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Business and Information Technology Education
Procedural Coding
This course introduces the basic principles and conventions of the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System coding. It simulates the application of coding principles with examples and exercises based on actual case documentation.
Jaimee Sizemore
Instructional Coordinator
Ph: (918) 828-5093
Foundations of Medical Office Assistant/Medical Terminology, Medical Insurance, and Patient Billing
A. Utilize Appendices.
1. A-D Descriptions1
2. Definitions1

B. Understand Introduction to CPT and HCPCS Coding.
1. Identify the uses of the CPT manual.
2. Name the developers of the CPT manual.
3. Identify placement of CPT codes on the CMS-1500 insurance form.
4. Know the importance of using the current-year CPT manual.
5. Recognize the symbols used in the CPT manual.
6. Identify the content of the CPT appendices.
7. Locate the major sections found in the CPT manual.
8. Interpret the information contained in the section Guidelines and notes.
9. Describe the CPT code format.
10. Append modifiers.
11. Describe what is meant by unlisted procedures/services.
12. Review Category II and III CPT codes.
13. State the purposes of a special report.
14. Locate terms in the CPT index.
15. Demonstrate the ability to assign HCPCS codes.
16. List the major features of Level II National Codes, HCPCS.

C. Applying Modifiers.
1. Recognize modifiers.
2. Understand the purpose of modifiers.
3. Assign Increased Procedural Services modifier -22.
4. Assign Unusual Anesthesia modifier -23.
5. Assign Unrelated E/M Services by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period modifier -24.
6. Assign Significant Separately Identifiable E/M Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service modifier -25.
7. Assign the Professional Component modifier -26.
8. Assign Mandated Services modifier -32.
9. Assign Preventive Services modifier -33.
10. Assign Anesthesia by Surgeon modifier -47.
11. Assign Bilateral Procedure modifier -50.
12. Assign Multiple Procedures modifier -51.
13. Assign Reduced Services modifier -52.
14. Assign Discontinued Procedure modifier -53.
15. Assign Surgical Care Only modifier -54.
16. Assign Postoperative Management Only modifier -55.
17. Assign Preoperative Management Only modifier -56.
18. Assign Decision for Surgery modifier -57.
19. Assign Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period modifier -58.
20. Assign Distinct Procedural Service modifier -59.
21. Assign Two Surgeons modifier -62.
22. Assign Procedure Performed on Infants Less than 4 kg modifier -63.
23. Assign Surgical Team modifier -66.
24. Assign Repeat Procedure or Service by Same Physician modifier -76.
25. Assign Repeat Procedure by Another Physician modifier -77.
26. Assign Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period modifier -78.
27. Assign Unrelated Procedure or Service by the Same Physician During the Postoperative Period modifier -79.
28. Assign Assistant Surgeon modifier -80.
29. Assign Minimum Assistant Surgeon modifier -81.
30. Assign Assistant Surgeon (When Qualified Resident Surgeon Not Available) modifier -82.
31. Assign Reference (Outside) Laboratory modifier -90.
32. Assign Repeat Clinical Diagnostic Laboratory Test modifier -91.
33. Assign Alternative Laboratory Platform Testing modifier -92.
34. Assign Multiple Modifiers modifier -99.

D. Evaluation and Management (E/M) Services.
1. Identify when to use E codes.1
2. Identify and explain the three factors of E/M code assignment.
3. Differentiate between a new and an established patient.
4. Differentiate between an inpatient and an outpatient.
5. Explain the levels of E/M service.
6. Review the key components.
7. Analyze the key component history.
8. Analyze the key component examination.
9. Analyze the key component in medical decision making.
10. List contributory factors.
11. Analyze code information.
12. Analyze the types of E/M codes.
13. Demonstrate the ability to code E/M services.
14. Identify CMS Documentation Guidelines.

