HIM1103 Module 01 Lab Activity - Explore 3 Coding Systems Student Worksheet update 2023 11

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May 2, 2024

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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. Page 1 of 4
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 of 4
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