone anything you learn from uh previous sessions what is medical coding okay uh fine I'll explain you again uh medical coding is a process of taking Patients health information which can be any diagnosis uh symptom illness anything or abnormal finding uh from patient report or any medical procedure whether it can be diagnostic or surgical procedure any any procedure details patient undergone or any medical necessity medical equipment or any other Medical Services the patient took that we have to uh took from physician or we can say we have to extract extract that information from patient Healthcare uh report and then we have to con as a medical coder we have to convert that information into uh medical code which are uh accepted worldwide okay and which are numeric or alpha numeric CES okay uh so this process is called this process of conversion of uh medical or Healthcare information into medical course is called medical coding Right medical coding is Technical and rapidly uh changing field that offers practition us a variety of career opportunities like we discussed in previous sessions also right if you uh choose us Healthcare uh is your profession or if you have decided to work in US Healthcare field then you have many options right you can work as a medical coder you can work as a medical biller you can work as a medical transcriptor uh or ar caller denial coder or any compliance manager or different different position there are many positions available in this field but if you choose medical coding particularly medical coding as your profession then you have variety of career opportunities uh for instance skilled medical coders may become consultant remote medical coder or medical coding trainer or you can say medical coding educator or medical coding Auditors right also you can become a TL and manager uh as you gain more and more experience right coding as a profession has evolved over the past several decades and will continue to do so as the business of medicine embes uh new technologies Cod set new code sets and payment methodologies okay and I think medical coding is very good opportunity for those who are just completing or about to complete their graduation because this is the only one uh field where you can directly start your job as soon as you completed your graduation right so this is the main or advantage of this profession okay uh and soon after your completion of your graduation you get chance to work with doctors you get chance to work for doctors and those doctors who is working in us so I think this is very good opportunity right now we'll see coding as a profession okay each time an individual receives healthcare service a record is maintain of a resulting observations medical or surgical interventions diagnostic tests and studies and treatment outcomes okay coding is a process of translating this written or dictated medical record into series of numeric and alpha numeric CES right there are separate code sets to describe diagnosis medical and surgical services or procedures and supplies we uh we discussed this uh in previous sessions also in first step in medical coding right uh what are those for impatient coding uh we focuses on Physician Services and care provided while patient is being admitted in the hospital right uh in patient coders will focus on learning ICD 10 PCS and ICD 10 cm codes ICD 10 PCS codes are used for inpatient procedure coding while ICD 10 cm codes are used for Diagnostic coding where icd1 codes are common for whether it is in patient or outpatient any patient okay iidd 10 codes are common for all types of patient because these are disease cods okay disease symptoms uh illness abnormal finding course okay just difference is ICD 10 PCS code are used for procedure coding on inpatient Okay so so if you want to become a inpatient medical coder you have to uh take to training for ipdg okay where you you get trained with ICD 10 PCS and ICD 10 cm course okay otherwise if you uh take only medical coding training you'll get uh train on ICD 10c M which are used for Diagnostic coding then CPD code and hcpcs code okay so again inpatient coders also will assign medical severity diagnosis related groups Ms drgs also known as Ms drgs so again if you want to choose ipds as your coding specialty and you are going for for ipdg training then there you will get trained with msdg ICD 10 PCS and ICD 10 cm course okay then outpatient coding focuses on medical uh sorry outpatient coding focuses on physician Professional Services and outpatient facility coding okay outpatient coders will focus on learning CPT hcpcs level two and ICD 10 PCS uh sorry icd1 CM course okay generally in medical coding training you will get trained on CPT hcpcs level two course and ICD 10 cm course okay CPT CES are also known as can anyone tell me CPT course are also known as try to give answer it's okay if you are wrong just give me answer anyone and proceed the no no I'm asking scpcs are level two course CPT CES are also known as these are level one course okay hpcs hcpcs are level two course whether CPT course are level one course so they also known as level one code okay fine then regardless of the setting means any specialty you choose code updates and insurance payment policies may change as often as quarterly okay that's the reason forers require continuing education to stay a breast of these changes okay so you have to be continue learning your learning process should be continuous uh to get updated in this field because ICD 10 CES are get updated uh every year in October whereas CPT hpcs CES are updated quarterly okay now we'll see the hierarchy of providers now you tell me who who is provider earlier we discussed about RCM cycle revenue cycle management right that time I told you uh we discuss about provider patient and payer so who is the provider to prepare a standardized a bill for services given to a patient correct so a provider is any doctor whether physician or non- physician anyone uh whether it is MD or do anyone can be a provider who is certified to give Medical Care to the patient right whether it can be MD uh do or radiologist anesthesiologist pathologist anyone can be a provider or uh again uh midlevel providers Al also there which include practitioners or nurses right so we'll see hierarchy of providers a variety of medical providers uh provider staff physician offices and hospitals including Physicians and non-physician providers non-physician providers also known as npps okay npps NPP not npps npps non- physician providers such as uh physician assistant and nurse practitioners npps are often reimbursed at a lower rate than Physicians and require Physicians oversight correct different providers have different levels of education and each state has scope of practice guidelines for various provider levels if provider is physician uh if he's MD medical doctor or if he's do then they uh complete their study uh like four years College four then four years of medical school then 3 to 5 years of residency residency means training in speciality of practice okay then uh if they have mid level of providers they include physician assistant PA also known as PA then nurse practitioner also known as NP and both PA and NP both called as physician extenders okay these are licensed to practice medicine with physician supervision okay and provider obviously provider is highly skilled Highly Educated uh I'm sorry the physician which is MD or do is highly qualified and they have higher skill skill sets that's why they reimbursed at higher rate than the npps or uh physician extenders okay because of their education so this is the hierarchy of providers now we'll see the different types of pairs pair means who is pair the amount to be paid to the provider U sorry come again to determine the amount to be paid to the provider no no payer is the one who is going to pay to the doctor right this is not related to amount I'm asking you who is pay okay it can be uh patient itself or insurance provider okay who will going to pay to the doctor although some patients will pay in full for their own medical expenses most patients will have some type of insurance coverage what happen in India we have uh few of us have insurance right we have covered under insurance but uh to Avail those insurance benefits we need to get admitted into the hospital right for at least 24 hours then and then only we are eligible to get those insurance benefits right but in us uh what happened their cost of living their cost of service their cost of pro procedures their quality of procedure is way too high than India that's the reason why they they have buy insurance or they pay some amount as a premium to the insurance company right and most of the people in us uh will covered under some form of insurance either private insurance or government insurance okay and that's the reason why uh there in us they even though that is small outpatient visit that is also covered under those Insurance okay which is not happen in India in India we are our small outpatient visit is not covered under insurance right only if we get admitted into the hospital for at least 24 hours we'll get insurance benefit but in us even though you go for normal fever or cuff and cold then also insurance company will going to pay on the behal of you okay so there are two primary types of insurance or Insurance commercial and government first we'll see Commercial Insurance uh these are private payers that may offer both group and individual plans the contracts they provide vary but may include hospitalization basic and major medical coverage for example Blue Cross Blue Shield organizations are private payers who usually operate in the state in which they are based okay Blue Cross Blue Shield is most of the private insurance okay now we'll see government insurance there are two types of government insurer Medicare and Medicare Medicare and Medicare okay first we'll see Medicare Medicare is a federal health insurer program administered by centers for Medicare and Medicaid services also known as CMS centers for Medicare and Medicaid services that provides coverage for people over the age of 65 years or blind or disabled individuals and people with permanent kidney failure or endstage renal disease andal disase also known as ESRD okay so please make sure that if you want to make your career in medical coding Please be aware of this Medicare and Medicaid difference between Medicare and Medicaid okay because uh surely you your interview are going to ask you this question what is difference between Medicare and Medicaid okay so Medicare is uh federal health insurer program which provide coverage for people over age of 65 years okay or blind or disabled people or people with permanent kidney failure or esid okay there are uh the Medicare program is made up of four parts there are four parts of Medicare okay first one is Medicare part A Medicare part A covers inpatient hospital care as well as care provided in skilled nursing facilities hospit care and health uh home healthare okay healthare part A covers impatient hospital care okay then next one is Medicare Part B Medicare Part B covers medically necess necessary Physician Services outpatient care and other Medical Services outpatient care and other Medical Services not covered under Medicare part A you can see here here Medicare have made up of four parts okay part A which cover impatient Hospital care Part B which covers outpatient care okay so here Outpatient Care is also included in Medicare then third one is Medicare Part C also called medic Medicare Advantage because it combines benefits of part A and Part B and sometimes Part D also okay so part C Medicare Part C is combination of other three three parts okay part A Part B and sometimes Part D also so if uh patient wants to get benefits of both the parts means in patient care also and Outpatient Care also they have to choose Medicare Part C sorry then fourth one is Medicare Part D which is related to prescription drug program available to all Medicare beneficiaries okay these are related to drugs okay so again Medicare part A covers inpatient hospital care Medicare Part B covers Outpatient Care Medicare Part C covers uh benefits of other three okay and Medicare part DE covers drug prescription okay this is the differentiation between four of them part a hospital coverage impatient care in hospital including critical exess and long-term care hospitals then Part B covers uh doctor's services and outpatient care when medically necessity then part C covers it is also known as Medicare Advantage plan includes all of part A Plus Part B as well as extra benefits like Part D also sometimes and next part D is prescription drug coverage Avail available in Standalone plans or as part of Medicare Advantage okay so uh please note of this part A covers inpatient care Part B covers Outpatient Care part C cover benefits of part A plus b and sometimes Part D also and Part D covers drug prescription understand any doubt hello H okay so now we'll see another uh type of insurer government insurance which is Medicade okay Medicade this is Health uh this is a health insurance assistance program for some lowincome people supported by federal and state governments okay this Medicare program is for lowincome people Medicare is for above 65 year old or physical physically blind or disabled people right but Medicaid is for lowincome people and this is sponsored by federal and state governments it is administered on a state by state basis but State programs must are to certain federal guidelines okay state by state their rules get changed okay state funded Insurance programs providing coverage for children up to 21 years of age may include Children's Medical Services made uh children's Indigent disability services and children with special Healthcare need and others okay now we'll see difference between Medicare and Medicaid please make note of it because this is most important part in uh medical coding you surely get question on this point Medicare and Medicaid governance federal health insurance program Medicare is federal health insurance program strictly governed by federal government okay whereas Medicaid is join medic uh federal and state program but governed by state governments okay eligibility criteria for Medicare 65 year or older for the older than 65 years okay under 65 with dis uh certain disabilities blindness or any other disabilities okay if below 65 year old then any age and who have end stage renal disease or uh any other other diseases life-threatening diseases okay then Medicaid Eligibility criteria is individual and families with limited income and resources are covered under Medicaid then coverage includes for Medicare inpatient care Skilled Nursing Facility uh these are covered under part A then outpatient and some uh preventive care covered under Part B and prescription drugs covered under Part D okay and part C include all of these three okay whereas uh coverage include for Medicaid is inpatient care Skilled Nursing Facility Outpatient Care in federally qualified Health Centers and Rural health clinics okay then costs for Medicare cost depend on the coverage means means uh which part you are choosing for your coverage it depends on that how much it will cost for you then uh Medicaid cost depends on the individual's income and the rules rules policies and proced proces in the given State each state has their own Medicaid rules okay so this is difference between Medicare and Medicare the major difference is at least you have to remind that Medicare is uh for 65 year or older than that people or if under 65 year age then with certain disabilities or lifethreatening diseases like ESRD okay and Medicaid is for low income family that's the difference between Medicare and Medicare now we'll see what is rbrvs okay this is medicare payment for Physician Services are standardized using a resource based relative value scale resource based relative value scale which is nothing but RB RVs this scale is used for uh determining the payment for Medicare okay Medicare Physicians okay the resource cost are divided into three components physician work practice expenses and professional liability insurance okay you might have thinking what is the importance of learning all these terms but if you are going for in Daily medical coding you may not uh need to use this all of this but if you want to go for medical coding interview or most important if you want to go for medical coding certification exams then you going to get at least five marks question on this topic or on this chapter which is business of medicine okay and these questions are straightforward question you will get uh answer directly on in your book if you know it properly okay okay so that's the reason why this is the important uh chapter okay so rbrvs are depend on Physicians work phys practice expense and resource based professional liability insurance also known as P physician work is measured by by the time it takes to perform the service the technical skill and phys physical efforts the required mental effort and judgment and stress due to potential risk to the patient okay means uh complicated surgery if surgery is complicated the value is more right physician have need more technical skill physician has to do do more physical efforts mental efforts judgment and tress is also more if it is threatened to that surger will surger will going to threaten to Patient life like then second is practice expenses practice expense relative value are resource based and differ by site of service for example the expense of providing a service in hospital may be different than the expense of of providing same service in a physician's office okay if service is provided in Physicians office the expense May def differ than service provided in hospital correct then third one is the resource based uh professional liability insurance PL this component accounts for 4% of total Rel ative value of each service okay you no need to buard this all this term you just have to remember the full form of rbrvs okay other things you will going to get in the book then we'll see what is medical necessity so the medical necessity refers to whether a procedure or service is considered appropriate in a given circumstances okay medical necessity refers to whether a procedure of service is considered appropriate in a given circumstances or not okay generally a medically necess necessary service or procedure is the least rad radical service or procedure that allows for effective treatment of the patient complaint or condition okay medical necessary services or procedure are important Services which allows for effective treatment for patients complaint when a physician provid us services to a Medicare Medicare beneficiary he or she should build only those services that meet the Medicare standard or of reasonable and necessary for the diagnosis and treatment of a patient okay there are two types of coverage determinations within Medicare national and local okay two types of medical coverage determinations which are national and local first one is National coverage determination NCD also known as NCD National coverage determinations these are applicable Nationwide in the US to spec to specify the Medicare coverage of certain Services all Medicare contractors have a follow the ncds okay means if uh physician perform some procedure okay the diagnosis should be covered under that procedure okay that is called medical necessity that can be nation National or local okay second one is local coverage determinations also known as LCD local coverage determination these are made based on medical necessity and are relieved by Medicare contractors LCDs are applicable only to the contractor's region as these are local coverage determinations okay these are applicable only to the contractor's region okay in cases where an item or service is not covered by NCD the local contractor has to take responsibility for the decision for its coverage okay if any service or proc procedure or any atem provided to the patient is not covered by NCD National coverage determination then local contractor uh it's responsibility of local contractor uh for the decision of its coverage okay non-medicare or you can say commercial payers May develop their own Med uh medical policies okay the advanced beneficiary notice also known as ABN Advanced beneficiary notice and ABN is a written notice from Medicare given to you before receiving certain items or Services notifying you that Medicare may deny payment for that specific procedure or treatment okay this is is uh you can say return notice from Medicare given you before receiving any item or service anything okay to notify you that Medicare may deny payment for that specific procedure or treatment okay the ABN list the item or services that your doctor or healthc care provider expects Medicare will not pay for okay along with an estimate of the cost for that item or services and the reason why Medicare may not pay okay ABN Leist the items or services that your doctor or healthcare provider expects Medicare will not pay for along with estimate of cost okay cost for items and services and reason why medic care may deny your payment okay this is called AB which is nothing but return notice from Medicare given you before receiving any item or services to notify you that Medicare may deny payment for that particular service or treatment the need for privacy and security Hippa remember Hippa Hippa means nothing but health insurance portability and accountability act health insurance portability and accountability act Hippa Hippa protocols regulate the information and transmission of patient health records data this system requires Healthcare Providers to implement data security uh data security measures so they fulfill the regulations from the government prevent any kind of theft of any information stored on Healthcare record and guarantee patients privacy okay Hippa coding is one such regulation of the Hippa system that is designed to instruct medical coders on how to follow fair and honest data use uh data usage when of coding and how to keep Patients health record safe and secure basically this IA coding is regarding keep the patients Healthcare information private okay how you can keep patients patients Healthcare record safe and secure okay Hippa teach you or Hippa educate you on that to keep the Patients health record safe and secure you can't leak any patient information any or with any other company or any other person okay covered entities of HIPPA covered entities under Hippa are individuals or institutions or organizations that transmit protected Health in information electronically in transactions for their uh for which the Department of Health and Human Services HHS has published standards okay uh covered entities of HIPPA means uh who are eligible to use the uh eligible or trans who are allowed to transmit the patients uh health information data the entities the covered entities are providers which include hospitals Clinic nursing homes doctors or pharmacies okay they can use patients uh health insurance uh health information data and uh trans uh transmit them okay in protected manner then Health Plans hm uh private company government and veter in uh Insurance Etc then Clearing Houses which processes and transform data for a healthcare organization okay then Associates which perform functions for Hippa entity that involves the use or disclosure of Phi patient health information Phi means patient health information okay then subcontractors which receives uh maintains or transmits Phi means Patients health information on the behalf of a business associate okay like uh we as a medical coder we also need to use uh patients Private health information right so we are also covered under Hippa then just a minute Hightech and its impact on hipop now we see what is Hightech okay the health information technology for economic and clinical Health act or also known as Hightech Hightech means health information technology for economic and clinical Health Act was enacted as a part of American Recovery and reinvestment act of 2019 uh 2009 which is also known as a a American Recovery and reinvestment act of 2009 okay the Hightech Act was introduced in 2009 in United State of uh United States to strengthen Hippa privacy and access goals okay to strengthen uh Hippa privacy and access goal Hightech comes in picture Hightech Act was introduced in 2009 okay Hippa introduced more than a decade ago in 1996 okay in 1996 Hippa was introduced where uh and that Hippa regulations wasn't written with the explosion of internet and web applications in mind okay at the time in 1996 uh internet explosion different web applications are not in use right so uh that Hippa return without keeping in mind that uh explosion of internet and web applications okay so the Hightech act plugs the technology Gap and take responsibility of securing Patients health information on healthare organizations and related entities with access to Patient health information okay to fill the Gap technology Gap the Hightech Act is introduced okay Hightech also mandate that organizations notify Health Plan members or practition uh or patients if their files get Bridge their file get Bridge the Hightech also mandate that organization must notify Health Plan members or patient okay now we see fraud what is fraud fraud is when some uh someone knowingly gives false information that allows someone to get a benefit that is not allowed okay fraud means when someone knowingly gives false information that allows someone to get a benefit that is not allowed okay examples of fraud uh like double billing okay means submitting multiple claims for the same service is an example of fraud again uh Phantom bilding uh also meaning billing for a service visit or supplies the patient never receive okay which is also example of fraud then unbundling submitting multiple bills for the same service remember I uh told you about uh modifiers right at the time I told you that we as a medical coder or in the medical bill we can't assign same CPT code more than once okay and if we need to we have no choice we have to use uh only one CPT code twice or Thrice okay or more than one time then we have to openend proper modifier otherwise the claim will denied or get rejected okay but uh some person who her uh intention is to make a fraud they uh submit multiple bills for the same service okay and that is example of fraud then upcoding billing for a more expensive service than the patient actually received okay then bogus marketing convincing people to provide their health insurance information number uh sorry health insurance identification number and other personal information to Bild for non rendered Services still their identity and or enroll enrollment uh them in fake benefit plans okay bcus marketing means convincing people to provide their health insurance identification number and other uh personal information to bill for uh or to bill for non- render services or steal their identity okay or enroll them in a fake benefit plan then uh next example is identity tip or identity swiping means using another person's health insurance or allowing another person person to use your insurance okay that is also example of fraud so the fraud is when someone knowingly