E. Anesthesia and Surgery Guidelines.
1. Define types of anesthesia.
2. Explain the format of the Anesthesia section and subsections.
3. Understand the anesthesia formula.
4. Demonstrate the ability to code anesthesia services.
5. Identify use of other modifiers with anesthesia codes.
6. Understand the Surgery section format.
7. Locate notes and Guidelines in the Surgery section.
8. State the uses of the unlisted procedure codes.
9. Interpret elements of a special report.
10. Examine the separate procedure designation.
11. Analyze the contents of a surgical package.
12. Determine the contents of the General subsection.

F. Explain the Link Between Codes and Medical Billing.
1. Identify how CPT and ICD-9-CM codes are used in medical billing.1

G. Practice Coding-Integumentary System.
1. Describe the format of the Integumentary System in the CPT manual.
2. Identify the elements of coding Skin, Subcutaneous, and Accessory Structures services.
3. Review the main services in Nails, Pilonidal Cyst, and Introduction.
4. Identify the major factors in Repair.
5. State the important coding considerations in destruction, Mohs micrographic surgery, and breast procedures.
6. Demonstrate the ability to code integumentary services and procedures.

H. Practice Coding-Musculoskeletal System.
1. Differentiate between fracture and dislocation treatment types.
2. Understand types of traction.
3. Identify services/procedures included in the General subheading.
4. Analyze cast application and strapping procedures.
5. Understand elements of arthroscopic procedures.
6. Demonstrate the ability to code musculoskeletal services and procedures.

I. Practice Coding-Respiratory System.
1. Differentiate between services reported with codes from the Respiratory System subsection and those reported with codes from other subsections.
2. Explain the effects of extent and approach when reporting endoscopy respiratory procedures.
3. Identify highlights of nasal procedure coding.
4. Analyze the codes to report services to the accessory sinuses.
5. Categorize the codes in the Larynx subheading.
6. Explain the structure of the trachea/bronchi codes.
7. Distinguish the difference between the codes assigned to report lungs and pleura services, and procedures.
8. Demonstrate the ability to code respiratory services and procedures

J. Practice Coding-Cardiovascular System.
1. Understand cardiovascular services across three sections—Surgery, Medicine, and Radiology.
2. Review cardiovascular coding terminology.
3. Recognize the major differences in the subheadings of the Cardiovascular subsection.
4. Define rules of coding cardiovascular services when codes from the Medicine section are used.
5. Identify the major rules of coding cardiovascular services using the Radiology section codes.
6. Demonstrate the ability to report Cardiovascular services.

K. Practice Coding-Hemic, Lymphatic, Mediastinum, and Diaphragm System.
1. Review the Hemic and Lymphatic Systems subsection format.
2. Understand the Hemic and Lymphatic Systems subheadings.
3. Demonstrate the ability to code Hemic and Lymphatic Systems services.
4. Review the format of the Mediastinum and Diaphragm subsection codes.
5. Understand the Mediastinum and Diaphragm information.
6. Demonstrate the ability to code Mediastinum and Diaphragm services.

L. Practice Coding-Digestive System.
1. Understand the format and codes of the Digestive System subsection.
2. Report procedures of the lips.
3. Report procedures of the vestibule of the mouth.
4. Report procedures of the tongue and floor of the mouth.
5. Report procedures of the dentoalveolar structures.
6. Report procedures of the palate and uvula.
7. Report procedures of the salivary gland and ducts.
8. Report procedures of the pharynx, adenoids, and tonsils.
9. Report procedures of the esophagus.
10. Report procedures of the stomach.
11. Report procedures of the intestines (except rectum).
12. Report procedures of the Meckel’s diverticulum and mesentry.
13. Report procedures of the appendix.
14. Report procedures of the colon and rectum.
15. Report procedures of the anus.
16. Report procedures of the liver.
17. Report procedures of the biliary tract.
18. Report procedures of the pancreas.
19. Report procedures of the abdomen, peritoneum, and omentum

M. Practice Coding-Urinary and Male Genital System.
1. Understand the format and codes of the Urinary System subsection.
2. Review the subheadings and categories of the Urinary System subsection.
3. Report services with Urinary System codes.
4. Understand the format and codes of the Male Genital System subsection.
5. Review the subheadings and categories of the Male Genital System subsection.
6. Report services with Male Genital System codes.

