HIM1103 Module 01 Lab Activity - Explore 3 Coding Systems Student Worksheet update 2023 11.11.22
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Module 01 Lab Activity - Explore 3 Coding Systems
Note: There are three sections to complete for this lab worksheet. Each section is for a different coding system. Pre-requisite:
Read the Lesson Content for Module 01 and listen to the Live Classroom session recording.
Instructions:
Enter all responses directly in this worksheet. Submit the completed worksheet to the drop box for grading.
Tip:
A good rule to remember in coding is that reading slowly for understanding is very important in learning the skill of coding, even when you are coding on the job. Even experienced coders have to remember this rule. And always double check your work to ensure accuracy…even experienced coders do that.
Section 1: ICD-10-CM Coding System
Instructions:
For each diagnostic statement on the left, identify the Main Term, and list it in
the column on the right.
Diagnostic Statement
Main Term 1.
Benign Hypertension
Hypertension
2.
Follicular Cyst
Cyst
3.
Acute sinusitis
Sinusitis 4.
Juvenile arthritis, knee
Arthritis
5.
Adult onset diabetes
Diabetes 6.
Chronic persistent atrial fibrillation
Fibrillation
7.
Cystic fibrosis
Fibrosis
8.
Acute aspiration pneumonia
pneumonia
9.
Chronic orthostatic hypotension
hypotension
10. Appendicitis with rupture NOS
Appendicitis
11. COPD unspecified
COPD
12. Hyperlipidemia, unspecified Hyperlipidemia
13. Nausea, unspecified, without vomiting
Nausea
14.
Cirrhosis, liver
Cirrhosis 15.
Viral hepatitis
Hepatitis
Instructions:
For each characteristic description on the left, specify the unique characteristic of the ICD-10-CM, and list it in the column on the right.
Characteristic Description
Unique Characteristic
1.
Indicate the number of characters in an ICD-10-CM code
An ICD-10-CM code consists of 3 to 7 alphanumeric characters.
2.
State the character that is ALWAYS an alphabetic character
The first character is always alphabetic. 3.
Are there any letter values not used in ICD 10 CM codes?
All letters are used in the ICD 10 CM coding system
4.
Specify where the decimal point is placed in the code
A decimal point is placed after the first three characters.
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5.
Indicate the character that is ALWAYS a numeric value
The second character is always numeric. 6.
State the Placeholder character value The placeholder character is always the letter X
Section 2: CPT Coding System
Instructions:
For each characteristic description on the left, specify the unique characteristic of the CPT Code, and list it in the column on the right.
Characteristic Description
Unique Characteristic
1.
State the number of digits in the CPT
5-digit code.
2.
Indicate the type of setting where CPT codes are typically used
Outpatient facilities, office, lab, 3.
Indicate what is included in the term “procedures” which describes services and what type of tests
Procedures include diagnostic test as well.
4.
Specify where the guidelines for CPT
coding are located in the code book
Specific guidelines are located at the beginning of each section. 5.
Identify the next step in the coding process after identifying the main term index
The next step would be the modifying term.
6.
Name the 2 character extension applied to the 5-digit CPT to provide information regarding certain circumstances that are relevant to the service performed
Modifiers are 2 characters extensions to the
CPT code. 7.
State the 2 categories of office visits
New Patients and Established Patients are the two categories for office visit.
8.
Name the 4
th
classification of main terms in addition to:
Procedure or service (Endoscopy or
splint)
Organ or other anatomical site (Fibula, bladder)
Condition (Abscess)
Synonyms, Eponyms, and abbreviations. (brace, cast , bartholin’s gland, EKG)
9.
Explain the purpose of a “Modifying Term”
The modifying term brings more detail to the main term. 10. State where the Index is located in the CPT code book
The index begins on page 1082 in the back of the book. Page 2
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Section 3: ICD-10-PCS Coding System
In this section, you will be identifying the 3
rd
Character (Root Operation) and the 4
th
Character (Body Part) from the statements provided. Use the Root Operation Information provided below to help you complete this section. Root Operation Information
Name
Definition
Examples
Resection
Complete removal of a body part
Appendectomy, cholecystectomy, tonsillectomy
Excision
Partial removal or biopsy of a body part
Removal of a cyst or lesion, biopsy, sampling of a body part
Detachment
Complete removal of an extremity
Amputation
Fragmentation
Breaking up solid matter into pieces
Lithotripsy
Reposition
Moving a body part to its normal location or other suitable location
Reduction of a displaced fracture
Inspection
Visual or manual exploration of a body part
Colonoscopy, bronchoscopy, examination of the ear
Occlusion
Completing closing off a tubular body part
Sterilization-ligation of the fallopian tubes
Replacement
Placing a device that replaces a body part
Knee or hip replacement
Repair
Restoring the body part to its normal structure
Suture of a laceration
Bypass
Altering the route of passage
Coronary artery bypass, colostomy
Instructions:
For each procedural statement below, list the associated root operation and body part(s). Be sure to include all descriptors for the body parts (e.g., left, distal etc.).
Procedural Statements
Root Operation
Body Part(s)
Example: Colonoscopy with removal of a polyp from the ileocecal valve for diagnostic purposes.
Excision
Ileocecal Valve
1.
Cholecystectomy with complete removal of the gallbladder Resection
Gallbladder
2.
Sigmoidoscopy for diagnostic purposes
Inspection
sigmoid
3.
Total Right Knee Replacement
Replacement
Knee
4.
Partial removal of a lymph node for biopsy Excision
Lymph node
5.
Sterilization by ligating the vas deferens
Occlusion
Vas deferens
6.
Suture of a large laceration on
the right index finger
Repair
finger
7.
Non-coronary bypass of the left femoral artery
Bypass
Femoral artery
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8.
Amputation of the right foot due to necrosis
Detachment
foot
9.
Extracorporeal shockwave lithotripsy (ESWL) of the right kidney due to calculus
Fragmentation
Kidney
10. Reduction with internal fixation of a displaced fracture
of the right tibia
Reposition
Tibia
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