gives false information that allows someone to get a benefit that is not allow this is called fraud now we see abuse abuse is when someone knowingly take actions that result in unnecessary cost or service abuse is when someone knowingly take actions that result in unnecessary cost or Services example of obuse is uh are incorrect use of medical codes okay use of wrong medical code is example of abuse if you assign more complicated code obviously patient it will C cost patient higher value okay but that is not correct that is called abuse okay charging uh excessively for services or supplies okay then uh billing the brand name instead of generic name of a drug to gain an unfair o AG because generics are 80% to 85% less expensive than the brand name okay then upcoding is when a provider assign a in inaccurate billing code to a medical procedure or treatment to increase reimbursement okay sometimes what happen the provider also code directly give you code okay rather than uh giving whole description of the CPT there they also code the report and as a medical coder your job is to audit that report a it those scores okay and that uh in that cases some provider also assign inaccurate billing code to the pro medical procedure or treatment to increase reimbursement that is example of abuse then last is uh unbundling in the coding service es unbundling takes place when a provider files separate CPD codes for each treatment despite the fact that a relevant integrated CPT code covering the entire procedure is usable means uh instead of using the combin CPT okay the uh in procedure coding in CPD coding few procedure have combined code also okay means if there is uh bilateral uh knee CP knee x-ray was done okay but doctor is the what can I say doctor or provider files separate CPT for them okay separate CP for uh knee right knee and separate CPT for left that will cost more okay rather than combine CPT this is also example of abuse so abuse is when someone knowingly take actions that result in unnecessary cost or Services okay if you are going for medical coding certification exam you're going to uh means uh that exam include at least five question five mark question on this topic okay which is business of medicine and these questions are straightforward question okay you'll get their answer directly in your book as this exams are open book uh exams you'll get their answer in book itself just you need to go through your ICD CPT all the books Okay so that at the time of exam you must have to know where you can find your answer okay so don't worry if you didn't understand some part of it it's okay okay just try to uh recollect the um measure what can I say full form of those short forms okay like Hippa uh uh other the difference between Medicare Medicaid and like this okay now we'll see some acronyms here you can find all the full forms of the shortcuts okay or you can say acronyms ABN means Advanced beneficiary notice of non- coverage you can get question like this also ABN means what what is the full form of ABN and you get four options you have to choose one option okay so ABN is Advanced beneficiary notice of non- coverage then AMA is American Medical Association APC means ambulatory payment classifications a r r a means American recover recovery and reinvestment act of 2009 American Recovery and reinvestment act of 2009 you may get question like this in which year a Act is uh published okay then ASC ASC is ambulatory surgical centers then CF conversion factor is known as CF CMS is centers for Medicare and Medicare services this is commonly used acronym CMS centers for Medicare and Medicare Services then CPC is certified professional coder CPT is current professional terminology okay then drg is nothing but diagnosis Related Group this is related to in patient coding okay then EHR means electronic health record is nothing but EHR em or enm means evaluation and management this is also one type of specialty okay medical coding specialty gpca gpca means oh sorry gpci gpci means Geographic practice cost index hcpcs hcpcs also known as hipic means Healthcare common procedure coding system then HHS HHS means Department of Health and Human Services then Hippa Hippa means health insurance portability and accountability Act of 1996 please remember this uh year also 1996 okay then Hightech itic means health information technology for economic and clinical Health okay then hmm means hm o means Health maintenance organization Health maintenance organization then ICD 10cm means International classification of diseases 10th clinical modification International classification of diseases 10th clinical modification ICD 10 PCS means International classification of diseases 10th revision procedure coding system okay PCS means procedure coding system these code sets are used for only for impatient impatient procedure coding okay then LCD local coverage determinations then m means Medicare administrative contractor then MP means Mal practice msdg means Medicare severity diagnosis Related Group again MSD also related to inpatient coding NCD means National coverage determinations okay NP means nurse practitioner oig means office of Inspector General office of Inspector General and OCR means office for civil rights office for civil rights then PA means physician assistant PE means physician expense then PFS means physician fee schedule Phi means protected health information protected health information p means professional liability insurance rvu means relative value unit and rbvs means resource based relative value scale so these are few acronyms you have to keep it in mind okay and on this uh chapter you surely get five questions in your CPC examination okay so this chapter is very very important chapter okay then lastly if you have any question you can ask me anyone no question then thank you for your attention no ma'am thank you for your attention and thank you for making this session interactive if you uh want to register yourself for medical coding course with our organization please go on to the given link below www.great onlinetraining decom and register yourself bye-bye take care welcome to Great online training this is day six and today we're going to discuss about overview of ICD 10 cm and we'll divide this session in two parts uh today we'll cover part one and tomorrow we'll cover part two okay uh myself Nik I JBC certified medical coding trainer in great online training and today we're going to discuss about overview of ICD 10 cm okay you know that ICD 10cm we use for coding diagnosis diseases uh or any condition abnormal findings this uh these things we going to code using ICD 10 cm course right and uh we use B book to code icd1 is also known as ICD 10 cm book okay see so today we're going to cover uh following uh topics first introduction then guidelines of ICD 10cm then section one convention which is uh first one is the alphabetic index and tabular index then format and structure of ICD CES then use of CES for reporting purposes then what is placeholder character then seventh character then abbreviations different kinds of abbrevation punctuation how to use uh the word and then other and unspecified CES how we going to use and in which scenario we have to use other or unspecified codes that we'll see then we'll see inclusive includes note inclusion notes exclude notes then ethology manifestation conventions then how to use with uh term C and C alsoo term code also note okay uh default code like this we'll see in this session okay first of all introduction ICD 10 cm is nothing but International classification of disease 10th clinical modification International classification of disease 10th clinical modification also known as ICD 10 cm is used as a source for diagnosis course in United State of America okay this C set reviewed every year okay the C set for the 2024 uh fiscal year applies to Patient discharges and encounters between October 1st October 2023 and octob sorry September 3rd 13th 2024 okay after uh again after October 1st 2024 we'll follow different guidelines means updated guidelines few updations are there will be there each every year okay then World Health Organization wh authorized the publication of the international classification of diseases 10th revision icd1 okay the US developed uh develop a clinical modification for medical diagnosis based on wh's icd1 CMS develop a new procedure coding system ICD 10 PCS for inpatient procedures ICD 10 cm replaces ICD 9 cm volume 1 and two and ICD 10 PCS replaces ICD9 C CM volume 3 okay so uh as I uh told you in previous sessions uh earlier it was ICD nine right and those books are in volume volume one and two for I 9 cm codes okay whereas volume 3 was for uh procedure coding in patient procedure coding now it is replaced with ICD 10 PCS whereas volume 1 and two ICD9 replaces with ICD 10 cm book okay and wh authorized the publication of icd1 CM course okay they update this course every year in the October month center for Medicare and Medicare Services which is nothing but CMS and the International Center for Health statistics nchs two departments within the US Federal Federal government's Department of Health and Human Services DHHS provide the following guidelines for coding and Reporting using icd1 CA okay the guidelines have been approved by the four authorizations the American Hospital Association aha the American health information management association which is nothing but Aima then CMS and nchs okay now we'll see what are those guidelines okay you need to go through these guidelines again and again you will find this guideline in book itself okay but you have to buy heart these guidelines these basic General guidelines okay because uh while coding you have to follow those guidelines and each and every time you will not it is not possible for you to go uh through these guidelines and check correct because uh medical coding is productivity based so you have to manage your time to complete your work whether it it will be your job or it will be in your exams related to medical coding you have to be quick to find find the correct medical code so that's the reason why you need to go through this guidelines again and again and once you used to it you will get by heart this guidelines okay so there are four sections in this uh book Session One includes three primary sets of guidelines which includes conventions General chapter specific guidelines then section two includes guidelines for principal diagnosis selection for non outpatient setting non outpatient means nothing but inpatient okay there are two categories inpatient and outpatient so non outpatient means inpatient settings okay section three includes guidelines for reporting additional diagnosis in non outpatient settings again this session is also for impatient so session two and three are for inpatient coding okay if you want to learn inpatient coding or if you want to go for CCS exam which are specifically for mostly for inpatient coding in that time you will going to learn about session two and session three but as this is the general uh medical Cod introduction General medical coding guidelines we're going to discuss about this session one and session four only okay session four includes outpatient coding and Reporting okay so in this session we'll going to discuss about session session one and session 4 okay this is the table of content I'll show you how ICD 10 cm book looks here this is book by APC okay ICD 10 cm expert diagnosis course for provider and Facilities 2023 this is 2023 Edition okay you can see here some introductory part then you can see the table of content this is nothing but uh what is included in this uh book and on which page you will going to find it that is mentioned okay and these are guidelines this will going to discuss today this is table of content which says uh guideline I said DM official guideline lines for coding and Reporting okay then guideline tips then uh different symbol convention icd1 index ICD 10cm index to decision injuries is on 39 page likewise and then tabular list we'll see what is uh alphabetic index what is tabular index and all okay so today going to discuss about session one which consist conventions General coding guidelines and chapter specific guidelines okay a part is conventions for ICD 10 cm today we we can cover only uh a part conventions for the ICD 10 cm the conventions for I and CM are general rules for use of the classification ation independent of the guidelines these conventions are Incorporated within the alphabetic index and tabular list of the ICD 10cm as instructional notes okay so the first one is the alphabetic index and tabular index what is alphabetic index and what is tabular index okay the alphabetic index as name suggest it is arranged alphabetically okay alphabetic index consist uh their corresponding icd1 CES also it list thousands of main terms alphabetically under each of those main terms there is often a subl list of more detailed term for instance for instance cont uh cataract has Su list of 84 terms okay then the tabular list of ICD 10 codes plus their descriptors is organized Alpha numerically from a00 .0 to Z 99.89% main term which are arranged alphabetically and tabular list uh organize Alpha numerically from A to Z course A to Z course and it is divided into chapter based on body parts or condition I'll show you how it looks just a minute I have to go on page 87 okay so this is alphabetic index see okay ICD 10 cm index to diseases and injuries you can see here uh what are the terms they included on this page okay a a in it starts with a a terms all the a terms you will going to find under this a okay the vertical yellow line appears at the second and four indentations throughout the index okay you can see here this yellow lines standing lines right it means if you can say uh we see one example aberant so under the aberant term or condition abent for adrenal gland you can uh get this code Q 89.1 then uh here you get your one code okay Q8 9.01 then you have to search for this code in tab Lang likewise you have to go for uh your selection of code I said it in course okay it is specified that uh aent AR uh artery and suppose cerebral artery then you have to choose Q 28.3 but you can't choose directly your code from here okay because it may be incomplete code you going to find more instructions about this code about this codes you will found in Al alphabetic index in tabular list okay so always choose start choosing your code from alphabetic index but go and verify that code into tabular index now we'll see how tabular index looks here it is on 692 number page this is how tabular index look like tabular list you can see this this is for disas of I and adnexa code ranges from h00 to h59 okay you can see here different symbols are there each symbol consist different color each uh word consist different color okay there are you can see more more and more colors here right okay so this is how uh your tabular index look like okay so after choosing your code into this alphabetic index you have to go on that code that particular code if you want to go on this uh suppose d61 818 okay you have to go and verify that code into the tabular index okay we'll see uh more guidelines regarding this so this is how alphabetic and tabular index look like the alphabetic index consist of the following parts index of diseases and injury which are shown showed you right now then index of external causes of injury then the table of neoplasm and then table of drugs and chemicals okay now we'll see format and structure of ICD 10 same course the ICD 10 cm tabular list cons contains categories subcategories and course okay characters for categories subcategories and codes may be either letter or a number all categories are three characters categories are of three characters the three character category that has no further subdivision is equivalent to a code for example B20 B20 is complete code because it is not further divided okay sub subcategories are either uh four or five characters course may be 3 4 five 6 or seven characters that is each level of subdivision after a category is a subcategory okay here is the one example these are the this is category and this is subcategory okay the first character is always representing the chapter okay here in this example example the first character is s so s is representative of injuries poisoning certain other external causes related to single body organ okay s alphabet is representative of these terms or this chapter okay then second level is 864 864 so now s86 is representative of injury of muscle faia and tendon at lower leg okay then we have point after this point we have subcategory okay few codes uh consist only category like B20 that is complete code B20 is complete code so uh which only consist three characters but here uh this is injury code okay our this is example of strain code which consists seven characters okay the characters after this point is are called uh subcategory okay first character Zero is for site then this one is for severity then uh next one is for details okay and last character is for extension okay here the zero represents strain of a kill's tendon okay sight kill standon is site and this one represents strain severity strain okay then now if you see s 86.01 which represents strain of right aill standards this is detail okay our uh in this code this code is specific for right side okay right side a tendon this one is representative of right side okay then D is for subsequent encounter okay so this full code representative of strain of right sided aill tendon subsequent encounter okay this is this is the structure of icd1 CM code use of codes for reporting purposes for reporting purposes only codes are permissible not categories or subcategories and any applicable seven character is required okay now we'll see what is placeholder the ICD 10 cm utilizes a placeholder character X okay X is used for placeholder character okay the x is used as a placeholder at certain code to allow for further expansion an example of this is at the PO adverse effect and um under doing codes categories from T 36 to 3 uh sorry t50 okay where a placeholder exist the X must be used in order for the code to be considered a valid code okay if uh some code is completed after seven characters only and you have not not specific character or specific information for six or fifth character but you have to assign seven character okay in at that time you have to use X as a placeholder CMS guidelines states that diagnosis CES are to be used and reported at their highest number of characters available and that three character code should only be used if it is not further subdivided like B20 okay B20 code is not sub further subdivided that's the reason why that is complete code we can use that code B20 directly because there is no further division of that code but uh codes mostly from category t36 to t50 or you can say qus from injury chapter uh which consist of fractures and all that those CES require seven character okay for uh subsequent encounter for initial encounter we need to uh assign particular that alphabetic character okay we'll see that in further slides okay so a code will be considered in invalid if it has not been coded to the full number of characters required including a seventh character if applicable okay let's see sorry let see one example if the diagnosis is unspecified open angle gloma severe stage submit h41 X3 while some gloma course require you to indicate laterality using the six character that's not the case in h410 you can see here in this example they said unspecified open angle gloma s State okay we'll see this example H 4010 X3 we see this we'll go by Loma just a minute okay we have to go on this gloma and here you can see different course okay see here here is example you can see here un specified open angle glaucoma and severe stage okay this consist this x character which for which is used for placeholder use as a placeholder okay because we have no specific I here this code is for un specified I when our provider not specify which I is affected that uh in that case we have to use this code okay the six character is for I you can see here this code is for right I okay here is one for right I here is two for left ey three for bilateral okay but here this is for unspecified ey because we don't know which I is affected but we have to specify the stage we know which stage is there there so we need three we need to assign three but we don't know which I is affected that's the reason why X is used here okay because we need to add three here so this is the complete code understand sorry now we'll see seventh character just I told you certain ICD 10 cm categories have applicable seventh character the applicable seventh character is required for all CES within the category or as the notes in the tabular list instu the seven character must always be a seventh character in the data field mean it's it's at the seventh number of uh in that particular code okay if a code that requires seven character is not six characters okay like just we saw in one example gloma example uh there there we didn't have any uh specification about which I is affected so we use X as a placeholder uh in six six position so that we use seven character for stage right if a code that requires seven character is not six characters a placeholder X must be used to fill the empty characters okay for example o 64.3 xx1 which is for uh obstructed labor due to Bro presentation fetus 1 okay then S 0211 0b type one means in uh in this example we don't have any specific information about these two characters okay fifth and sixth character that's the reason why XX is used here as a placeholder to assign the seventh character okay here in this example s 0211 0b this is full code complete code okay and uh seventh character is B which is uh for open fracture okay type two oal quile fracture initial encounter for open fracture okay then t 17220 d here D is representative of subsequent encouter okay likewise you have to use seven character if that code is uh not six character code means you have if when you didn't have specific information to assign six character or fifth character you will go going to use x in that place okay because if you uh if in this code you will not uh if you want to assign this one because without this one this code is not completed this is invalid code okay if you want to use this one you have to assign XX two times here if further uh specific information about fifth and sixth character is not there in that time okay these are the characters used in case of fracture fracture coding okay seven character A is for initial encounter Clos fracture if Clos fractures in initial encounter is there we'll use a we'll use B for initial encounter open fracture we'll use d for subsequent encounter or fracture fracture routine healing mean if patient come after uh doing just to check healing process of that uh fracture or to change that plaster of the fracture in that case we use d d character in seventh position okay then G is for subsequent encounter fract delayed healing okay K is for fracture non union P is for fracture Mal Union and S is for S okay when seven character is applicable and no fifth and sixth character is applicable placeholder X must be ass set okay because this fracture codes are fracture code should be seven characters only they require this seven character but if you uh don't have any particular information about fifth and sixth character at that time you have to use X as a placeholder okay now we'll see abbreviations NEC NEC is nothing but non elsewhere not elsewhere classified okay not elsewhere classified please if you want to uh go for any medical coding interview or Test please uh go through these guidelines again and again because interviewer will going to ask you question on this these terms these are most important terms regarding your exam also and uh regarding with your interview also okay these questions are asking frequently n EC is nothing but non elsewhere classified these abbreviation in the alphabetic index represent other specified now what is other specified and all we'll going to discuss in further session so the abbrevation NEC means not elsewhere classified is nothing but other specified okay when a specific code is not available for a condition the alphabetic index directs the coder to a other specified code in the tabular list okay if there is no specific code uh is there for par any particular condition in that case the alphabetical index guide you to or directs you to other specified code okay sometime it uh it is indicated as nec okay for example alphabetic index cataract okay tabular index specified NE c h 268 which is cod for other specified cat I'll show one more example here if you go for Mass okay now I want to search code for retr peronal mass retr peronal comes under abdomen but here under the abdomen there is no code for retrop peror right in this in in this case I have to go on the specified site okay if I go here it says other intraabdominal and pelvic swelling mass or and Lum okay and here is the synonyms retr peronal Mass okay likewise you have to choose so the NC is used for other specified code whereas the next one is no NOS is nothing but not otherwise specified this abbreviation is the equivalent of unspecified okay NEC for other specified whereas noos not otherwise specified is for unspecified noos is more commonly used and means the provider did not give you a specific fix okay this is one example tabular list I 50.9 heart failure which is called for heart failure unspecified okay B ventricular heart heart failure noos cardiac heart or myocardial fure noos congestive heart disease congestive heart fill your in okay means these codes are unspecified code you will use you can use this code i50.9 for this following terms because this is unspecified code okay when your uh provider not specifies which type of heart failure is there in that case you have to use this code uh we'll see one example again this Mass only we search for Mass if your provider only says Mass okay abdominal mass in that case you have to go on this code you can see here intraabdominal and pelvis swelling mass and Lum unspecified set okay this is code for unspecified abdominal Mass if your provider only says mass or oh sorry sorry abdominal mass in that case you have to use this unspecified code because your provider not specified any site of that mass okay previously we saw that is for other specified because we search code for our our provider said that it is retrop perom M okay means he give you give us some specific side but there is no particular code for that side that's the reason why we use other specified code but here our provider not stated or not specifies any site particular site in the abdomen that's the reason why we choose this unspecified code for abdominal Mass okay and in case of noos we have to use unspecified in case of NEC we have to use other specified anyc not elsewhere classified is equivalent to other specified whereas in one minute okay NOS which is not otherwise specified is equ equivalent to unspecified clear now we'll see punctuations brackets there are these are used in tabular list to enclose synonyms alternative wording or explanatory phrases brackets are used in alphabetic index