N. Practice Coding-Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery.
1. Describe reproductive services.
2. Report reproductive services.
3. Report intersex surgery services.
4. Understand the format of the Female Genital System subsection.
5. Identify elements of component coding with Female Genital System codes.
6. Define the critical terms in maternity and delivery services.
7. Define services in the global maternity and delivery package.
8. Understand the format of Maternity Care and Delivery subsection services.
9. Demonstrate the ability to code Female Genital and Maternity Care and Delivery subsection.

O. Practice Coding-Endocrine and Nervous System.
1. Review the Endocrine System subsection format.
2. Understand the Endocrine System subheadings.
3. Demonstrate the ability to code Endocrine System services.
4. Review the Nervous System subsection format.
5. Understand the Nervous System subheadings.
6. Demonstrate the ability to code Nervous System services.

P. Practice Coding-Eye, Ocular Adnexa, Auditory, and Operating Microscope.
1. Review the Eye and Ocular Adnexa subsection format.
2. Understand the Eye and Ocular Adnexa subheadings.
3. Demonstrate the ability to code Eye and Ocular Adnexa services.
4. Review the Auditory System subsection format.
5. Understand the Auditory System subheadings.
6. Demonstrate the ability to code Auditory System services.
7. Review reporting use of an operating microscope.
8. Demonstrate the ability to report the use of an operating microscope.

Q. Practice Coding-Radiology.
1. Demonstrate an understanding of Radiology terminology.
2. Analyze the elements of component coding in the reporting of radiology services.
3. Identify the elements of the global procedure.
4. State the appropriate coding of contrast material.
5. Explain the format of the Radiology section.
6. Demonstrate the ability to code Radiology services and procedures.

R. Practice Coding-Pathology/Laboratory.
1. Explain the format of the Pathology and Laboratory section.
2. Understand the information in the Pathology and Laboratory Guidelines.
3. Demonstrate an understanding of Pathology and Laboratory terminology.
4. Differentiate amongst the Organ or Disease Oriented Panels codes.
5. Recognize Drug Assay codes.
6. Identify Therapeutic Drug Assays codes.
7. Classify Evocative/Suppression Testing codes.
8. Explain Consultations (Clinical Pathology) codes.
9. Interpret Urinalysis, Molecular Pathology, and Chemistry codes.
10. Evaluate Hematology and Coagulation codes.
11. Describe Immunology codes.
12. Discriminate amongst Transfusion Medicine codes.
13. Interpret Microbiology codes.
14. Evaluate Anatomic Pathology codes.
15. Summarize Cytopathology and Cytogenic Studies codes.
16. Explain Surgical Pathology codes.
17. Choose Other Procedures codes.
18. Demonstrate the ability to code Pathology and Laboratory services.

S. Practice Coding-Medicine.
1. Analyze the format of the Medicine section.
2. Report psychiatric services.
3. Identify biofeedback services.
4. List components of dialysis reporting.
5. Demonstrate ability to report gastrointestinal services.
6. Understand ophthalmology and otorhinolaryngologic reporting.
7. Report cardiovascular services.
8. Identify services reported with pulmonary codes.
9. List the important elements of coding allergy and clinical immunology services.
10. Report endocrine services.
11. Define neurology and neuromuscular services.

1ODCTE objectives
The class will primarily be taught by the lecture and demonstration method and supported by various media materials to address various learning styles. There will be question and answer sessions over material covered in lecture and media presentations. Supervised lab time is provided for students to complete required projects.
ICD-9 and ICD-10
American Academy of Professional Coders (AAPC)
Step-by-Step 2015 Text and Workbook, by Buck, Elsevier Publishing (2015)
2016 ICD-10-CM Profession Edition, 1st Edition, by Buck, Elsevier Publishing
2016 Current Procedural Terminology, Professional Edition, AMA Publishing
2016 HCPCS Level II, Professional Edition, AMA Publishing
*Coding manuals ae updated annually and correspond to the current year.
Various supplemental materials.
Career Majors That Sequence This Course
Career Cluster Pathway Career Major
Business Management & Administration Business Information Management Medical Coding