to identify manifestation CES okay for example b06 rubel also the synonym for Rella is German Ms sorry missiles is synonym for rubella that's the reason why they enclose that term into bracket whereas J 00 which is for acute n of fitis also known as common Cod okay so the synonyms are enclosed in the brackets then parenthesis these are used in both the alphabetic index and tabular uh tabular list to enclose supplementary word that may be present or absent in the statement of a disease or procedure without affecting the Cod number to which it is assigned this is the example alphabetic index example is diabetes or a diabetic which contains uh melitus sugar words okay hemophilia which contains classical means it that code is applicable for classical hemophilia also familial hemophilia also hereditary hemophilia also okay the same code is apply for all these three terms if it is in tabular list this is the example of tabular list parenthesis I 10 code is for essential also known as primary hyper hypertension then k51 point 011 which is code used for ulcerative whether it it is chronic we'll use same code chronic ulcerative code okay okay then we have colons these are used in tabular list after a incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category it is used with both includes and exclude nodes see here one example G 73.7 myopathy in diseases classified elsewhere includes you can see here this colon okay myopathy in again colon these characters are same in overall the I book now we'll see and the word and should be interpreted to mean either and or or when it appears in a title for example cases of tuberculosis of BS tuberculosis of joint and tuberculosis of BS and joints are classified to subcategory a 18.0 tuberculos A 18.0 is for tuberculosis of Bones and Joint whereas A 18.03 is for tuberculosis of other BS okay and word means either and or or then we have other and unspecified CES other or other specified CES when a specific code is not available for a condition the alphabetic index Direct decoder to other specified code in the tabular list just we saw an example of retr peronal mass okay in that case we use other specified code because there is no specific code for other uh sorry retr peronal Mass but we have specific location that's the reason why we use other specified code in case of retr peronal mass and the second category is unspecified code unsp code title unspecified are used when information in the medical record is insufficient to assign a more specific code for this we saw abdominal Mass example right where we have no specification about any specific site in the abdomen right we see one this is a flow chart does the provider documentation provide specific detail for condition if answer is no report the unspecified code like in abdominal Mass okay where we assign only unspecified code if answer is yes if our provider specified detail about the condition like uh the retr peronal mass our answer is yes is there specific code for the specified condition no we didn't find a specific code for retr perator right right that's the reason why we use other specified code okay and if the answer is yes then report that specific code we see one more example there are multiple codes for or hypothyroidism if the cause of patient hypothyroidism is known but is not one of the existing codes then code e03.8 would be used which is for other specified if the type of patient hypothyroidism is known code e03.9 would be use you see this hypothyroidism we have to go on this index mypo thyroidism and mostly the code uh you will find next to this m are unspecified code or default code okay okay hypothyroidism if our provider specified that is is neetal then we'll choose this code then post infectious then we'll choose this code okay if uh provider specify some condition and we not going to find a particular code for that or that particular term in this uh index in that case we have to choose this specified you can see here specified NEC which is for other specified hypothyroidism okay and this is for hypothyroidism unspecified okay and noise understand now we see includes notes this note appears immediately under a a three character code code title to further Define or give examples of the content of the category example a02 which is for other salmona infections which you will find include note under this uh code a02 which says infection or Hood born intoxication due to any cell species other than S typ Simon typ or Simon Pary okay second example is case 25 which is for gastric ulcer which include says include erosion acute of stomach acute erosion of stomach pylorus UL peptic pyos Al or peptic stomach also so these terms are also included included in the same code okay or some same category then inclusion nodes the inclusion nodes list of the term is included under some codes these terms are the conditions for which that code is to be used the term may be synonymous of code title or in the in case of the other specified Cod the terms are list of the various conditions assigned to that code the inclusion terms are not necessarily exhaustive additional terms found only in the alphabetic index may also be assigned to a code okay then we have excludes no ICD TCM has two types of exclude notes exclude one and exclude two okay we'll first see exclude one you can see symbol like this exclude one okay A type one excludes no uh a type one exclude note is a pure exclude note it means not coded here okay and exclude one note indicates that the code excluded should never be used at the same time as the code above the exclude note okay and exclude one is used when two condition cannot occur together such as congenital form versus an acquired form of some same condition okay you can't use conal form of this conal and acquired form of same condition at the same time okay mean and the uh on the same patient same day same encounter you will not you are not permissible to use the both the code on the same record okay same date of service for same patient because both CES are excluded each other okay you will going to find exclude One Note under that code so exclude one is not coded here the example is E1 type 2 diabetes milites it says exclude one gestational diabetes okay we not going to use this uh o 24.4 code with E1 because this code already says gational diabetes okay you can't use both the code at the same time on the same patient record or it also exclude postprocedural diabetes M e13 type 1 diabetes Mill because this is type two one one patient can be present at the same time with two type of condition right two type type of Diabetes type one and type two that's the reason why they exclude type two sorry type one from type two okay so exclude on one notes which P your exclude note means that main code and exclude one code you will not going to assign at the same time then we have a type two exclude note type two or exclude two exclude two note represents not included here exclude word is not coded here whereas exclude two is not included here and exclude to note indicates that the condition excluded is not part of the condition represented by the code but a patient may have both condition at this same time exclude one is purely different from exclude two okay exclude one not coded here whereas exclude two not included here okay opposite to each other when an exclude two note appears under a code it is acceptable to use both the code and the excluded no uh code together okay when appropriate you can see an example J 37.1 which is for chronic lingo TR Tres okay it says exclude two exclude to note contains acute Ling lingo track is code for a code is j0 4.2 and acute track is J 0 4.1 if patient has both the condition chronic and acute we can code both the condition at the same time because it is it comes under exclude two note okay so exclude two means not included here whereas exclude one means not coded here please keep it in mind at Le this basic difference between exclude one and two okay here is one example d23 other Bine neoplasm of skill can see here include node also these terms are include in this code in the same code means this is the same category code you will going to use if there is a term B neoplasm of hair follicle B neoplasm of CVS gland n neoplasm of sweat gland or for all these terms we going to use the same category b23 because it says includes okay next we have exclude one exclude says Bine lipus neoplasm of skin okay if you have Bine lipomas neoplasm of skin you have to choose from this category okay and you can quote d23 category code and D1 17.02 d7.3 category at the same time on same patient same data of service okay we have exclude to melanos Navy this code uhod d22 Point per uh which you can use at the same time okay so d23 category and d22 category you can use at the same time same date of service okay because it says exclude two exclude one is not coded here whereas two is included here sorry not included here means you can code both the the main code also and that exclude to code also at the same okay then next one is itology manif station just a minute iology manifestation conventions code first use additional code and in disas classified elsewhere nodes okay certain conditions have both an underlying itology and multiple body system manifestations due to the underlying itology for such conditions the ICD 10 cm has a coding convention that requires the underlying condition be sequenced first if applicable followed by the manifestation okay wherever such a combination exist there is a huge additional code note at the ethology code and a code first note at the manifestation code okay this instruction note indicate the the proper sequencing order of the course iology followed by manifestation okay first we have to assign code for itology then we have to code for manifestation okay so this use additional code or code first indicate proper sequencing order of that code if there is code first notice there that particular code you have to you can see here one example e66 overweight and obesity you can see two type of notes Here code first obesity complicating pregnancy child birth and prium if applicable we have to choose 9921 as a primary code okay then we'll going to code this e66 because it says code first okay and the second note is use additional code it says to identify the body mass index if no okay if you have specific body mass index in case of this overweight and obesity you have to code z68 code category code AS additionally okay so this is the example of code first and use additional code first says you have to codee that particular code at the starting or first listed code and use additional means you have to additionally add that code now we'll see with the word with or in should be interpreted to mean associated with or due to when it appears in a code title the alphabetic index or an instructional note in the T list the classification presumes a causal relationship between the two conditions linked by those terms in the alphabetic index or tabular index okay next we have C and C also a c to uh note directs you to a more specific term under which a correct code or more specific code may be found example leaky heart if you go and search for leaky heart it says see endocarditis okay then we also have C also know which instruction indicates additional information is available that that may provide an additional diagnostic code okay for example this is if you go on this is in the alphabetic index it says CL so syndrome okay we see this example you can see here a brism it says C poisoning food okay also it says you can see here absis okay it says with with diverticular disease with bleeding means with or due to okay absess with or due to diabetes oh sorry diabetic Lis disease uh with bleeding like this this c c also terms we'll have to use next we have code also note a code also note instruct that two codes may be required to fully describe a condition but this note does not provide sequencing Direction the sequencing D depends on circumstances of the encounter okay for example E20 810 autosomal dominant hypocalcemia okay code also notice there if applicable any Associated condition such as calculus of kidney and cod is so there n2.0 chronic kidney disease n18 respiratory distress j8 seizure cesure disorder j40 r56.9 okay if you see this code you going to find code also note under that particular code that means if patient also has this following condition you you have to quote that conditions also and the sequencing is depend on reason for encounter if patient come for calculus of kidney and it also has autosomal dominant hypocalcemia in that case you have to choose N20 as a primary cord and then E20 as a secondary okay if patient comes with autosomal dominant hypocalcemia that is the main reason and plus patient also has respiratory distress in that case you will choose E20 as a primary and JT as a secondary clear then we have default codes a code listed next to a main term in the ICD 10cm alphabetic index is referred to as a default code okay a default code represents that condition that is most commonly associated with the term or is is the unspecified code for the condition okay if the condition is documented in in a medical record without any additional information such as acute or crony the default code should be used okay for example appendicitis it says uh appendicitis Neal if let is Nal appendicitis you have to choose K k37 if it is retral appendicitis you have to choose k37 category okay if it is not documented as acute or chronic because appendic itis can be acute or can be chronic but if your provider not specified that this condition is accute or chronic in that case you have to choose this by default code here in this case it is k37 okay instead of the specific acute or chronic code being reported the default code would be used right next we have code assignment and clinical criteria the assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exist okay the provider statement that the patient has a particular condition is sufficient the code assignment is not based on clinical criteria used by the provider to establish the diagnosis if there is conflict conflicting medical record documentation query the provide means to assign the uh the code you have provide us diagnostic test uh statement then the particular condition is exist that is enough to assign the code okay if you have any conflict conflicting medical record documentation query the provider okay lastly we have some symbols okay this n is for newborn P is for Pediatric okay if the symbols are behind any code it says that particular code is for newborn if n is there if p p symbol is there those code is for Patric only if m is there then those code are for maternity A is for adult this m this is for M male sign few codes are uh only for male few codes are only for female okay this this sign is for new go this is for new text then Revise Code title revise text this side is for exclude one which is for not coded here exclude two is for not included here then fourth fifth 6 7th means it says character required okay if it says fourth only then it means that particular code require four character okay if it says seventh seventh symbol like this is present or behind any code that means that code requires seventh character okay then seven means extension X alert is there HSC symbol is there which is for hospit acquired condition I'll show you this can find this here the symbols are at each and every page at the end of the each and every page of tabular list this tabular list here you can get the number range of the course and here you can find this symbols okay you can see here this is not much clear this exclude one exclude two this fifth character is there right uh here you can see see this use additional code to identify nonmagnetic foreign body okay this is called unspecified okay like this you can find your code in the tabular list and these are the different symbols you'll get the symbol you came across the symbol behind each and every ICD code okay okay so that's this is all about General conventions and coding guidelines of ICD 10c thank you for your attention thank you for attending this uh session okay if you find this session interesting and want to join our medical coding program or medical coding training program please go on this link www.r online training.com and register yourself okay bye-bye take care welcome to Great online training myself Nikita I'm CPC certified medical coding trainer in great online training this is day seven and current sessions we are discussing about overview of ICD 10 cm okay we are discussing about uh different coding guidelines regarding icd1 CM right uh in previous session we discussed about session one which is uh which is for conventions General coding guidelines and chapter specific guideline and uh in previous session we discussed about first part of it which is conventions okay and this is today we'll discuss about part two which include B part of it session one's B part which is General coding guidelines okay if you find these sessions interesting if you want to learn more about medical coding please go to the given link below www.great onlin training.com and register yourself okay we'll see what are the topics we going to cover in this class we'll see General coding guidelines this is the session B of uh sorry part B of Session One ICD 10 coding guidelines okay in previous session we discuss about part A which is for conventions okay the in the previous session we discussed about different kind of symbols different kind of notes terms present in uh the ICD 10cm book right and today we'll see uh General coding guidelines so in this uh session we discuss about locating a code in ICD 10cm how can we locate the code in ICD 10cm level of detail in coding then code or codes for from a00 .0 through T 88.9 and uh z00 and u0 and so on okay then we'll see sign and symptoms if if sign and symptoms are there how we'll go to code about it codee them okay then conditions that are an integral part of a DC process okay then we'll see how we code conditions that are not an integral part of this process multiple coding for single condition that we'll see AC and croing condition how we going to code how we assign combination code s codes also known as late effect code again we'll see impending or threatened condition diagnosis okay reporting same diagnosis code more than once okay then documentation by clinicians other than the pro patient provider then syndromes laterality documentation of complications of care borderline diagnosis how to use uh signs symptoms specified code that we going to see and lastly we'll see coding for healthcare Encounters in Hurricane aftermath and the last we see how to find a correct code in five simple steps okay so we start with today we're going to discuss about B part of session one which is B part is for General coding guidelines okay you might might have thinking if these guidelines are there in ICD coding book then why we need to learn about this okay we can uh go through this guideline whenever we need to use them you might have thinking like that right because medical coding exams are also open book exam and even while doing daily medical coding if you if you are medical coder in that time also you go through your uh uh what that I can say go through your books and read those guidelines right but if you want to be a successful medical coder or go for coding exams you must be aware about all these guidelines about all the symbols note terms present in the book then and then only you can choose correct code easily and quickly because coding jobs are prod productivity based you need to complete your daily Target plus you need to complete your uh sorry you need to maintain your uh 95 to 98% accuracy also okay even if you go for medical coding exam it consists lots of questions around 150 questions you need to complete in 4 hours I'm talking about CPC exam okay so though these exams are open book you need to buy hard these guidelines because you have to manage your time during these exams okay if you waste your time uh reading these guidelines during exams you will be not able to complete your paper or uh while doing your daily coding job you are not able to complete your daily productivity Target or or it may be possible that you choose wrong code which will hamper your accuracy okay that's the reason why you need to go through this guidelines again and again for few times if you read these guidelines you will go by hard these guidelines okay don't worry about it these are easy guidelines okay we'll see what are the different guidelines first one is locating a code in icd1 cm how you going to locate the uh icd1 CM code in the book to select a code that correspond to a diagnosis first locate the term in the alphabetic index and then verify the code in the tabular index right remember we uh saw how to search search for code I show you uh how the ICD 10 cm book look like looks like okay how alphabetic index look like and then how the tabular list is looking like I'll show you again yeah this is the alphabetic index you can see here it start like a terms okay here also you can see the side of the page you can see the uh different terms okay so you can go through and easily find those terms then uh this is tabular index give me minute it takes some time to go on the particular page okay so this is uh how tabular List look like okay it shows different colors yellow color highlighted uh terms mostly unspecified codes the highlighted with yellow color Okay different kind of symbols are there means detail guidelines uh you get detailed instructions in the tabular index only okay not in the alphabetic index we see it is essential to use both the alphabetic index and tabular list when locating and assigning a code okay the alphabetic index does not always provide the full code selection of the full code including laterality and any applicable seventh character can only be done in the tabular list okay a dash at the end of the alphabetic index entry indicates that additional characters are required okay remember the structure of the course in ICD 10 these CES are of seventh character okay maybe few CES are of three character minimum three characters are there this is three characters are called category whereas other fourth fifth sixth seventh are called subcategory course okay few characters of three uh only consist three three characters okay first character represents chapter and it is alphabet uh alphabet starts with alphabet always okay and next two are next one is mean second one is numeric whereas third fourth fifth 6 7 alphabet or numeric anything okay but mostly few codes are three digigit whereas other chodes are maybe fourth fifth six or seven digit okay fourth digit represent e fifth represents anatomical site sixth represents severity and seventh is for extension okay now we'll see level of details in coding diagnosis code are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record okay if uh your provider give you specifications you need to use the all those specification if possible to code that diagnosis okay if the code is available for that specification you need to use that code with three characters are included in ICD 10 cm as the heading of the category of course that may be further subdivided by the use of fourth and or fifth character and or sixth character which provide greater detail as I told you few CES consist uh only three characters few consist four fifth six or seven characters okay which provide greater detail acid CM diagnosis codes are composed of codes with three four five 6 or seven characters code or codes from a0 through t99 uh sorry T8 T 88.9 z00 to Z 99.8 and u00 to U 85 the appropriate code or codes from a00 .0 through U 85 must be used to identify diagnosis Sy terms conditions problem complaints or other reasons for the encounter or visit okay we see how to code sign and symptoms codes that describes symptoms and signs as opposed to diagnosis are acceptable for reporting purposes when a related definitive diagnosis has not been established by the provider not been established or confirmed by the provider if uh your provider not confirm the why those sign and symptoms or that condition is uh occurred okay uh if your provider not confirm any disease at the time of that encounter in the medical record then you have to choose P for those reason for exam which consist silencing symptoms okay you have to quote only that sign and symptoms fifth one is conditions that are an integral part of a disease process sign and symptoms that are associated routinely with a disease process should not be assigned as additional course unless otherwise instructed by the classification okay so for example patient with gastroenteritis with nausea and vomiting COD only gastroent enteritis because nausea and vomiting are the sign and symptoms of gastroenteritis only those nausea and vomiting symptoms produce because of that gastroenteritis only that's the reason why you need to code only gastroenteritis in this case okay this is the flow chart how you have to go for sign and symptoms or you have to go for the particular disase here patient is seen for a symptom for example chest pain okay then you have to see does the provider document a definitive diagnosis if the answer is no then report the sign and symptom as the diagnosis condition stated as possible suspected questionable rule out or working diagnosis are not reported as definitive diagnosis okay we we are discussing these guidelines about outpatient coding only okay we are not discussing guidelines for inpatient coding inpatient guidelines are uh different than outpatient coding guidelines these are General coding guidelines General coding guidelines means these guidelines are for out patients okay if you want to go for inpatient coding if you want to go for inpatient coding certification guidelines are slightly different they follow different guidelines okay so remember that these guidelines are General guidelines and mostly used for outpatient coding so here condition stated as probable suspected questionable rule out or working diagnosis are not reported as definitive diagnosis okay in that case you need to choose the uh reason for encounter which is if there is sign and symptoms you need to code the sign and symptoms only now if provider document definitive diagnosis answer is yes it's the symptoms are integral part of that definitive diagnosis that you need to look for okay if the answer is no then report definitive diagnosis and the symptoms okay if answer is yes means those sign and symptoms are integral part of that diagnosis uh that definitive diagnosis only in that case you need to code that definitive diagnosis only like in this example okay if a patient comes with uh another example like patient comes with infection in infection mostly we the fever is the symptom of any infection right so if patient come with fever and doctor gives definitive diagnosis as infection okay viral infection in that case you will code only that uh viral infection okay will not C fever condition that are not an integral part of a disease process additional signs and symptoms that may not be Associated routinely with a disease process should be coded when present example patient with irritable bowel syndrome with diarrhea NOA and vomiting okay if patient comes with with irritable boil syndrome plus diarrhea NOA and vti in that case you'll quote irritable boil syndrome plus nausea and vomiting also because here diarrhea is symptom of irritable Bo syndrome but nausea and vomiting are not sign and symptoms of irritable B okay that's the reason why we need to code all three irritable boil syndrome NOA and vomiting okay now next one is multiple coding for a single condition in addition to itology manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems there are other single condition that also require more than one code okay use additional code notes are found in the tabular list is to CES that are not part of an ethology manifestation where where a secondary code is useful to fully describe a condition okay sometime you need to add the second code additionally okay we need you know three Cod remember uh the example is like sepsis sorry cvsis if cvsis is there we need to assign sepsis code okay as a primary code and then we need to add the S sepsis code add plus we need to add uh additionally any organ dysfunction okay use additional code indic uh indicate that secondary code should be added if no for example for bacterial infection that are not included in chapter 1 a secondary code from category b95 stus St stus and ENT ocus as the case a cause of diseases classified elsewhere or B96 other bacterial agents as the cause of di uh disease classified elsewhere may be required to identify the bacterial organism causing the infection okay mean if you go for bacterial infection you need to add secondary code additionally to specify that particular uh organism okay infection causing organism acute and chronic conditions if the same condition is described as both acute or Subacute and chronic and separate sub entries exist in the alphabetic index at the same uh IND uh indentation both code and sequence the acute or Subacute code first okay means if patient has both acute and chronic condition and alphabetic index at the same indentation level uh both the codes are present in that case you need to code both the condition in which you have to sequence acute condition at the first then we'll see combination code a combination code is a single code used to class classify two diagnosis okay combination code is single code used to classify two diagnosis a diagnosis with an Associated secondary process means also known as manifestation and a diagnosis with an Associated complication sometimes you find combination code for it for example uh K 5721 this code is used for diverticulitis of L L intestine with perforation and absis with bleeding okay there is separate code for only diverticulosis but this is combination code of diverticulitis with perforation and absess with bleeding okay then E1 11.34 1 this code is for type 2 diabetes milus with severe non proliferative diabetic retic retinopathy with macular okay this type of code we will going to assign if there if you if your provider documented combination of the uh that particular condition then we'll see how to code sqa sqa is also known as late effects what is sqa or late effect can anyone tell me because this is uh this question also your interviewer going to ask you what is s or L def tell me what do you know about s anything no it's okay s is nothing but long-term effect of any condition okay or a condition which is consequence of previous disease or injury is known as Sela or late effect okay it maybe appear after few days or few time after uh that main disease sella is the residual effect after acute phase of an illness or injury has terminated okay there is no time limit on when a s code can be used H the uh the residual may be apparent uh early such as in cerebral in infection or it may occur months or years later such as uh that due to a previous injury okay coding of Sela generally requires two uh two codes sequence in following order the condition or nature of the sea is SE sequence first and the sqa code is sequence second okay the current condition or complication or or currently the patient suffering from that condition that condition we have to sequence first and then we have to sequence squel a code for that main condition okay what is the exact reason of that particular condition for example scar formation resulting from a burn deviated septum due to a nuzzle fracture and infertility due to tubal occulation from old tuberculosis okay Scar from uh sorry scar after burn in case of scar after burn you need to First Code scar because scar is originating condition and secondly you have to go B bir SQL of bir okay because reason of that scar is B you need to assign SQ code of b as is second second code then we'll see impending or threatened condition code any condition described at the time of discharge as impending or threatened as follows if it did occur cod as confirm diagnosis okay if it did not occur refresh the alphabetic index to determine if the condition has a subentry term for impending or threaten and also main term entri for impending and for threaten okay if you came across uh impending or threaten diagnosis in your patient's medical record okay in that case if that diagnosis is confirmed you need to confirm in the uh me if provider confirm that diagnosis in impression then you need to quote that particular diagnosis as a confirm diagnosis if it did not occur means if your uh provider not confirm that uh this impending or threaten diagnosis is confirm in that case uh you have to refer alphabetic index to determine the condition has sub term for impending or threaten and also you need to refer that main term entry for uh impending and for threaten okay because we have few CES uh under the item impending coronary syndrome delirium trimmer then myocardial infection okay then also for threaten we have abortion code means threatened abortion we have code for threaten abortion with subsequent abortion okay or we have code for threaten abuse okay auth and labor like wayse you have to go and search for the course then we'll see sorry reporting same diagnosis code more than once each unique ICD 10 cm diagnosis code may be reported only once for an encounter okay this applies to bilateral conditions where uh when there are no distinct codes identifying laterality or two different conditions classified to the same ICD 10 cm diagnosis code okay each unique ICD 10 cm diagnosis code may be reported only once for an encounter okay if even there is the if some bilateral conditions are there and there is no distinct code for specific laterality in that case also you need to code only once that particular code then we'll see documentation by clinicians other than of patients provider code assignment is based on the documentation by the patients provider that is physician or other qualified Health practitioner legally accountable for establishing the patient's diagnosis there are a few ex uh exceptions when code assignment may be based on medical record documentation from clinicians who are not a patients provider these exceptions include CES for uh body mass index BMI depth of non pressure chronic ulcers pressure aler stage Coma Scale NIH uh Stroke Scale laterality course uh blood alcohol level course okay then we'll see how to code syndromes follow the alphabetic index guidelines when coding syndromes in the absence of alphabetic index guidance assign codes for the documented manifestations of the syndrome okay if you uh not finding particular code for that particular syndrome in that case you need to assign that documented manifestations okay additional codes for manifestations that are not an integral part of that disas process may also be assigned when the condition does not have have unique code then we'll see how to code laterality some I TM CES indicate laterality specifying whether the condition occurs on the left right or is bilateral okay if no bilateral code is provided and the condition is bilateral assign separate code for right and left okay if the side is not identified in the medical record assign and specified code then documentation of complications of care code assignment is based on providers documentation of the relationship between the condition and care or procedure unless otherwise instructed by the classification okay code assignment depend on providers documentation of relationship between condition and care for procedure not all conditions that occur during or following medical care or surgery are classified as complication if your provider stated that this is complication because of this is the surgery complication or medical care complication in that case only you will uh allow to use the complication code there must be a cause and effect relationship between the care provider and the condition and the documentation must support that condition is clinically significant it is not necessary for the provider to document the term complication if uh provider give you cause and effect relationship between care provided and the condition that is enough to code complication comp complication code is not necessary in that case okay but provider must be document cause and effect relationship between the surgery or care provided and condition for example if the condition Alters the course of surgery as documented in operative report then it it would be appropriate to report a complication code and if there is no clarification in the from the document ation documentation is not clear about relationship between condition and the care or procedure you need to carry the provider okay then we'll see how to quote borderline diagnosis if we provide a documents a borderline diagnosis at the time of discharge the diagnosis is coded as confirm okay if the provider documents borderline diagnosis at the time of discharge that diagnosis is coded as confirm unless the classification provides specific entry for example there is a specific entry for borderline diabetes if you go for go through diabetes you will get the code for borderline diabetes which is nothing but R 7.03 okay otherwise you have to code that particular diagnosis as a confirmed diagnosis if a borderline condition has a specific index entry in ICD TCM it should be coded as such like this uh diabetes code borderline diabetes code how to use sign and symtoms and unspecified codes okay sign and symtoms and unspecified codes have acceptable even necessary uses okay if a definitive diagnosis has not been established by the end of the encounter it is appropriate to report CES for sign and symptoms as we see earlier also if there is no if our provider confirm the diagnosis and those diagnos those sign and Sy reason for encounter are mostly sign and symptoms only okay and then doctor did evaluations did test procedure and confirm the diagnosis the main reason for that sign and symptoms okay in that case if those sign and symptoms if those sign and symptoms are integral part of that confirmed disease then you don't need to quote that sign and symptom you need to quote that particular diagnosis or disase only okay but if those sign and symptoms are not integral part of that particular disease in that case you need to First Code that confirm disas okay and then you have to quote that non integral integral part sign and symptoms also okay and if the provider not give specification about some disease or any condition in that case you need to choose unspecified code like if uh provider not given uh more information about which s which side right side or left side is affected in that case you need to choose unspecified okay likewise when sufficient clinical information isn't known or available about particular health condition to assign a more specific code it is acceptable to report appropriate unspecified code for example a diagnosis of pneumonia has been determined but not the specific type okay if your provider just give you uh pneumonia word in the impression in that case you have to choose unspecified code for pneumonia okay because you don't know which type of pneumonia is there which is causal organism of the pneumonia and all that's the reason why you need to choose unspecified pneumonia C okay now see coding for healthcare Encounters in Hurricane aftermath in this first guideline is use of external cause of morbidity course an external cause of morbidity cord should be assigned to identify the cause of the injury or injuries in uh incured uh as a result of Hurricane okay external cause of morbidity Cordes are never to be recorded as a principal diagnosis or first listed diagnosis in non-inpatient settings okay as these guidelines are uh outpatient guidelines and general coding guidelines so here we can't code this external cause code as a primary or principal diagnosis okay or first listed diagnosis because in patient coding guidelines are different and these are guidelines for General coding or outp coding okay then sequencing of external causes of morbidity course course for Catal uh cataclysm symic events such as hurricane take priority over all the external cause code except child and adult abuse and terrorism and should be sequenced before other external cause of injury CA okay if uh some injury cause because of the hurricane you need to assign external cause code for Hurricane as a not primary you can say after that main diagnosis code when you start coding for external cause CES in that sequence you need to assign that uh first external cause code AS hurricane okay but exception for child and adult abuse or terrorism okay assign as many external cause of morbidity CES as necessary to fully explain each cause Okay sometimes uh if patient uh I can say one example if one patient fall during dancing in the uh in the Zumba class you can say okay and cause some injury in that case you need to asside fall code okay particular code for external cause code for that fall first you need to assign injury code okay particular injury code then you start coding for uh external cause in that case you assign first fall code as a in external cost then you need to assign activity code also and play activity is dancing and then you need to assign the location code or place of occurrence code which is Zumba class okay means you need to assign three code in case of this condition or this scenario okay we'll see one more example if an injury occurs as a result of a building collapse during the hurricane external cause code for both the hurricane and building collapse should be assigned with the external cause code for re can being sorry being sequenced as the first external cost code not first listed first external cost code okay first we need to start our coding from that particular injury or particular condition code and then when we start coding for external cost code in that case we need to start with hen as a first external cost Cod then we'll see other external causes of morbidity Cod issues for injuries that are not a direct result of the hurricane such as an Evac uh that has incured an injury as a result of motor vehicle accident an appropriate external cause of morbidity codes to describe the cause of injury but do not assign code x37 which is for Hurricane okay because here reason for injury is or cause of injury is motor vehicle accident not hurricane okay in this scenario you need to uh code motor vehicle as a cause of injury or external cause of injury okay if it is not C clear whether the injury was a direct result of the hurricane assume the injury is due to the hurricane and assign code X 37.0 which is for Hurricane as well as other applicable external cause of morbidity course also in this first scenario they our provider is documented that that injury is a result of motor vehicle accident okay that's the reason why we need to uh assign motor vehicle accident external cause for motor vehicle accident okay but in this scenario if uh there is no clear documentation about what is the reason or cause for that injury that's the reason why we use hurricane is a cause of injury okay in addition to code uh X 37.0 which for Hurrican other possible applicable external cause of morbidity CES in these Cordes are like x30 which is for exposure to excessive natural heat X31 is for uh exposure to excessive natural cold or x38 is for flood okay if applicable you need to assign this course also then we'll see use of Z course you need to call this course as a z code not Z course okay Z CES are also known as other reason for healthcare encounters okay G Codes other reasons for healthcare encounters uh explain the reason for presenting for healthcare services including transfers between Healthcare facil ities or provide additional information relevant to a patient's encounter okay the icd1 CM Official Guidelines for coding and Reporting identify which codes may be assigned as principal or first listed diagnosis only uh secondary diagnosis only or principal or first listed or secondary okay depending on theum S assign as many course as necessary to fully explain each Healthcare encounter okay this Z course explain the reason for present for healthcare service okay sometime if the few CES are first listed code few course as secondary CES we need to assign those CES secondary depending on the circumstances means if for example says if patient come came for pre-operative exam okay in that case we need to assign pre-operative code Z code for pre-operative evaluation as a primary and other sign and symptoms as secondary okay possible applicable Z codes include uh G 59.0 which is for homelessness then Z 59.1 inadequate housing G 59.5 extreme poverty the 75.1 person awaiting admission to adequate facility elsewhere okay like this these are course you going to encounter in your you going to find in your I 10cm book now we'll see last this is the last part of this session how you can find correct code in five steps okay ICD how you will going to find ICD 10 cm codes correctly in five steps first step is search the alphabetical index for a diagnosis term okay after identifying the term note its as aicd 104 okay first you go through uh first obviously after reading the uh medical record you need to check for first you need to check for uh reason for encounter okay which mostly consist of conditions like sign and symptoms okay then you need to see impression if provider confirm any diagnosis or not okay if provider give any particular confirm diagnosis you need to go and search code for that diagnosis okay also you need to see uh whether the sign and symptoms patient comes with are integral part of that particular diagnosis or not if the sign and symptoms are integral part of that particular diagnosis you need to code only that particular diagnosis or disease if not you need to Cod that particular disease plus the sign and symptoms also okay so after identifying the term note its icd1 CM code okay when you go through I alphabetic index you going to find one code right after your mum okay and you need to note down that code okay and then you need to check that code into tabular list okay that's that's the reason why you need to note that particular icd1 code here one tip is there the term you are looking for might not be one of the main terms in the index but it might be listed under one of those Main for example first shoot here of the retina is listed under break retina we'll see we'll go by this index only I said the same index we see if you go from here if you want to find the code for hor shoot here we need to go to there okay the in here does it or Sho present or not we have to search for it okay you can do contrl F and search for Horseshoe okay here you can find horseshoe under the retina to okay directly Hors shoe is not there but behind the besides the retina you can find horseshoe and it suggest you to see also break retina for Sho okay if you click on it it directly go onto the break retina and you have to choose this Hors shho okay so first step of first step is to choose your particular diagnosis and go into the alphabetic index and find code for that particular diagnosis or condition okay this is your condition and note down that icd1 code then second step is check the tabular list before you use the icd1 code that you find in ICD sorry alphabetic index it is important to check that code in tabular list to see if there are special instructions are there or not okay you can directly choose any code from alphabetic index you need to verify that code in tabular list otherwise sometimes it is the same code sometimes that code requires uh six character 7 character or some there are many instructions or there in the tabular list okay or sometimes what happen uh remember we learn about the exclude term include term or exclude one exclude two those instruction you will going to find in the tabular list only okay that's the reason why you need to check that particular code which you find found in alphabetic index you need to verify that code in tabular list to see if there are special instructions for example if you look only at the alphabetic index you won't know you will know that some glooma diagnosis course require a six character to represent laterality okay then third step is read the codes instruction the Cod entry in the tabular list provides all the diagnosis code requirements okay for example a tabular list Flags code that can't be submitted for same I on same day this kind of uh instructions they will go give as a exclude one term exclude two CES okay then next step is ADD seventh character for some diagnosis tabular list instruct you to add a seventh character okay remember the symbols we uh discuss previously I'll show you again here in tabular list here you can find all those symbols at the end of each uh page of tabular index okay n is for newborn P is for Pediatric pediatric maternity here are the uh four fifth six seven character required symbols also okay so this kind of symbols you will going to find in tabular index only that's the reason why you need to verify your code in tabular index if it is an injury or trauma add a seventh character use one of the following character a is to indicate initial encounter D is for subsequent encounter and S is for S okay for example a patient present with a complaint of pain in right eye for 2 hours Coral abration is diagnosed the code is s 05.01 which is for injury of conjuctiva and coral abration without foreign body right I okay but that for entry in the tabular list instruct you to add seventh character from a d or S okay as a seventh character remember but this code is 1 2 3 4 5 digit code only and we need to add seventh character okay since uh this code is only five character log use X as a placeholder in the six sixth position okay sixth position we need to use X as a placeholder because we don't have any specific information about the six character we need to use X as a placeholder in the six position in the seventh position add a to indicate initial encounter if it is initial encounter we need to add a if it is follow up or subsequent encounter we need to add D if it is uh if the patient develop or recurrent erosion as a result of operation in that case we need to add S as a seventh character which is for sigila okay so this kind of instruction you will going to find in tabular list only that's the reason why you need to First choose your code from alphabetic index then note down that code and then you need to verify that code uh for Specific Instructions in tabular list without that you will not going to assign any code okay without verifying in tablea list you should not uh assign any code otherwise it will uh it may be possible that you will choose wrong code or invalid code then uh fifth step is always code to the highest degree of accuracy and completeness okay if there is fourth fifth sixth or digit available you must use it lastly the important tips for coding the bestas code is the actual diagnosis okay if you have the confirmed diagnosis in your impression of the report you need to choose that actual diagnosis or confirm diagnosis as a primary obviously following the guidelines the next BAS is sign and symptoms the last reason the last is the circumstance or V course or xcode or sometimes dord also okay only code establish conditions you have to code only establish or confirm conditions only not probable uh suspected possible or rule out condition you are not allowed to code the pro prob suspected possible or Ru out conditions okay if you have a particular code for borderline condition you need to code that borderline condition so please keep it in mind these important tips while coding or while you go for your any coding exams okay so that's all about it thank you all for your attention if you like this uh session if you like to learn more about medical coding you uh and join our medical coding training sessions please go on this link given below www.r onlinetraining and register yourself okay bye-bye take care welcome to Great online training myself Nikita I'm a CPC certified medical coding trainer in grade online training today onwards we're going to discuss about uh different coding guidelines ICD coding guidelines chapterwise okay so from today onwards we'll going to discuss chapter wise ACD coding guidelines right and this is the uh chapter 1 today we're going to discuss guidelines about chapter 1 which is certain infectious and parasitic diseases code ranges between a0 to b99 and u07.1 to U 9.9 okay you uh you will get all these guidelines in your ICD book okay so but you have to go through these guidelines because uh even though uh these guidelines are already there in your book uh ICD book but each and every time it is not possible for you to go and check each and every guideline right uh while uh you're doing your medical coding job or either you are preparing for your medical coding test uh means if you are uh going for CPC uh test or CCS test or any other test right because it will uh take too much time because these books are consist lots of lots and lots of pages okay so you can't waste your time in turning the pages of books that's the reason why you have to go through again and again through this guidelines right so we'll start just a minute okay so today we're going to cover the following topics HIV infections sepsis severe sepsis and septic shock then methylin resistant St cus orus also known as MSA then we see zika virus infections then Corona virus infections and lastly question and answers okay so first one is HIV infection what do you know about HIV infection can anyone tell me what is the meaning of HIV full form of HIV human immuno virus you miss some part human imuno deficiency virus okay it's okay so uh and what is difference between HIV and it's both are same or different it's okay I'll tell you so HIV is a human imuno deficiency virus okay and HIV virus causes AIDS which is nothing but acquired imuno deficiency syndrome okay if HIV is not uh treated then will uh then it will cause AIDS okay this is the difference HIV is the virus that causes HIV infection okay and the HIV virus damages the immune system by killing CD4 cells we have CD4 cells uh in our immune system right and the HIV virus kills both CD4 CD4 cells and uh weakens our immune system and it is the last stage of HIV infection okay you can see here in this test tubes okay yes without HIV medicine if you if anyone having HIV infection and uh it's not going treated then the HIV will increase and causes AIDS means acquired imuno deficiency syndrome okay so AIDS is uh the last stage of HIV infection as HIV infection advant uh advances to H the amount of HIV in body increases and the number of CD4 C decreases you can see here just give me one minute okay so HIV is the virus that causes HIV infection and AIDS is the last stage of HIV infection uh in which uh HIV infection means amount of HIV virus increases in your body and uh number of CD4 cells decreases okay that stage is called AIDS we move forward it is uh it is clear about uh difference between HIV and s or you need more explan yes okay good so HIV attacks CD4 cells okay and the amount of HIV uh virus increases and CD4 cells decreases that stage is called AIDS acquired imuno deficiency syndrome right uh there is currently no effective cure once people get HIV they have it for life but with proper Medical Care HIV can be controlled the possible signs and symptoms include fever headache sorry fever headache muscle ache pain joint pain sore throat painful mouth sorce diarrhea weight loss and night sweats okay these are the possible sign and symptoms of HIV you need to know uh sign and symptoms of uh the infections or any diseases because uh while coding ICD if it is confirmed any disease is confirmed even though patient come with some sign and symptom obviously patient mostly come with sign and symptom then they uh go through some test uh right and then after it is confirmed that which infection is there or which disease is there so and in that case we have to code the confirm cases means if it is confirmed that HIV infection is there the symptoms sign and symptoms are due to HIV okay then we have to code only HIV we will not going to code this sign and symptoms that's the reason why you have uh to aware about the sign and symptoms of the uh infections or diseases okay now we'll see guidelines for HIV mean human imuno deficiency Virus Infection okay first guideline is code only confirm cases okay as I just told you code only confirm cases of HIV infection or illness this is an exception to hospital impatient guidelines okay okay the inpatient coding is slightly different from outpatient coding this training session is uh about General medical coding so here we'll going to discuss uh the guidelines about outpatient coding okay if you if anyone wants to uh go for inpatient coding then the training will be different in the uh there you have to go through in patient coding guidelines their coding guidelines are different okay so these are uh outpatient coding guidelines or you can say General coding guidelines okay so uh code only confirm cases of HIV illness okay in this context confirmation does not require documentation of positive serology or culture of HIV the providers do diagnostic statement that the patient is HIV positive or has an HIV related illness is sufficient okay means you confirmation word is not mandatory in the report if you have if your provider says or patient's provider says patient is HIV positive or has HIV related illness that is sufficient to cause HIV infection okay then now we'll see example the patient admitted with anemia with possible HIV infection here uh the our provider says possible HIV infection provider also not confirm that uh HIV infection is confirmed or not okay he says possible HIV infection okay it is not yet confirm that HIV is there or not so they stated as possible HIV infection so while coding in uh means outpatient coding or in general coding we not coded possible conditions okay possible suspected conditions we are not coding so here our ICD code is Will code only anemia okay see here explanation only the anemia is coded in this scenario because it has not been confirmed that an HIV infection is present right our provider says possible HIV infection that's the reason why we'll only C anemia okay again here you can see I written this is an exception to guidelines session 2 H for Hospital inent coding because this session uh session two H is for inpatient coding okay because in impatient you have to code possible conditions also because in impatient uh they have to go through test if you are admitted in the hospital doctor has to uh test you right uh to confirm the disease or infection if anything is suspected that's the reason why in inpatient coding we'll have to code possible conditions also but this uh training session is regarding General medical coding that's the reason why you have to keep it in mind that we not going to code possible conditions okay if you going for CPC exam okay CPC exam is related to outpatient coding okay then you have to go through these guidelines only the same guidelines you have to follow which are followed for outpatient coding and if you want to go for inpatient coding and inpatient coding uh certification then you have to go for CCS string okay so now it is confirmed that you have to code only confirm cases okay this is the first guideline of HIV okay we have to code only confirm cases if anything is possible like possible HIV infection or suspected HIV infection we not going to code it next guideline is selection and sequencing of HIV CES in this session uh first one is patient admitted for HIV related condition if patient admitted for HIV related related condition the principal diagnosis should be B20 okay B20 description of B20 is human imuno deficiency virus disease okay because patient is already admitted for HIV related condition only that's the reason why we have to assign B20 code okay which is for HIV disease okay means it is confirmed that this patient has HIV followed by additional diagnosis code for all reported HIV related conditions other conditions uh HIV related conditions will code afterwards okay while coding it is very important that it is a very crucial part to choose principal diagnosis principal diagnosis means uh well uh you code the report you have to choose many diagnosis right so the main cause or the main uh reason for encounter that you have to code as a primary primary means you have to code it first remember I told you about sequencing so while sequencing you have to code uh primary only those cases which are confirmed or which are the main reason for encounter okay so here if patient is admitted for an HIV related condition then our principal diagnosis should be B20 which is nothing but HIV disease Then followed by additional diagnosis course for all reported HIV related conditions okay an exception to this guideline is if the reason for ad is hemolytic uremic syndrome associated with HIV disease assign code d59 D 5931 which is nothing but infection Associated hemolytic uremic syndrome followed by code B20 okay this is the one exception for this guideline we'll see one example HIV with PCP okay PCP means pumo pumos cystic uh car pneumonia okay if patient admitted with HIV with PCP then we have to code we have to assign B20 as a PR principal diagnosis which is nothing but HIV disease and then b59 which is for PCP okay okay because pneumonia due to pneumocystis uh car is an HIV related condition so the HIV diagnosis code is reported first followed by the code for pneumonia any doubt okay now the second uh next guideline is patient with HIV disease admitted for unrelated condition if a patient can you please uh mute your mic okay so next guideline is patient with HIV disease uh admitted for unrelated condition if a patient with HIV disease is admitted for an unrelated condition such as traumatic injury okay the code for the unrelated condition for example nature of injury code okay should be the Principal diagnosis other diagnosis will be B20 followed by additional diagnosis code for all reported HIV related conditions see one example if patient is admitted for unstable angina okay native coronary artery atherosclerosis okay and HIV then so unstable angina native coronary AR atherosclerosis it is unrelated to HIV okay so we have to assign I25 110 which is nothing but atherosclerotic heart disease of native coronary artery with unstable angina Vector just give me one minute so ICD CES we going to assign our i25.110 which is nothing but atherosclerotic heart disease of native coronary artery with unstable angina pectoris and here the second diagnosis is B20 which is HIV disease because patient admitted for unstable angina and HIV and instable angina is not related to HIV okay okay both the conditions are unrelated to each other right that's the reason why we'll assign primary the unstable anina then B20 next one is whether the patient is newly diagnosed okay if the patient is newly diagnosed or has had previous admission or encounter for HIV conditions is irrelevant to sequencing decision we see one example newly diagnosed multiple cutaneous kosis saroma lesions in previously diagnosed HIV disease here we have to assign B20 as a primary or principal code which is hi which is for HIV disease and then we have to assign c46 .0 which is for kosis saroma of skin because even though HIV was diagnosed on a previous encounter it is still sequence first when coded with an HIV related condition composit because composit saroma is an HIV related condition okay that's the reason why we we assign B20 as a primary code okay so as of now we uh learn that we have to code only confirm cases if uh there is if our provider mentioned uh that possible or suspected HIV then we not going to code that HIV okay we'll code other diagnosis then we'll uh we learn that if any related condition with HIV if patient admitted with any HIV related condition then we have to assign first B20 and then other condition right if patient is admitted any unrelated un uh means any unrelated condition with HIV okay then we have to assign that other condition first and then B20 means HIV Cod and now this guideline is whether the patient is newly diagnosed okay means if uh the patient has B20 and means B20 means HIV disease and admitted with some another newly diagnosed uh condition then we have to assign B20 as a primary because if the that condition is related to HIV okay like in this example where kosis saroma patient is admitted for kosis saroma of skin but as kosit saroma is related to HIV we have to assign B20 as a primary code and then C 46.0 for kosis as a secondary code okay or second diagnos next guideline is a symptomatic human imuno deficiency virus those guidelines are about confirmed diagnosis confirm HIV diagnosis okay those three guidelines are about now here we'll see if patient has a symptomatic H human H imuno deficiency virus or HIV infection then which code we going to use that we'll see Z 21 is the code for asymptomatic human imuno deficiency Virus Infection status okay is to be applied when patient without any documentation of symptoms is listed as being HIV positive or non HIV or HIV test positive or similar terminology okay means if you find in your report or in your question that patient has patient is HIV positive or non HIV or HIV test positive okay then you have to append on this number or you have to assign this number which is z21 a symptomatic HIV infection status okay do not use this code if the term s or HIV disease is used okay or if the patient is treated for any HIV related illness or is described as having any condition resulting from his or her HIV positive status okay in that case you have to use B20 okay as we uh discussed in previous guidelines we have to use B20 if uh AIDS or HIV disease or any HIV related condition is present or HIV positive status given in the report or question then we'll use B20 this z21 code is for a symptomatic HIV infection okay I know this is little bit uh confusing but when you go through these guidelines again and again you're going to Bard these guidelines okay don't worry about it we'll see one example patient admitted with acute appendicitis status positive HIV test on on Atria with prior symptoms okay in this case we have will use K 35 80 okay unspecific acute appendicitis k35.80 is for unspecified acute appendicitis code because patient is admitted with acute appendicitis okay and Status HIV positive test okay so here we'll use z21 which is for a symptomatic human imuno deficiency Virus Infection status code z21 is SE when second since documentation indicate that patient has had a positive HIV test but has on uh but has been asymptomatic okay being on medication for HIV is not an indication the code B20 is used instead of z21 unless there has been documented that patient has had current or prior symptoms or HIV related complications C use uh code B20 is not used here B20 is not used because uh there is uh no any HIV related complication present okay that's the reason why we use z21 because appendicitis is not an HIV or its related complication okay that's the reason why we assign appendicitis as a primary code and then z21 as a secondary clear next guideline is patients with inconclusive HIV serology patient with inconclusive HIV serology but no def uh definitive diagnosis or manifestation of the n may be assigned code r75 r75 description is inconclusive laboratory evidence of HIV okay if it is not confirmed or patient has inconclusive HIV serology then we'll have to use our 75 then next guideline is previously diagnosed HIV related illness patient with any known prior diagnosis of an HIV related illness should be coded with B20 okay if patient previously also have HIV related illness then throughout his life we have to use B24 okay because once you get infected with HIV it will be for lifetime so that's the reason why we have to use B20 if patient with any prior diagnosis of HIV related illness okay once a patient has developed an HIV related illness patient should always be assigned B20 on every subsequent admission or encounter okay patients previously diagnosed with any HIV illness B20 any HIV related illness means B20 code should never be assigned to r75 or z21 which is for r75 for inconclusive laboratory EV evidence you not going to use because if the patient already diagnosed with HIV illness there is no use there is no need to use r75 right because that is for for inconclusive serology and Z 21 is for a symptomatic HIV infection status okay so if the patient previously diagnosed with any HIV illness we have to use B20 and if patient has uh inconclusive serology we have to use r75 and if patient is asymptomatic for HIV infection status then we have to use z21 next guideline is HIV infection is in pregnancy child birth and the puparium during pregnancy child birth or the puparium a patient admitted or presenting for a healthcare encounter because of an HIV related illness should receive a principal diagnosis is code of 98.7 and uh this code is not completed 98.7 it has other characters also because O Series is for pregnancy related diagnosis okay and if patient is pregnant we going we have to assign o code as a primary okay means there is separate session we're going to discuss it in uh further sessions while discussing chapter wise we're going to discuss it uh about O course O Series course if patient is pregnant we have our principal diagnosis should be o Cod okay so here also we have different HIV related code for pregnancy okay if HIV related illness should receive a principal diagnosis code 98.7 human imuno deficiency disease complicating pregnancy child birth and pum then we have to use B24 okay we can't uh will not directly append on B2 good because this patient is pregnant okay that's the reason why we have to use o 98.7 as a primary code and then additionally we have to use B20 Cod okay for HIV related illness course from chapter 15 always take sequency quity just uh I have told you as this uh patient is pregnant in on a pregnant patient we have to use chapter 15 course means O Series course which are for pregnancy the patient with asymptomatic HIV infection status admitted or presenting for healthcare encounter during pregnancy child birth or puparium should receive code of 98.7 and z21 so you have to keep it in mind that o90 8.7 is you have to use if patient with any HIV related condition okay then other guidelines are uh same as previous guidelines okay if it is confirmed that HIV is there HIV disease or HIV related disase illness is there then you have to use B20 and if it is a symptomatic HIV infection you have to use z20 but as a primary code as this patient is pregnant if patient is pregnant you have to use 98.7 98.7 is code for pregnant patient with HIV disease okay then next one is encounters for testing for HIV okay if patient is uh came for only testing of HIV if patient is being seen to determine his or her HIV status use code z11.4 which is for encounter for screening for HIV okay if patient is uh encounter for determining his or her HIV status we have to use z11.4 okay use add addal codes for any Associated highrisk Behavior if applicable if other diagnosis are there then we have to use those diagnosis as additional code okay but primary if patient is uh encounter for determining his or her HIV status we use z11.4 code okay if patient with sign or symptoms is being seen for HIV testing quote the sign and symptoms and additional celing code z71.7 human immun deficiency virus counseling may be used if counseling is provided during encounter for the test okay if patient with sign and symptom is being seen for HIV testing okay if patient having some HIV related if anyone have it's possible that there are many common sign and symptoms of many diseases right so if patient with some sign and symptoms like HIV okay and seeing for HIV testing also okay and the doctor provided counseling to that patient then we have to first assign uh those sign and symptoms and then additionally we have to use z7 1.7 if HIV is not confirm in that case I'm talking okay if that is confirm those guidelines are separate those will we saw in previous sessions right so if only counseling is provided then we have to assign sign in symtoms and then the 71.7 which is for HIV counseling then when a patient returns to be informed of his or her HIV test result and the test result is negative use code z71.7 which is for counseling HIV counseling okay see if one patient done his HIV testing okay and then he return backs to the uh provider to so to show them the reports to inform them that his test result is negative obviously that doctor provide some counseling right so we'll use z71.7 code which is for HIV counseling okay we we can't use z11.4 or r75 or other course we have to use z71.7 if sorry if the results are positive see previous guidelines and assign course as appropriate okay R will again repeat B20 if HIV or HIV disease or Aids is present in the report means it is confirmed that the patient has HIV whether it is previously diagnosed or anything if he's infected with HIV once he has he or she has HIV disease it will be coded lifetime okay we have to code it on each and every encounter okay with B20 code which is for HIV disas and then or SS and but the sequencing depend on reason for encounter as I as we discussed in previous uh slides right then z20 1 is for a symptomatic HIV infection status for HIV positive or non HIV then r75 is for inconclusive HIV serology but no illness okay then Z 11.4 is for encounter for screening okay and z71.7 is for HIV counseling okay use if even though so uh if patient is with negative test of HIV we have to use z71.7 and if patient present with sign and symptom and seen for testing we have to use z7 those sign and symptom as a primary and then z71.7 as secondary C and if patient is pregnant and seen for any HIV related illness or with HIV DCS or else we have to use o 98.7 as a primary and then B20 or z21 code corre clear what you have to do I know this is very much confusing you will get confused very much right about these guidelines you just have to make a note of this code just as just have told you how many coures I have told you only six course like B20 z21 r75 z11.4 z71.7 and O 98.7 and you have to make a note that you know which cases you have to use those codes okay you have to buy hard those six codes only okay now we'll move ahead our next type of infection which is sepsis severe sepsis and septic shock do you what do you know about sepsis anyone anything you know about sipsis it's okay sepsis is lifethreatening medical emergency condition okay sepsis happens when an infection you already have triggers a chain reaction throughout your body okay how it happens we'll see first those bacteria comes into your lung okay first the bacteria infect your lungs source of infection okay then those bacteria enter into your blood then it leaking through your blood vessels and through blood vessels it will infect other organs also and you you will face start facing organ dysfunction and lastly death so this is very severe disease or medical emergency thisas sepsis is the body's extreme response to an infection it is a life-threatening medical emergency sepsis happens when an infection you already have triggers a change reaction throughout your body here you can see from lungs to uh blood blood vessels and then they will leak from blood vessels and then goes to other organs and the other organs start dysfunctioning and lastly death so infection that leads to sepsis most often start in the lung and then after go through urinary tract skin or uh gastrointestinal tract okay now now we'll see there are several stages of sepsis SS okay SS any uh more than two or equal to two of following if the temperature symptoms like uh temperature is more than 35 5 cius okay or heart rates are more than 90 bits per minute or uh are more than 20 bits uh per minute okay uh or wbcs are uh more than 10% bands okay so uh SS gives you these symptoms or this test results okay just give me 1 minute okay so what is meaning of ss SS is systemic inflammatory response syndrome okay systemic inflammatory response syndrome it is one stage of sepsis okay then we have sepsis means two uh any two two conditions between This Ss systemic inflammatory response syndrome and then confirm or suspected infection that is uh unine tra infection PNA wound Etc then we have sever stepsis uh in which there is sepsis Plus any uh sign of organ failure that we call as severe sepsis then lastly septic shock okay septic shock means severe sepsis what is severe sepsis severe sepsis means sepsis plus organ failure so the septic shock means sepsis plus signs of organ failure plus extremely low BP that does not respond to fluid replacement okay that is called septic sh these are different stages of sepsis okay we'll see guidelines for it okay coding or for sepsis and severe sepsis so the first guideline for sepsis is for the diagnosis of sepsis assign the appropriate code for the underlying uh systemic infection if the type of infection or causal organism is not forther specified assign code a 41.9 which is for sepsis unspecified organ if the organism is not mention okay if your provider is not mention any organism which causes sepsis then you have to assign a 41.9 which is for sepsis unspecified organism okay a code from subcategory are 65.2 which is for severe sepsis severe sepsis means what sepsis with any symptoms of organ failure it's called severe sepsis then we have to use r65.2 this should be assigned uh sorry should not be assigned unless severe sepsis or any uh Associated acute organ dysfunction is documented right because severe sepsis is sepsis with any related organ dysfunction okay so if there is uh no documentation of any sign and symptoms of organ dysfunction or failure then you'll not use sever sepsis code okay for example gram negative sepsis if your provider is documented gram negative sepsis then we have to use a 41.50 which is for G negative csis unspecified stoc coca sepsis okay and uh second code is a 41.2 which is for sepsis due to unspecified stus here we know that this sepsis is due to stel focus okay that's the reason why we use 8 41.2 okay in both the examples about the uh the organism causing the sepsis is identified therefore a 41.9 sepsis unspecified organism would not be appropriate as this code would not capture the highest degree of specificity found in the documentation because a 41.9 is for sepsis unspecified organism if you have uh if your provider given you any specified organism you have to use that particular code only we'll see here show you go on this ICD 10 if you type here cpis you'll find this Cod see a41 1.9 this is for unspecified organism here it is mentioned seps is unspecified or generalized okay this code is for by default code if uh you you need to assign any unspecified code you have to choose this code okay which is directly behind the main ter and if your provider is uh given specific organism okay then you have to choose from these categories okay the specific code there are too many codes present but if it is not specified any organism name you have to choose a 41.9 only clear okay the next one is negative or inconclusive blood cultures and sepsis negative or inconclusive blood cultures do not uh preclude that uh diagnosis of sepsis in in patients with clinical evidence of the condition however the provider should be quer okay if negative or unconcluded blood cultures and sepsis is there we have to query the provider then eurosis the term ospis is a non-specific term it is not to be considered synonymous with sepsis eurosis is not sepsis if you uh encounter with ospis term in your report or in your during your exam it is not synonymous to sepis keep it in mind okay cpis and eurosis is different it is it has no default code in the alphabetic index okay should a provider use this term he or she must be quered for clarification if you while uh you doing your job medical coding job if you encounter with eurosis term in any patient report then you have to query the provider for clarification okay because there is no code for eurosis in the alphabetic index now next one is sepsis with organ dysfunction if a patient has sepsis and Associated acute organ dysfunction or multiple organ dysfunction M mod multiple organ dysfunction follow the instructions for coding severe sepsis okay we'll see here you can see sepsis then we'll see see here there is no code for eurosis right so if uh your provider given you provider given you Euros sepsis in patient report then you have to query the provider for clarification okay and if you have to code for severe sepsis or uh like if the patient has sepsis and Associated acute organ dysfunction or multiple organ dysfunction follow instruction for coding severe sepsis like here you can see severe under the sepsis you will see severe okay if there is severe with septic shock you have to go on this code if you have only severe sepsis or any uh related organ failure or sign symptoms of organ failure then you have to see here you can see applicable to see sepes okay if there is any additional code needed or any principal diagnosis is necessary then it will be mentioned here okay code first or something just a minute okay so next guideline is acute organ dysfunction that is not clearly associated with the sepsis if the patient has sepsis and an acute organ dysfunction but the medical record documentation indicates that organ dysfunction is related to a medical condition other than sepsis do not assign a code from category r65.2 which is for severe sepsis okay if the patient admitted or patient encounter with acute organ dysfunction but that dysfunction is not clearly associated with csis then you should not use CV sepsis code which is r65.2 because to use r65.2 which is for severe sepsis it must be documented that that organ dysfunction or sign and symptoms of dysfunction is related to seis then and then only you uh are allowed to use r65.2 code okay an acute organ dysfunction must be associated with the sepsis in order to assign the S sepsis code if the documentation is not clear as to whether an an organ dysfunction is related to sepsis or another medical condition where the provider okay for example sepsis and acute respiratory failure due to COPD exacerbation here we'll use a 41.9 which is for sepsis unspecified organism because organism is not mention here then R sorry j44.1 which is for COPD and then J 96. which is for acute respiratory failure okay because although acute organ dysfunction is present in in the form of acute respiratory failure severe sepsis R 65.2 is not coded in this example as the acute respiratory failure is attributed to COPD exacerbation rather than sepsis so the sequencing of this course would be determined by circumstances of the admission okay because here in in this means in this example the acute respiratory failure is due to COPD exacerbation okay this is not related to severe sepsis that's the reason why we not going to use r65.2 code okay we see sever sepsis the coding of severe sepsis requires a minimum of two code first a code for underlying systemic infection followed by a code from category sorry subcategory r65.2 which is for severe sepsis if the causal organism is not documented assign code a 41.9 which is for sepsis if causal organism is given then we have to assign for that causal organism then additional course for Associated uh acute organ dysfunction are also required due to the complex nature of sever sepsis some cases may require quering the provider prior to assigning of the code okay means if any uh CVS coding for when you go for C cpis coding you have to assign at least two code first code is for infection if caal organm is not mentioned then you have to use r60 Sor a 41.9 and then you have to use C seis 4 r65.2 okay then coding for septic shock septic shock generally refers to circulatory failure associated with with severe sepsis and therefore it represents a type of acute organ dysfunction okay for cases of septic shock the code for septic uh sorry systemic infection should be sequen first followed by code r65.21 which is for S sepsis with septic shock or code T 81.1 2 which is for post procedure septic sh and then any additional CES for additional other acute organ dis function should also be assign okay so it means if septic shock uh is present okay then we have to code first a 41.9 okay because uh if anything related to sepsis we have to primary code a 41.9 for infection or which is for uh sepsis sepsis code a 41.9 seis unspecified organism if organ is spe organism is specified then you have to choose accordingly but you have to code sepsis as a primary then we'll choose R 6421 which is for severe sepsis with septic shock okay or t 81.1 which is for postprocedural septic shock okay if septic shock happens after any procedure then we have to choose T 81.1 12 and then third one is organ fure code okay or organ dysfunction code so this this is sequencing for septic sh first a 41.9 then r65.21 or t 81.1 two and then organ failure clear here again sequencing of severe sepsis if severe sepsis is present on admission and meets the definition of principal diagnosis the underlying systemic infection should be assigned as primary diagnosis followed by the appropriate code from subcategory r 64.2 as required by sequencing rules in the tular list okay if C seis is present on admission then the underlying systemic infection should be assigned as a primary diagnosis mean seis code assigned as a primary the for unspe specified it is a 41.9 if the organ is specified we have to choose that specific organism Cod seis Cod okay but for unspecified a 41.9 and then r65.2 we can't assign r65.2 as a primary okay according to guidelines then next one is sepsis or sever seis with a localized infection if the reason for admission is sepsis or severe sepsis and a localized infection such as pneumonia or cellulitis codes for underlying systemic infection should be assigned first and the code for the localize infection should be assigned as a secondary diagnosis okay primary as underlying systemic uh infection report and the localized infection code should be assigned secondary if the patient has severe sepsis a code from subcategory r65.2 should be assigned as a secondary code okay secondary diagnosis if patient has severe sepsis if patient had two types of infection okay mean sepsis or severe sepsis and the localized infection also such as localized infection such as pneumonia or cellulitis okay in that case uh mean here reason for admission is sepsis or sever sepsis and plus that patient has pneumonia or cellulitis like localized infection in that case you have to assign first the underlying systemic infection means sepsis Cod Okay then if that is severe sepsis then we have to assign a 41.9 first then r65.2 and then the code for localized infection then if the patient is admitted with a localized infection such as pneumonia and sepsis severe sepsis doesn't develop until after admission the localized infection should be assigned first followed by the appropriate sepsis or C sepsis Cod okay if the patient is admitted with localized infection okay here in this case if the patient admitted with localized infection such as pneumonia or uh that cellulitis okay and sepsis or cvsis doesn't develop until admission it develop after admission then in that case we have to uh assign first code for localized infection because patient is admitted for localized infection and then he develop the sepis or S sepis okay that's the reason why we'll use the sepis code as a secondary means it is depend on admission reason for admission if patient has two type of infection sepsis plus localized infection uh you have to the sequencing for coding is depend on reason for admission okay if reason is sepsis then we have to sequence sepsis as a primary if reason is localized infection then we have to choose localized infection as a primary code clear then next guideline is sepsis due to a postprocedural infection okay in this case first is documentation of causal relationship as with all postprocedural complications code assignment is based on the provider's documentation of the relationship between the infection and the procedure okay with all postprocedural complication code assignment is based on Pro providers documentation of relationship between infection and procedure then sepsis due to Pro procedural infection okay for infection following on following a procedure a code from t81 40 to to T 81.4 3 infection following procedure or a code from 86. to 86.3 infection of obsteric surgical wound that identifies the site of infection should be coded first if no okay if if infection following procedure code from T8 1.40 to t8.435 to 86.0 that will go first assign a addition an additional code for sepsis following a uh procedure T 81.4 4 or sepsis following an obstal procedure 86.4 use an additional code to identify infectious agent okay if sepis is due to post pral infection we have to uh code the uh use this t81 44 codes as a primary or 86.4 code as a primary and then additionally we have to pute infectious agent okay if the patient has severe sepsis the appropriate code from subcategory r65.2 should also be assigned with the additional CES or codes for any acute renal organ dysfunction okay if the patient has sever cpes the appropriate code from subcategory r65.2 should be assigned with additional code now we'll see ICD codes for HIV coding here I have uh gathered all the uh C to make it easier to digest okay because I know you must be confused uh learning the all the guidelines okay but at least you have to by hard this Cod for uh for the particular term okay if the term is uh sorry if the term is HIV disease okay HIV disease is confirm then or it is mentioned that AIDS or a related complex okay or EDS related condition HIV infection symptomatic if terms like this are there then you have to choose code from B20 to B24 okay from this code range you have to choose your code if the patient is asymptomatic HIV infection status uh then we have to code z21 okay this code also apply for this uh other terms like HIV infection HIV positive HIV non HIV HIV virus HIV status HIV positive uh or HIV test positive HIV infection but asymptomatic okay that time you have to choose z21 okay uh to code B22 B24 series it is compulsory that HIV disease is mentioned okay or HIV infection symptomatic this word are compuls compulsory or else if these C these terms are not there uh the patient is asymptomatic HIV infection status or just HIV uh test positive like this then you have to choose c21 okay then uh if there is laboratory evidence of HIV this ter is mentioned in your report then r75 okay HIV disas complicating pregnancy you have to choose o 98.7 and then uh B20 or z21 use additionally okay as a secondary code then encounter for screening for HIV is there uh for that g 11.4 code is there okay G 11.4 is for encounter for screening for HIV HIV counseling or patients test results are negative for HIV and then patient come back to show the report the provider that in that case you have to choose 3 71.7 okay then contact with or exposure to HIV is there uh for this G22 uh z20.6 4 you have to use and for family history of HIV HIV disase Z 83.0 okay so this is the table for terms and ACD CES of hi okay different terms for which you can choose this C okay if you go through this table also it will be easy for you okay then we see next one is SS or SE then sepsis several sepsis and septic shock SS means systemic inflammatory response syndrome okay systemic inflammatory response syndrome this is response to uh the inflammatory response of our body to the any infection or something okay like uh we have fever or increased body temperature or any rashes or something like that okay when the source of ss is an infection it is called sepsis when it is called sepsis when source for systemic inflammatory response syndrome is infection an infection at that time it is called SE is okay it is body's extreme response to an infection it is life threatening medical emergency sepsis happen when an infection you already have triggers a chain reaction throughout your body okay CH reaction like this uh mostly they infect your lungs or any anything like this here infection that lead to sepsis most often start in lung urinary tract skin or gastrointestinal tract okay infection can start from any of this uh site and then it will those bacterias goes into your bloodstream and then they start leaking from your blood vessels and likewise there then uh go to your different organs so after that your organs start dysfunction okay and last stage is organ failure and then death if it is untreated sever sepsis occurs when one or more of your body's organ is damaged from this inflamatory response okay means CVS depis is next step of sepsis okay first sepsis and then severe sepsis s SE happen when one or more of your body organ is damaged from this inflammatory response to assign code for C sepsis it is compulsory uh that means you have to uh find out the term that any organ dis function or organ failure must be present in your patient report then and then only you can assign code for severe sepsis okay because C sepsis occurs when one or more of your body organ is damaged then next step is septic shock septic shock is last and most severe St stage of sepsis causes extremely low blood pressure and organ failure due to sepsis organ failure happens during sever sepsis but uh when it causes extremely low blood pressure or any disase related to circulatory system it call call as septic sh okay treatment may include antibiotics oxygen and medication the first one is SS then sepsis and then severe sepsis and then septic shop okay when you go for any medical coding interview the at the time your interviewer going to ask you this type of question okay what is sepsis what is severe sepsis uh what is septic shock or what is sequencing of coding like this so be prepared for it uh see here these are the stages of sepsis SS then sepsis then s sepsis and then septic sh SS means uh your body start showing these symptoms like increase temperature increase heart rate like this okay wbcs count increase then next step is seis when when your body shows any uh two symptoms of uh SS and then uh plus confirm or suspected infection that is UTI or PNA or wound Etc okay then comes sever sepsis where uh you have sepsis plus signs of organ failure as I told you before to code cious sepsis any sign of organ failure or dysfunction must be there to code cious sepis okay then last step is or last stage is septic sh in which SE sepsis is there means sepsis plus any sign of organ failure or dysfunction plus extremely low BP okay these are the stages of sepsis SS then sepsis then Cal sepis and then septic sh next we'll see coding guidelines for sepsis for diagnosis of sepsis assign appropriate code from underlying systemic infection if the type of infection or causal organism is not specified assign code a 41.9 which is for sepsis unspecified organism okay if organism is given who causes the that infection you have to choose code accordingly this is the by default code default code for sepsis okay sepsis unspecified organism which is nothing but a 41.9 a code from subcategory R 65.2 is for S sepes should not be assigned unless severe sepes or and Associated acute organ dysfunction is documented right to C CES uh the term C sepsis or any Associated acute organ dysfunction or failure must be documented okay and code for C is r65.2 okay r65.2 is not a complete code R 6 65.2 or 2 one this is complete word but this is subcategory of the S csis okay the next character after two that will choose according to condition okay for example G negative csis A 41.50 is for G negative csis unspecified stus cpis okay and a 41.2 which is for sepsis due to unspecified stel cus in both the examples above organ organism causing sepsis is identified therefore a 41.9 SE which is for sepsis unspecified organism would not be appropriate as this code would be would not be capture the highest degree of specificity found in the documentation okay do not use the additional code for severe sepsis unless documented as severe sepsis with acute organ dysfunction okay in this example they have given gr negative subsis so uh we know causal organism for the sepsis that's the reason why we we not use a 41.9 because a 41.9 this code we have to use use only when we have not specified organism okay then negative or un inconclusive blood culture and sepsis negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patient with clinical evidence of the condition however the provider should be qu okay if negative or inconclusive blood cultures uh are there we have to query the provider eurosis the term eurosis is a non-specific term okay it has no default code in alphabetic index okay if uh the provider use this term he or she must be very for the clarification sepsis with organ dysfunction if a p patient has sepsis and Associated acute organ dysfunction or multiple organ dysfunction which is also known as m o mod if you uh come across the term mod that means multiple organ dysfunction okay follow the instruction for coding C sepsis okay you'll get uh coding instruction below the below each and every code we'll see here I'll show you here just a minute we have to go on to the index okay now here we have to choose sepsis okay here we can see cvsis code for CIS CIS okay r65.20 and if you see here directly r 65.2 because this is sub category of CES okay if you go go on this uh this code you can see here coding instructions applicable to this these terms use additional code okay if uh what what type of failure is there accordingly you have to choose the code from this categories okay if kidney failure 17 respiratory J 96 likewise and here they also mention that code first underlying infection okay this different kind of code we'll go through this guidelines also now but you can see here sepsis okay so to code s sepsis first you have to code seis code first you can see here code first A4 1.9 and this or any other code from this category okay okay so next one is acute organ dysfunction that is not CLE clearly associated with the sepsis if a patient has sepsis and an acute organ dysfunction but medical record documentation indicates that the acute organ dysfunction is related to medical condition other than sepsis do not assign a code from subcategory r65.2 which is for severe sepsis okay if that acute organ dysfunction is not associated with sepsis then you should not use r65.2 okay an acute organ dysfunction must be associated with the sepsis in order to assign severe sepsis code okay if the documentation is not clear query the provider to code r65.2 cvsis the documentation must be clear that that that organ dysfunction is due to sepsis for example sepsis and acute respiratory failure due to COPD exageration okay here we'll choose uh a 41.9 which is for sepsis unspecified organism then j44.1 which is for uh COPD with ex asservation uh then j96.00 which is for acute respiratory failure okay here although acute organ dysfunction is present in the form of acute respiratory failure will not we should not use sever sepsis Cod okay because acute respiratory failure is attributed to COPD ex asservation rather than the sepsis you can see here they mention that acute respiratory failure is due to cop they already mentioned okay so this respirator failure is not related to sepsis that the reason why we not use r65.2 in this example okay clear next one is C sepsis guidelines for C sepsis the coding of s sepsis requir minimum of two codes as I told you earlier first code for underlying systemic infection from like a 41.9 okay or any other code if causal organism is specified then you have to choose accordingly followed by the code from subcategory r65.2 which is for cbsis if causal organism is not documented assign a 41.9 which is pospis unspecified organism and the additional code for Associated acute organ dysfunction is also required okay so our coding must be a 41.9 then r65.2 and then additionally we have to code the associated organ dysfunction okay then next one is septic shock septic shock generally refers to circulatory failure associated with severe sepsis and therefore it represents a type of acute organ dysfunction okay for cases of severe septic shock the code for systemic infection should be sequenced first followed by code r65.21 which is for several sepsis with septic shock okay if only s CES is there then we have to choose r65.20 but here uh r65.21 because septic shock is there okay or code T 81.1 2 which is for postprocedural septic sh any additional CES for other acute organ dysfunction should be asside as additional okay sequenc sequencing of sever sepsis if sever sepsis is present on admission and meet the definition of principal diagnosis the underlying systemic infection should be assigned as a primary diagnosis followed by appropriate code from subcategory r 65.2 as required by sequencing rule in the table list as I told you earlier uh to CIS first we need to assign infection code like a 41.9 and then we'll code r65.2 okay and then any Associated organ failure next guideline is sepsis or sever sepsis with localized infection just a minute okay if the reason for admission is sepsis or severe sepsis and a localized infection such as pneumonia or cellulitis a code or codes for the underlying systemic infection should be assigned first and the code for localized infection should be assigned at secondary diagnosis okay if the patient has sever sepsis a code from subcategory r65.2 should be assigned as a secondary diagnosis okay if uh means if any patient come with sepsis or S sepsis plus localized infection such as pneumonia and cellulitis in that case first you have to uh code underly systemic infection okay and then the localized infection if the patient is at admitted with localized infection such as pneumonia and sepsis sever sepsis doesn't develop until after admission the localized infection should be assigned first followed by appropriate sepsis or sever sepsis Cod here in this guideline this guideline is for patient is already admitted for localized infection right so treatment is going on for uh localized infection in that case you have to first code localized infection and then after the patient develop sepsis or severe sepsis that's the reason why we'll code severe sepsis or sepsis as a secondary diis okay means uh it depends on reason for admission okay if reason for admission is sepsis and localized infection then we we have to choose sepsis as a primary but if the patient is already admitted for localized infection in that case we have to choose localized infection as a primary okay next is sepsis due to postprocedural infection documentation of causal relationship as with all postprocedural complications code code assignment is based on providers documentation of the relationship between the infection and the procedure okay sepsis due to postprocedural infection for infections following a procedure a code from t uh 81.4 to T 81.4 3 which is for infection following a procedure or a code from 86. to 86.3 infection of obsteric surgical wood remember I told you that if patient is pregnant we have to start our coding our primary code should must be from this uh pregnancy chapter which is started with o letter okay that's the reason if infection of obsteric surgical wound we have to choose o 86. to O 86.3 that identifies the side of infection should be coded first if no okay then assign additional code for sepsis following a procedure t 81.4 or sepsis following an tical procedure 86.4 and then then use an additional code to identify the Infectious agent me like a 41.9 okay so our first question must be if the sepsis due to postprocedural infection then our first course must be from T 81.4 to T 81.4 3 or if the patient is pregnant or if it is infection of oberic surgical wound primary code must be from 86. to 86.3 and the secondary code from T 81.4 4 which is for steps is following the procedure or if it is oper than 86.4 and then additionally we have to C infectious agent like a 41.9 if the patient has severe sepsis the appropriate code from subcategory are 65.2 should be assigned with additional code for any acute organ failure other guidelines are same as sever sepsis okay but primary uh we have to code this two we have to choose this two code okay next guideline is postprocedural infection and postprocedural septic sh if the postprocedural infection result in septic sh talk the ICD 10 cm chapter one guidelines instruct to First C stepsis due to postprocedural infection okay like uh we just saw in the previous guideline okay followed by code T8 1.12 postprocedural septic shop we have separate code for postprocedural septic shop okay we didn't have code for post-procedural severe sepis we have code for postprocedural sepsis and postprocedural septic sh okay so if postprocedural septic shock is there then we have to code those previous two codes then sepsis and then postprocedural septic shock code and then any related uh organ failure okay we'll see one example a 52 year old male is admitted with septic shock due to a postoperative infection of the small intestine following an appendectomy that has caused acute liver failure in this case we first code T 81.4 3xa which is for infection following a procedure organ and space surgical side initial encounter okay then we have to to code T8 1.44 XL which is for sepsis following procedure initial encounter then we have to code T 41.9 which is for sepsis unspecified organism then t8.1 2xa which is for postprocedural septic shock initial encounter and then T sorry K 72.00 which is for acute and Subacute failure without Cod if here uh this patient has C in that case we here instead of T 81.1 toxa we we have we must be coded r65.20 okay so this is the summary of of all the acidic codes for sepsis okay acidic codes for sepsis coding if the term sepsis is there we have to code from a 41.9 this is unspecified code for sepsis if causal organism is specified then you have to choose accordingly from this category okay but unspecified uh or default code is a 41.9 then if s seis is there our primary code must be a 41.9 which is for sepsis uh then r65.20 okay 20 is for sever sepsis without septic shock and plus additionally we have to code any related acute organ dysfunction Okay then if septic shock is there paramet code should be a 41.9 then r65.21 okay if septic shock is there then r65.21 okay because this code description is Sever sepis with septic shop right and then additionally any related organ dysfunction at least you have to uh bead this table this table is very much important okay in case of your uh medical coding interview medical coding exam or uh daily medical coding okay then we'll see seis coding for post procedural sepsis postprocedural sepsis is there then we have to go uh T 81.4 to t81 43 which is for infection following procedure or if just give [Music] me so this is table for postprocedural sepsis SE sepsis and septic shock if postprocedural sepsis is there we have to start our coding from T 81.4 to uh T 81.4 3 which is for infection following procedure okay or if the obsteric surgical wound is there or infection of obic surgical B is there then 86.2 86.3 so our first primary code should be from this category only okay then uh secondary code must be from T 81.4 which is for seis following procedure or if the OB if it is OB then 86.4 and then we have to code a419 okay for SE if it is s sees then uh coding changes from here 1 2 3 fourth fourth code okay fourth code must be R r65.20 if C is there other codes are same and additionally we have to code any acute organ dysfunction okay and if poster septic shock is there then also till a 41.9 it is same changes it changes from 1 2 3 4 fourth code must be t81 point 12 X8 okay which is for postprocedural septic shock okay here there is uh if even though patient is pregnant or it is uh this infection is related to obsteric there is no need of O code because uh we already given or assigned primary and secondary code from o okay that is the reason why there is only code for postprocedural septic shop this is common for optic wound and uh normal infection also normal postprocedural infection also and lastly we have to additionally code any acute organ dysfunction this is clear this is all about sepis coding okay now we'll see our next type of infection methine resistant stus orus M RSA methine resistant stus orus MSA okay MSA stands for me resistance or is a type of bacteria okay MRSA skin infections often develop around open source like Cuts scraps or bites but they also can in affect intact skin red swollen painful bumps appears that sometimes oo fluid or P called an absis some people also get fever okay we'll see guidelines for this selection and sequencing of MSA selection and sequencing of MSA Cod combination codes for MSA infection when a patient is diagnosed with an infection that is due to methine resistant stalo Cocos orus MSA and that infection has combination code that includes a causal organism for example sepis or pneumonia assign appropriate combination code for the condition for example uh code A 41.2 is for csis due to MSA or code J 15.1 uh 212 is for pneumonia due to M okay you'll find combination code with Mr you have to choose accordingly okay next guideline is methine susceptible tus orus and MSA colonization the condition or state of being colonized or carrying mssa or MRSA is called colonization or Carriage while an individual person is described as colonized or being a carrier okay means the condition or state of being colonized or carrying mssa or MRSA is called colonization or Carriage colonization means that mssa or MRSA is present on or in the body without necessarily causing illness okay me that patient is carrier of mssa or mrss whether it is symptomatic or un symptomatic okay a positive MSA colonization test might be documented by the provider as MRSA screen positive or MSA nule SW positive okay basically here you have to keep it in mind that there are combination course for Ms uh sorry MRSA infection and you have to choose accordingly next one is next type of infection is zika virus infection zika virus disease is an emerging viral disease transmitted through bite of infected mosquitoes okay if infected mosquito bites you you may cause zika virus disease okay symptoms like oh most of the infected person are asymptomatic or show mild symptoms like fever rash conjuctivitis or body a joint pain like this yeah severe form of disase requires hospitalization is uncommon and rare okay there is no vaccine or drug available to prevent or treat zika virus disase at present okay there is no vaccine for zika virus zika virus infection during pregnancy can cause infants to be born with micral micral means with small head okay then normal size and other congenital malformations okay see here this is the normal size of head but this is micro head where size of head is smaller than normal size okay code only confirm cases code only a confirm diagnosis of jika virus a a 92.5 which is for jika virus disas as documented by the provider if provider gives you conf information about this diagnosis then and only you have to choose a 92.5 which is for Jaa virus D okay in this uh context confirmation does not require documentation of type of test perform the providers diagnostic test uh statement that the condition is confirm is sufficient if provider is confirmed that this uh condition is confirmed then you have to uh or you are able to choose the a 92.5 code if the provider documents suspected possible or probable Z do not assign code a 92.5 instead assign a code which explaining the reason for encounter such as uh symptoms like fever rash or joint pain or z20.828 and suspected exposure to zika virus okay if uh means if the provider doesn't give you proper confirmation about this disease uh it provide a document suspected possible or probable zika virus infection or disase then you have to choose uh z20.828 to quote the associated mean reason for encounter which are mostly symptoms like fever rash or joint clear now we'll see Corona virus infection Corona virus disease which is also known as covid-19 okay Corona virus is a family of viruses that can cause illnesses such as common cold severe acute respiratory syndrome SARS that's the reason why it is also known as SARS SARS covid virus like this okay and middle is respiratory syndrome Ms okay many people with covid-19 have mild to moderate symptoms and can recover on their own okay but uh many people also die because of covid-19 you know that this is very dangerous disease if any for those patient or for those people which are at higher risk which uh which includes older peoples or peoples with existing medical conditions like cardiovascular diseases diabetes chronic respiratory diseases or cancer okay these peoples are at higher risk okay getting covid-19 vaccine help prevent serious illness and need need for hospitalization care due to covid-19 and death from covid-19 if you get proper vaccination of course covid-19 the chances of uh serious illness or need of hospital care or death are less okay the common sign and symptoms are like fever curve fatigue loss of taste and smell diarrhea headache rash conjuctivitis edges and pain sore throat like this okay people in Ed with Corona virus including Delta can also be un asymptomatic they may not show any symptoms all the people not showing any symptom right some people show fever curve some may lost their taste or smell some have headache or few people have no symptoms me they are asymptomatic okay if even though they get infected with Corona virus that's the that's the main reason this virus get spread correct we'll see guidelines for coding Corona virus infection infection due to SARS CO2 okay code only confirm cases this is the main guideline for each and every disase that is you have to code only confirmed cases okay only confirm diagnosis of 2019 novel Corona virus which is also known as covid-19 as documented by provider or documentation of positive covid-19 test result okay for a confirm diagnosis assign code u07.1 which is for covid 19 then if the provider document suspected possible probable or inconclusive covid-19 do not assign u07.1 instead code sign and symptom this guideline is common for each and every disase if patient sorry if the provider give you confirmation about any disease then and then only you have to code that particular this is code otherwise you have to go for sign and symptoms okay then sequencing of course when covid-19 meets the definition of principal diagnosis code u07.1 which is for covid-19 should be sequenced for followed by appropriate codes for Associated manifestations except when another guidelines require that certain course does sequence first because few such as operis or transplant complication these types of code requires uh primary position or you must code this type of code like I said said earlier obser code if you code for any pregnant patient your first code must be code okay in that casee you can't code u07.1 as a primary right if sepis is there you can't code u07.1 as a primary you have to go for sepis as a primary if transplant complications are there you have to code that code primary and then u07.1 otherwise you have the code u07.1 as a PR okay then acute respiratory manifestation of covid-19 when the reason for encounter or admission is a respiratory manifestation of covid-19 assign code u07.1 as a primary or first listed diagnosis and assign code for Respiratory manifestations as additional course okay the following conditions are examples of common respiratory manifestations of covid-19 pneumonia acute bronchitis low respiratory infection acute respiratory distress syndrome acute respiratory failure if you came across uh these conditions which are manifestation and the your provider is documented that this certain condition are manifestations of covid-19 then you have to choose U 7.9 which is for covid-19 as a primary and then you have to as a secondary or Additionally you have to code this conditions okay okay next gu line is nonrespiratory man manifestations of covid-19 when the reason for encounter or admission is nonrespiratory manifestations like viral enteritis of covid-19 assign code u07.1 as a primary and assign code for those manifestation as additional C the same guideline for both uh if it is respiratory man manifestations or non-respiratory manifestations of covid-19 your provider given it is related to co9 you have to code u07.1 as a primary then the additional code for manifestations okay then exposure to covid-19 for asymptomatic individuals with actual or suspected exposure to covid-19 assign code g282 to contact with and suspected exposure to covid-19 and for symptomatic individuals with actual or suspected exposure to covid-19 and infection has been ruled out or test results are inconclusive or unknown assign code G20 822 contact with suspected exposure to covid-19 okay means even though patient is symptomatic or a symptomatic exposure to covid-19 code is G80 sorry g282 okay but the sequencing is different because symptom obviously symptomatic uh individual comes with symptoms like fever or uh Cod something okay uh in that case you have to primary code those symptom and then you have to assign Z 20. 822 but if patient is asymptomatic this is the primary code 0.822 because you have no other option right then screening for covid-19 for screening for covid-19 including pre-operative testing assign code z11 .52 is for encounter for screening for covid-19 Okay g uh C 11.52 is for screening for covid-19 then we have signs and symptoms without definitive diagnosis of covid-19 for patients presenting with any sign and symptoms associated with covid-19 such as fever cold C Etc or loss of tast order Etc but a definitive diagnosis has not been established assign of appropriate code for each presenting sign and symptom okay means if covid-19 is not confirmed you should not call covid-19 you have to go for signning symptom only okay if a patient with sign and symptom with covid-19 also has an actual or suspected contact with or exposure to covid-19 assign z20.828 contact with exposure or exposure to covid-19 as additional code as I told you in earlier guideline if sign and symptoms are present and means sign and symptom associated with covid-19 are there and has actual or suspected contact with or exposure to covid-19 then at that time first we have to go for sign and symptom and then as additionally we have to code z20 822 okay a symptomatic individuals who test positive for covid-19 although the individual is asymptomatic the individual has tested positive and is considered to have the covid-19 infection okay means as I told you earlier uh some people didn't show any sign and symptoms of covid-19 but they have infection okay so if any patient who is owns asymptomatic but their test results are positive for covid-19 in that case we have to code covid-19 okay personal history of covid-19 for patient with history of covid-19 assign code Z 8616 which is for personal history of covid-19 then follow of visits after covid-19 infection has resolved if patient uh patient who previously has covid-19 without residual symptoms or or condition and are being seen for followup evaluation and covid-19 result are negative in that case assign g09 code which is for encounter for followup examination after completed treatment for condition other than malignant neoplasm plus Additionally you have to quote Z 8616 which is for personal history of covid-19 okay then next guideline is encounter for antibody testing for antibody testing encounter that is not being perform to confirm a current covid-19 infection nor is a followup test after resolution of covid-19 assign z01.84 which is for encounter for antibody response examination if patient come only for antibody testing okay in that case you have to use this code z01.84 then we have multi-stem inflammatory system uh sorry syndrome multi-stem inflammatory syndrome for individuals with multi-stem inflammatory syndrome Mis and covid-19 assign code u07.1 which is for covid-19 as a primary and assign M 35.81 which is for multi-stem inflammatory syndrome Mis as additional code okay if patient has both Mis and covid-19 your primary code must be covid-19 code and then M code okay if individual with history of covid-19 and he develop Mis assign Mis code and then U 9.9 which is for postco 19 condition on specif okay if patient has both Mis and covid-19 in active state in that case you have to choose covid-19 code as a primary and then M Cod but if individual develops Mis okay and that patient has history of covid-19 in that case you have to uh code M code as a primary and then choose 9.9 which is for postco condition as a second okay in that case you will not going to choose u07.1 which is for current covid-19 infection if an individual with un known or suspected exposure to covid-19 and no current covid-19 infection or history of covid-19 develops Mis assign codes M 35.81 and z20.828 contact with and exposure to covid-19 okay means if patient suspected exposure to covid-19 but no current covid-19 infection or history is there and he develop he or she develops Mis in that case our primary code must be M code followed by z20 822 if history is there in that case will code U 9.9 as a secondary code additional codes should be assigned for any Associated complications of M then postco 19 conditions for seila of covid-19 or Associated symptoms or conditions that develop following a previous covid-19 infection assign a code for the systemic uh sorry uh specific symptoms or conditions related to previous covid-19 infection if not and code U 9.9 which is for postco 19 condition unspecified okay code 9.9 should not be assigned for manifestation of any active or current covid-19 infection okay if any manifestation of current or active covid-19 infection is there you should not assign U 9.9 because U 9.9 is for postco 19 condition okay if the patient has a condition associated with previous covid-19 infection and develops a new active or current covid-19 infection Cod 9.9 may be assigned in conjunction with code u07.1 which is for active covid-19 to identify that person also has a condition associated with previous covid-19 infection okay because uh even though you previously got infe infected with covid-19 you can again get infected with covid-19 in that case we have to choose our CES accordingly under immunization for covid-19 status okay code Z 28310 is used for unvaccinated for uh for covid-19 which is a sign when patient has not receive a covid-19 vaccine and code Z28 311 which is for partially vaccinated for covid-19 which is for which is assigned when patient has been partially vaccinated for covid-19 if you took only one dose of covid vaccine in that case that means you have you are partially vaccinated or that patient is partially vaccinated in that case you have to choose Z 28. 311 okay and not if any patient is not at all vaccinated if he or she didn't receive any dose of vaccination of covid-19 that case we have to choose Z 28. 310 okay so these are all uh covid-19 guidelines I know these are very much confusing and there are lots of guidelines but I try to cover up all those CES in this table of I codes for covid-19 okay if the term covid-19 or uh positive diagnosis of covid-19 is there then you have to choose u07.1 which is for covid-19 and additional diagnosis should be used to report manifestations okay of covid-19 then if contact with and or suspected exposure to covid-19 in that case you have to use z20.828 822 if the patient is a symptomatic you will directly use z20 822 as a primary okay for late effects of covid-19 or postco 19 conditions you have to choose U 9.9 for current infection first code current symptom current symptoms or conditions then add code 9.9 at secondary diagnosis okay then for personal history of covid-19 Z 86.1 16 then follow of visits after covid-19 has resolved without residual symptoms or condition in that case we will choose z09 if encounter for antibody testing z01.84 is there screening for covid-19 Z 11.52 is there unvaccinated for covid-19 Z 28310 is there and partially vaccinated for covid-19 Z28 311 okay if you go through this table if you uh again and again go through this table you'll get uh understand and you will buy this P okay now we see some example we'll solve some examples are you ready please turn on your mic yes ma'am yeah so our first uh question is a 19y old patient is diagnosed with viral menitis what is appropriate ICD 10 cm code we'll see we'll try to find out this code okay by Iain data.com what we need to look for viral menitis okay we have to go on to the index okay and here we have specified that it is viral okay we have to look for viral term we got one Cod here see here it is mentioned viral maner is unspecified the code is a 87.9 so our answer is b a 87.9 which is for viral menitis okay then next question is a patient represents for um patient presents for result of a HIV testing which were negative what is appropriate I said 10 cm code can anyone tell me we didn't need to go through uh any search that man ma'am which was come again g21 g21 yes no read the question carefully patient present for result of HIV testing which were negative option which one z71.7 correct good this is code for HIV testing with negative result okay or just for counseling correct then we have uh our next next question is when a patient has a blood test for HIV HIV that is inconclusive what I think 10 code is assign options are z21 z11.4 B20 or r75 for inconclusive HIV test if you have that table I showed you at the starting of the session you'll get the answer r75 correct very nice the answer is D r75 which is for HIV in conclusive serology or blood test okay next question is pneumonia due to adino virus what is ICD 10 code b 34.0 j 12.0 b 97.0 or B 30.1 go through icd10 dat.com as I show you and then tell me I'll give you J12 J1 12.0 J 12.0 correct we'll go through once okay here we have to go on Pneumonia Peter pneumonia and here you can see adino virus okay pneumonia due to adus we go this Cod J1 12.0 okay so this is our answer J1 12.0 which is for pneumonia due to airus next question is a patient has a history of MRSA she has just been diagnosed with pneumonia due to possible stus orus what ICD CES is are reported J 18.9 and uh what happened here come again you're right come again option C ma'am J 18.9 J 18.9 uh and uh Z 86.4 okay so this is the correct answer for uh history of MRSA we code Z 86.1 4 and uh for pneumonia due to pneumonia J 18.9 because it is due to possible storus is not confirm that storus this infection is due to stus is confirmed not confirmed right that's the reason why we'll choose only pneumonia code j18.9 plus history code of mrss well done girls good so these are the answers okay once again thank you for your attention and making this session Interactive thank you if you find these sessions interesting if you want to join our medical coding training program you'll go to this given link below www.great online training.com and register yourself okay once again thank you bye-bye Take Care thank you ma'am bye ma'am welcome everyone to Great online training this is date nine and we are discussing currently we are discussing uh ICD coding guidelines chapter wise right uh in previous uh session we discuss guidelines about chapter 1 and today we're going to discuss guidelines of chapter 2 which is of neoplasm and code ranges from c00 to D4 9 okay myself Nikita I am a CBC certified medical coding trainer in great online training if you find this training session interesting please go to the given link below which is www.great onlinetraining tocom and register yourself okay so let's start uh in this uh session we'll going to discuss about the following topics like neoplasm and types of neoplasm then different terminologies used in in neoplasm diagnosis or neoplasm coding so today we'll discuss about neoplasm and types of neoplasm then we'll discuss about different terminologies used regarding neoplasm then we'll see ICD coding guidelines like uh first guideline is for uh admission or encounter for treatment of primary side if uh this is happened then which which type of code will we need to uh choose okay then treatment for uh secondary side then coding and sequencing of complications then primary and malignancy uh primary malignancy previously existed then admission encounter involving chemotherapy immunotherapy and radiation therapy then admission encounter to determine extent of malignancy okay uh then sign symptoms and abnormal finding listing in chapter 18 associated with neoplasm are there then which type of code or how we going to code that report that we going to see again we'll see if uh encounter for pain Control Management then I will going to qu uh then malignancy in two or more non-contagious sides is there uh then have code then disseminated malignant neoplasm unspecified then malignant neoplasm without specification of side if it is there which code we going to use that we'll see and lastly we'll see sequencing of neoplasm course and then after we'll solve some questions okay so let's start what do you know about neoplasm can anyone tell me anything you know about neoplasm you can share what is neoplasm or neoplasm and cancer is same or different or different or if you know any type of neoplasm that you can share at least you can tell me what is cancer or what is neoplasm ma'am it's a tube it's a tumor tumor okay and is the neoplasm and cancer is same or different not sure it's okay' yeah uh I'll tell you don't worry okay so neoplasm is the abnormal tissue growth due to uncontrolled division of cells that can be Vine or malignant Vine means uh non-cancerous whereas malignant is cancerous so basically neoplasm is neoplasm and cancer is not same okay both the terms are different because neoplasm can be benign means non-cancerous growth or can be malignant means cancerous okay all the neoplasms are not cancerous clear is it clear because neoplasms are of two type one is of benign type which is non-cancerous and um second one is malignant which which is cancerous okay or can be precancerous tumors okay so these are the types of neoplasm it is neoplasm is nothing but abnormal tissue growth due to uncontrolled division of cells okay you can see here in this diagram cancer cells dividing tremendously while normal cells are in normal shape and dividing normally right then example of benign neoplasms are like skin tags skin moles or utero fibroids and C these mostly these are uh non means not creating much problem right but sometimes we need to remove uh remove them also those are not spreading to other organs but uh they cause some problem like fibroid uterine fibroid they cause bleeding in women because of that they need to remove it right but they are not lifethreatening or not too much too much dangerous like malignant neoplasms okay so examples of malignant neoplasms are like lung cancer breast cancer or any skin cancer or any type of cancer is the example of malignant neoplasm okay examples of liquid neoplasms are Leukemia and Lymphoma okay which is cancerous is called malignant neoplasm and non-cancerous neoplasm are benine neoplasm like skin TX skin moles fibroids and cyst this is clear so neoplasm and cancer are not same few NE neoplasms are benign which are non-cancerous whereas other are malignant which are cancerous or precancerous tumor okay so there are three types of neoplasm benine precancerous and malignant you can see here benign tumor benign tumor is Under the Skin okay it is not spreading anywhere but malignant tumor is spreading okay to other organs okay the cells are tumor cells are spreading to another organs benine neoplasms grow slowly and can't spread to another tissues like skin for example skin tag skin moles fibroid and cyst precancerous neoplasm is another type of neoplasm these are growths that have not yet spread but have potential to become cancerous okay precancerous neoplasms are can become uh they have potential to become cancerous but not yet spread that is the reason why they call it as precancerous neoplasms and the third type is metastatic neoplasm this is a cancerous growth metastatic neoplasm means cancerous growth malignant neoplasm can grow in any body part and metasta means it can be spread to any other part of the body for example carcinomas sarcomas myomas leukemia lymphomas carcinomas uh making about 90% of all cancer cases like uh they are originated uh in your epithelial tissues such as skin or lining of your organs okay these are called carcinomas then sarcomas are begins in your connective tissues like your bones cartilage uh muscles tendons and fat whereas myomas which are also known as multiple myomas forms in plasma cells means your immune cells of your bone marrow okay okay leukemias are also known as blood cancers correct leukemias are also known as blood cancers and it is cancer of bone me because blood forms in bone marrow so it is cancer of bone marrow and the next type is okay so uh next type is lymphomas lymphomas develops in glands or nodes of your lymphatic system okay so carcinomas are normal cancers okay mostly 90% cancers are carcinomas develop under epithelial tissues whereas sarcomas are connective tissue cancers okay myomas are like multiple myomas form in plasma cells means your human cells of sorry immune cells of bone marrow then leukemias are also known as blood cancers which is nothing but cancer of bone marrow and lymphomas are developed in glands or nodes of your lymphatic system clear so this is uh three type of neoplasms B neoplasm which are non-cancerous precancerous neoplasm which are not yet spread but have potential to become cancerous okay and third is metastatic neoplasm which is cancerous and can be spread to another organ now we'll see terminologies regarding cancer or neoplasm primary neoplasm or primary cancer or primary malignant neoplasm means primary means were related to where from from where it is originated okay then secondary means where it uh it spread to which organ it is called metastasis okay metastasis to secondary site is called secondary neoplasm okay then inc2 means it is early stage of cancer before spreading okay early early stage of cancer before spreading is called in benine means not yet spread okay or non-cancerous uncertain Behavior means mass is neither benign or malignant okay uncertain Behavior means the behavior of that mass is not yet identified means it is V or malignant that not yet identified then unspecified Behavior means provider has not or cannot determine the behavior okay here uncertain Behavior means Behavior can't be uh identified okay yet uh whereas un specified Behavior means provider has not or cannot determine the behavior you can see here in diagram primary tumor the cell detach from the tumor and then Invasion happens and it transport through blood vessels or blood vessel and exavation extra is there then micr metastasis then colorization and then macro metastasis happen Okay and it forms secondary tumor it is clear okay now we'll start our ICD coding guidelines for neoplasm chapter okay this chapter contains the CES for most benign and all malignant neoplasm okay mostly all the benign and malignant neoplasms covered in this chapter okay code ranges from C to uh d right certain Bine neoplasm such as prostetic adomas may be found in the specific body system chapters okay because uh few CES like prosthetic adomas you can uh you will find in specific chapters right to properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign in malignant or of Uncertain histologic Behavior okay if malignant any secondary metastatic site should also be determined okay obviously if it is malignant uh there it must be uh there is there must be first uh something primary site is there and secondary site is also there so you have to search for it in your reports in your patient report the table of neoplasm should be used to identify the correct topo topography code in some cases such as malignant um melanoma and certain neuron Endo endocrine tumors the morphology mean histology is included in category and course okay to search for neoplasm to make it easier uh we have or this course are arranged in table of neoplasm okay I'll show you how it is arranged I can show you here here I cd1 data.com here you can see uh in index icd1 CM index external cause index table of drug and lastly table of neoplasm if you click here okay we'll see this index again now you can see here name change table of neoplasm okay now here you have to search for your uh side specific side if if we need to search code for breast cancer then we'll go on B and type here breast okay see here you can find breast neoplasm and these are the types okay different types uh neoplasm Cordes are divided into six categories malignant primary malignant secondary okay then uh cancer in C2 then B9 then uncertain behavior and lastly unspecified Behavior okay like this this table is divided okay we'll see next guideline primary malignant neoplasm overlapping side boundaries overlapping implies that the sides invol are contigous contous means the sides are next to each other okay a neoplasm that overlaps continuious sides and whose point of origin cannot be determined should be classified to the subcategory8 okay means point8 is designated to overlapping Legion okay if any code consist uh8 in subcategory it means overlapping Legion unless the combination is specifically indexed Elsewhere for example uh overlapping tongue primary carcinoma of the tip and vental surface of the tongue okay here you can see overlapping tongue primary carcinoma of the tee and ventral surface of the tong mean these are two different uh sides okay of the tongue H it is not known which of the site the tumor originated okay we don't know in this uh in this example we don't know about the origination of the tumor whether it is uh tongue tip or vental Surface okay we don't know the origin of the tumor that's the reason why we'll assign c0 2.8 code which is for malignant neoplasm of overlapping Legion of T okay if our provider is specifically mentioned that uh it is originated from to T okay or originated [Music] from vetal surface then we'll code accordingly that site as a prim okay for multiple neoplasms of the same side that are not contagious such as tumors in different quadrants of the same breast okay if uh tumors in different quadrants of the same breast means uh in the right breast if uh two quadrants have tumors then code for each side should be assign okay the next guideline is malignant neop PLM of ectopic tissue malignant neoplasm of ectopic tissue should be coded to the site of origin documented for example ectopic pancreatic malignant neoplasm is coded to unspecified malignant neoplasm of pancrea which is nothing but c25.9 don't worry about it you don't need to by hard this course okay you have to learn how to search this course okay or how to uh give proper sequencing or select proper code for that scenario okay or for that condition because this CES can be changed in any year these CES are updated every year that's the reason why you don't need to by heart any code you just know how to search and uh in which category you will going to find this code okay so the first guideline is admission or encounter for treatment of primary site if treatment is directed at the primary site designate the primary malignancy as principle or first listed diagnosis okay means if treatment directed towards primary side you have to code that primary cancer as a principal diagnosis if administration of chemotherapy immunotherapy or external beam radiation therapy is cheaply responsible for occasion of admission or encounter okay means if patient is uh came to the hospital just for chemotherapy immunotherapy or external beim radiation therapy means therapy of uh cancer in that case you have to assign appropriate z51 point we have few character uh those codes we have to use as a first listed or principal diagnosis principal or first listed diagnosis means you have to uh give that code or assign that code as a primary okay while while coding there uh there is number for diagnosis okay so I first number you have to give this code okay that means first listed on principal diagnosis okay so Z 51 Point accordingly you have to choose the Cod but z51 is common and uh other characters changes according to chapy immunotherapy and external beam radiation therapy so if admission is for uh cancer therapy you have to choose Z 51 code for as a primary service then admission encounter for treatment of secondary site when a p patient is admitted because of primary neoplasm with metastatis and the treatment is directed towards secondary site only okay means patient has uh primary neoplasm with metastasis that primary neoplasm spread somewhere else and treatment is directed towards that secondary side only in that case you have to code uh that secondary neoplasm as primary diagnosis okay even though primary malignancy is still present okay because treatment is for secondary neuroplasm it's basically in this two uh two guidelines they said they want to say that your preference or sequencing preference or primary diagnosis must be depend on the treatment okay or reason for encounter if a reason for encounter is primary site of cancer then you have to code primary site as a principal diagnosis if reason for encounter is cancer therapy then you have to code uh therapy code which is nothing but z51 codes these are primary course if it is encounter for treatment of secondary side then you have to code secondary or neoplasm as a principal diagnosis okay next one is coding and sequencing of complications complications associated with malignancy or with therapy thereof are subject to following guidelines okay the guidelines are like if anemia associated with with malignancy okay anemia associated with malignancy the appropriate code for malignancy sequence as a principal diagnosis followed by appropriate code for Ania okay if because this anemia is associated with malignancy okay that's the reason why our principal code is that malignancy code that cancer code followed by d63.0 which is for anemia in neoplastic disease we have to choose this code d63.0 because this Ania is associated with neoplastic disease you can't choose other anemia code okay but our primary or principal diagnosis is cancer followed by d63.0 next anemia associated with chemotherapy immunotherapy and radiation therapy means cancer therapy when encounter is for management of anemia associated with an adverse effects of administrations of chemotherapy or immunotherapy and the only treatment is for anemia okay here if the treatment is for anemia the anemia code is sequenced first followed by appropriate code for neoplasm and adverse effects okay when anemia is associated with cancer therapy in that case you have to code anemia as a primary then that neoplasm and then adverse effect which is code used for adverse effect is t 45.1 x five okay and so on the characters other characters are also required Dash means okay this description is adverse effect of anti-neoplastic and immunosuppressive drugs then third guideline is management of dehydration due to malignancy okay if encounter is for management of dehydration due to Mal Y and only dehydration is being treated okay through intravenous rehydration the dehydration is sequence first followed by malignancy code okay next is treatment of a complication resulting from surgical procedure when treatment for complication resulting from surgical procedure design complication as principal diagnosis if treatment is directed at resolving that complication next guideline is primary malignancy previously excised when primary malignancy has been previously excised or eradicated from its side and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that particular site code from category z85 which is for personal history of malignant neoplasm should be used to indicate the former site of the malignancy okay if that uh previously existed or that primary malignancy has been previously excised uh excised or eradicated from its side and there is no evidence of uh primary malignancy at that particular side in that case only we can use history code okay personal history code which is from category z85 any mention of extension Invasion or metastasis to another side is coded as secondary malignant neoplasm to that site okay if uh in that uh if any mention of extension Invasion or metastasis to another site is present in that report uh then we have to code it as secondary malignant neoplasm okay the secondary side May um must be P principal diagnosis followed by z85 code as a secondary clear means if primary malignancy is ex excised or completely eradicated from that side and there is no evidence of uh primary malignancy at that particular s side we we have to use the code history code okay but that cancer already get spread to another side we have to quote that cancer as secondary malignant neoplasm plus we'll also have to give history code because there is no evidence of primary malignancy next guideline is admission encounters involving chemotherapy immunotherapy and radiation therapy first one is episode of care invols surgical removal of neoplasm when care in involv surgical removal of neoplasm primary or secondary site followed by adint chemotherapy or radiation treatment during the same episode of care the code for the neoplasm should be assigned as principle or first listed diagnosis okay okay next patient uh patients encounter solely for administration of cancer related therapy okay in that case we'll use G 51.0 which is for radiation therapy z51.11 which is for uh chemotherapy then Z 51.1 2 which is for immunotherapy okay this any one code from from this or if needed if uh if patient receive more than one of these therapies during the same admin uh ad admin if a patient receive more than one of these therapies during same admission okay we can choose more than one code also as for first listed or principal diagnosis right third one is patient admitted for radiation therapy chemotherapy or immunotherapy and develops complication when patient is admitted for purpose of external beam radiation therapy immunotherapy or chemotherapy and develops complications such as uncontrol nausea vomiting or dehy add the principal or first listed diagnosis is g51 okay g51 series followed by any course for complications okay if patient admitted for cancer related therapy and develops complication in that case we'll code z51 category code as a primary followed by complication code then we'll see admission encounter to determine extent of malignancy okay when the reason for admission or encounter is to determine extent of malignancy such as uh paracentesis or thoracentesis the primary malignancy or appropriate metastatic site is designated as principal or first listed diagnosis okay the patient go came for determin determining the extent of malignancy through the procedure such as such as paracentesis or thoracentesis our first listed diagnosis is that uh particular malignancy site symptoms signs and abnormal finding listed in chapter 18 associate ated with neoplasm chapter 18 is of sign and symptoms and abnormal finding chapter okay if these sign and symptoms are related with neoplasm in that case an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal or first listed diagnosis regardless of number of admission or or encounter for the treatment okay next is admission and encounter for pain control and management okay when pain control or pain management is reason for uh admission okay the underlying cause of pain should be reported as additional diagnosis if no pain control means like a patient with displac inter uh invertebral RK nerve impingement and severe back pain present for injection of steroid into SP uh spinal canal in that case underlying cause of pain should be reported as additional diagnosis next guideline is uh malignancy into or more non-contagious SES a patient may have more than one Mal alant tumor in the same organ okay patient may have more than one malignant tumor in the same site or same organ these tumors may represent different primaries or metastatic disease depending on the side should the documentation be unclear the provider should be caried as to status of each tumor so that correct code can be assigned okay if uh more than one malignant tumor present in the same organ and you have uh different type of them then and there is no clear documentation about it which is primary which is metastatic okay in that case you have to query the provider disseminated malignant neoplasm unspecified code c80 disseminated malignan neoplasm unspecified is used uh for only in those cases where the patient has advanced metastatic disease and no known primary or secondary side are specified okay if uh patient has advanced metastatic disease means so there is no documentation of any primary or secondary site uh in the report but patient has advanced metastatic disease in that case you have to choose C 80.0 code which is for disseminated malignant neoplasm unspecified side it should not be used in place of assigning codes for primary site and all known secondary s if you know uh code means nonn primary side or secondary side in that case you don't need to use this c80 code M next is malignant neoplasm without specification of site Cod c80.1 which is for malignant or primary neoplasm unspecified which is equivalent to cancer unspecified this code should only be used when no determination can be made as the primary site of malignancy okay if there is no documentation of primary malignancy site in that case you have to goote c80.1 which is for for unspecified cancer then we'll see sequencing of neoplasm C okay encounter for treatment of primary malignancy as we uh learned earlier if treatment is for primary malignancy we have to code that primary malignant neoplasm as a principal diagnos is followed by metastatic site encounter for treatment of secondary malignancy if treatment is for secondary malignancy we have to quote that metastatic site as a principal diagnosis along with primary malignancy as additional Cod means it depends on treatment or reason for encounter okay if for encounter is primary malignancy treatment for primary malignancy we have to quote primary malignancy cancer as principal diagnosis if treatment is for secondary malignancy we have to qu secondary malignant site as a principal diagnosis malignant neoplasm in pregnant patient when pregnant patient has malignant neoplasm a code from category 09 A.1 and so on which is for malignant neoplasm complicating pregnancy child birth and the puparium should be sequenced first because I have uh as I told you earlier for pregnant patient we have to code start our coding from o codes okay our primary code from the O category okay or uh this obsteric category there is code for neoplasm complicating pregnancy which is 09 A.1 series okay this Cod should be sequence first followed by appropriate code from this neoplasm chapter to indicate type of neoplasm clear then next one is encounter for complication associated with neoplas when encounter is for management of complication associated with neoplasm such as dehydration and treatment is only for complication in that case complication is coded first followed by neoplasm code then complication from surgical procedure for treatment of a neoplasm when an encounter is for treatment of complication resulting from from a surgical procedure perform for treatment of neoplasm designate complication as primary or principal diagnosis and pathological fracture due to neoplasm when encounter is for pathological fracture due to neoplasm the and the focus of treatment is fracture in that case code from subcategory M 84 .5 which is for pathological fracture in neoplastic disease should be sequenced first followed by neoplasm code okay if patient come with pathological fracture due to neoplasm and treatment is for that fracture only in that case we have to code M 84.5 which is for pathological fracture in neoplastic disease as a first listed diagnosis followed by neoplasm code okay and if the focus of treatment is neoplasm with Associated pathological fracture neoplasm code should be sequenced first followed by m4.5 which is for pathological fracture in neoplastic disease means again sequencing is depend on reason for encounter okay but you have to keep it in mind this code that M 84.5 which is for pathological fracturing neoplastic disease then current malignancy versus personal history of malignancy when primary malignancy has been excised but further treatment such as additional surgery for malignancy radiation therapy or chemotherapy is directed to that side the the primary malignancy code should be used until treatment is completed as we uh see in early previous guidelines also if there is presence of that uh primary malignancy site okay in that case or if treatment is going on uh for that primary malignancy site we have to use primary malignancy code for that side okay when primary malignancy has been previously excised or eradicated from its sides there is no further treatment of the malignancy directed to that side and there is no evidence of any existing primary malignancy at that side a code from category z85 which is for personal history of malignant neoplasm should be used to indic former site of malignancy okay mean if there is no evidence of that previously excised primary malignancy we have to use z85 code which is for personal history and if there is a treatment going on for that particular primary malignancy site we have to code primary malignancy code only we can code that scenario as history next is Leukemia multiple Myoma and malignant plasma cell neoplasms in remission versus personal history okay the category for leukemia and category C90 multiple Myoma and malignant NE malignant plasma cell neoplasms have Cordes indicating whether or not the leukemia has achieved remission okay there are also CES Z 85.6 personal history of leukemia Z 85.7 9 personal history of other malignant neoplasm of lymphoid hematopoetic and related tissues if the documentation is unclear as to whether leukemia has achieved remission the provider should be queried okay the next guideline is malignant neoplasm associated with transplanted organ if malignant neoplasm of transplanted organ it is called as transplant complication okay assign code from category t86 which is for complic ations of transplanted organs and tissue followed by code c8.2 which is for malignant neoplasm associated with transplanted organ okay and plus use additional CES for specific malignancy correct if malignant neoplasm associated with transplanted organ first you need to code from category t86 which is for complication of transplanted organ and then secondary code must be from c8.2 which is for malignant neoplasm associated with transplanted organ and then additional code for specific malignance next one is breast implant Associated anaplastic large cell lymphoma okay breast implants Associated anop plastic large lymphoma also known as b i a a l c l b i a l c means breast implant Associated anaplastic large cell lympo b i a a l c is a type of lymphoma that can develop around breast implants okay assign code C 84.7 A and plastic large cell lymphoma Al K negative breast for B A Al L CL do not assign a complication code from chapter 19 okay if breast implant Associated anop plastic lar lymphoma is there assign code c847 a next is secondary malignant neoplasm of lymphoid tissue see here this is the primary tumor which is primary site from here metastasis happen to lymph node and this cancer cell disseminated of Tolerance metastasis to distance isues okay when malignant neoplasm of lymphoid tissue metastases uh beyond the lymphoid node a code from category c81 to c85 with a final character nine should be assigned identifying extra noal and solid organ sites okay rather than a code for secondary neoplas plasm for affected solid organ okay for example for metastatis of B cell lymphoma to lung brain and left adrenal gland assign c c 8339 fourth character or final character four not fourth fifth character or final character must be n which is uh indicative of extra noal and solid organ s okay diffuse large B cell lymphoma extra noal and solid organ sites okay because this lymphoma is spread to another distant organs correct now we'll see questions please open your uh icd10 cmd.com and try to find out the answers our first uh question is a patient is seen for a malignant neoplasm of sigmoid colon try to search code and tell me then we will find you have to search into neoplasm table table of neoplasm ma answer is option C ma'am C see 18.5 okay we'll check anyone any other answer what okay we'll find I'm sorry M yes tell me no we'll find find it7 ma'am s we'll find out it okay we have to go on index and then table of neoplasm then we have to search for colon okay sigmoid colon is there that's the reason why we have to search for colon see here Cod is C 18.9 because it is malignant neoplasm Mal cancer of colon okay malignant tumor of colon clear so our answer is a c8.9 not 7 or .5 c8.9 is correct answer for NE malignant neoplasm of sigmoid colar next uh question is patient present with love on his left thigh it has been present for several months and is not painful exam reveals a lipoma mean you have to go and search code for lipoma of left th try to find out the rec code and tell me done any answer you have to go ma'am yes tell me D ma'am okay we'll search we have to to go on to normal index okay because we have to search board for lipoma then L term here we have to type it down lipoma then into the lioma we have to search for particular site we can see here site classification arms connective tissues then we have here uh do we have thigh no so we have to search for leg we have leg okay we have to click on this code and in here we can find left leg okay because we have uh lipoma of left side right so it is D 17.24 that is the correct answer very good you can see here lipoma of left lower limb okay or left leg so answer is d d 17.24 lipoma of left thigh because as there is no specific code for thigh we have to choose like cod okay if if there is a code for thigh we will go for that code only right next question is patient with carcinoma of the tip of the tongue extending to involve a vental surface carcinoma of the tip of the tongue extending to involve ventral surface of the term for this question you have to go through table of neoplasm any answer you have to search for tongue but in tongue also so we have specific site tip of the term this is little bit tricky question because options are almost same also option b option b okay any other answer okay we'll search for for it for this question we have to go on to table of neoplasm [Music] again what is happening okay and we have to search for tongue okay we we have here C 0 2.9 Cod we go on this code but here it says malignant neoplasm of tongue unspecified okay mean site is not specified here but we have a specific site okay so first we need to search whether we have code for that particular site or location okay for that reason we need to go on this C 02 C02 you have to click on this and here again greater level of detail because this code is not complete code you can see here Red symbol right so this is nonb or non-specific code we have to go on this greater level of details to search our code now you can see here different codes Under C02 C 0 2.0 is for dorsal surface then1 is for border of the ter then ventral surface and so on okay our in our question we have tip of the T tip of the t comes under border of the term right that's the reason why we'll choose this code this is the appropriate code you see malignant neoplasm of border of tongue you can see here applicable to malignant neoplasm of tip of the tongue right understand first you need to try to search for specific code because here we have term tip of the term so uh we can't directly choose unspecified code first we need to search for uh is there any specific code for that particular site or location okay and we have that code that's the reason why we append on this code c2.1 okay so our answer is C c0 2.1 next question is a patient is in her second trimester and was found to have follicular thyroid cancer here don't take tension about this o CES or Z CES just tell me answer for C CES means can answer for again to find this follicular thyroid cancer you have to go through neoplasm table just tell me code for cancer only you have only two options for that can C c73 or c759 because in this two options we have C7 5.9 C ma'am C o9 A113 Z3 a02 and c 75.9 means you want to say folicular thyroid cancer code is C 75.9 correct we'll find out it yes ma'am okay again we have to go on this table and go for search for thyroid here see 73 cancer for thyroid cancer for follicular thyroid okay this is wrong C option is wrong option again you can uh how can you rule out the options I'll tell you in this case first you have to search for uh there is no need to go anywhere okay to search the code at the first time because the this question has obsteric code okay and in obster codes the last digit is representing of trimester so here second trimester is there so we need two as a last character okay of this o code so we have only this two option correct these two options are wrong that is confirmed but our in these two options also we have two types of code thyroid code thyroid cancer codes c73 and C 75.9 so we have only two option A and B if you find the cancel code will will get c73 okay so our correct answer is a 09 a112 2 is representative of uh the secondary trimester second trimester then Z 3 a. and then c73 because follicular thyroid cancer is c73 okay while going for any uh exam this medical coding exam you'll get same type of question okay you have four type of four options multiple choice questions are there and you have four options so you need to know how to rule out the answers so that it will be easy to uh find the correct answer okay next question is patient with viral hepatitis C and continued alcohol use is diagnosed with malignant primary neoplasm of the liver just the code for malignant primary neoplasm of liver again you need to go through table of neoplasm only but try to find out D ma'am D you to you want to say C 22.9 is correct Cod okay we'll see we have to go here and I'm sorry we have to find for liver right okay in liver we'll find Malignant primary C 22.9 but if you uh read the description it says malignant neoplasm of liver not specified as primary or second right but in our question it is mentioned that malignant primary neoplasm of liver right so again like we do in previous question you have to go on this c22 category greater level of details and here we have to search for specific code here you can see C2 22.8 which is for malignant neoplasm of liver primary okay so this is code for primary malignant neoplasm of liver this is specific code C 22.9 not specified as primary or secondary okay but C 22.8 is specified for primary set malignant neoplasm of primary specified here also you can see primary malas of Li again here b19.20 is for viral hyptis C and F 10.99 is for alcohol use okay like this you have to solve your questions once again thank you for your attention thank you for making this session interactive and have a good day if you like this session if you like to learn medical coding with me and if you want to 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