June 3, 2024

Tips to Pass the AAPC CPC Exam

By Janine Mothershed

Tips to Pass the CPC Exam on Your First Try 

Medical coding is a fantastic career, and you’re so close to earning your Certified Professional Coder (CPC) credential that you can see it within your grasp.  Seeing it, and achieving it may feel out of reach for some students. Not to worry, though. We have the help you need. Let Coding Clarified “clarify” coding for you. We gathered tips for passing the AAPC CPC exam from the AAPC website and members of Facebook medical coding groups over the years and put them together in this blog.

Coding Clarified and AAPC have polled thousands of CPCs who have taken the AAPC CPC exam. Some passed their exam on the first attempt, others passed after numerous attempts, and many told of their insights into what they considered the best CPC exam study tips. So, courtesy of AAPC, Coding Clarified, and your peers.

Get a strategy for CPC preparation and commit to that goal. 

  • Make passing the exam a priority. Study regularly. Devise a strategy tailored to your weaknesses. Maybe that means no TV, cell phone, or games until you’ve logged your study time for the day.
  • Perhaps join our Facebook group in which the focus is on the AAPC CPC exam. Don’t let long periods pass between study sessions. Medical Coding for Newbies https://www.facebook.com/groups/1382076462179861
  • Spend time in the study session focusing on your exam strategy.
  • Experiment to find a routine and time increments that work for you. 
  • Believe in yourself and what you have been taught. You may have moments of anxiety. It will pass, so resist doubt. 

CPC Exam Basics 

The CPC exam is an open manual exam. Everything you need to know is in the manuals that you take to the exam. However, you need to be able to find information quickly, so it’s important to organize your books and mark them so that you can easily find the information you need during the exam. Coding Clarified students get access to the instructor’s audio files for each chapter to implement notes into their manuals. You will be given 4 hours to complete 100 multiple-choice questions. Passing will require you to answer 70% of the questions correctly.

Learn What to Study for the CPC Exam 

  • Not all areas of the AAPC CPC curriculum require equal study time. From your Coding Clarified CPC training course, you know that some chapters took longer to digest than others. Evaluation and management, for example, is more challenging than the digestive chapter. The same challenges will influence how you divide your study time. 
  • Concentrate on the more complex areas. Invest your time and effort to ensure you understand key concepts and difficult coding scenarios. Some examples are HIV, diabetes, CKD, hypertension, metastatic cancer, chronic pain, and infusions. 
  • Identify your weaknesses. Give those areas extra attention.   
  • Know your medical terminology. The exam will ask questions about anatomy and medical terminology, and you’ll need to know these subjects to extract important details for coding. Break out the flashcards for a refresher before exam day. 
  • Know your anatomy. Medical coders should know anatomy to accurately assign codes for procedures, diagnoses, and treatments. This knowledge helps them understand how the body is made and works, which allows them to select the correct codes from ICD-10 and CPT code sets. For example, codes can be highly detailed and indicate which side of the body a procedure was performed on. Anatomy knowledge also helps medical coders interpret charts and dictation, which can include medical terminology, organ names, and surgical approaches.
  • Know the letter ranges for ICD-10 and number ranges for CPT® codes. With limited time on test day, the ability to recognize basic info about a code because you know its ranges can mean the difference between passing the CPC exam and not having enough time to finish the test. This is where manual prep is needed to highlight the differences between code selections.
    Code ranges allow you to instantly narrow down potential answers. If a question asks about a code pertaining to the integumentary, for example, you can eliminate all codes that don’t begin with the number 1. 
  • Acclimate yourself to the language in the code sets. Exam questions use verbiage in code descriptors and code notes. You’ll want to understand the language well enough to find the answers.  
  • It is all about the guidelines: In preparation for the exam, review all coding guidelines and understand how they are applied. This pertains to all code sets (CPT®, ICD-10-CM, HCPCS Level II). Coding conventions and guidelines for ICD-10-CM are found in the front of the manual. CPT® guidelines are found in the introductory sections and throughout the codebook in selected subsections.  
  • Get your manuals prepped: Well-marked codebooks can be extremely helpful during the exam. Because coding guidelines contain instructions for what can be reported and what cannot be reported, Use different colored highlighters to quickly distinguish between the multiple codes in the same category as some codes only have a 1-word difference in the code description. 
  • Sequencing matters: Follow sequencing rules in coding guidelines and coding conventions. AAPC uses this example. Example: A urine culture confirms the patient’s diagnosis of a UTI caused by E. coli. The correct codes and sequence are N39.0 and B96.20. At this code is a note instructing you to use an additional code (B95-B97), to identify the infectious agent. This is Escherichia coli (E. coli). If there are code options with the same codes in a different sequence, pay close attention to the coding conventions and guidelines to guide you in the right selection.
  • Parenthetical notes provide valuable information: Paying close attention to the information in the CPT® parenthetical notes prevents you from making coding errors. AAPC uses this example. Example: There is a parenthetical note following code 10030 which states “Do not report 10030 in conjunction with 75989, 76942, 77002, 77003, 77012, 77021. This alerts the coder that imaging guidance cannot be reported with the surgical procedure code. 
  • Know your modifiers: Review the proper use for each modifier. Understand when each should be appended. AAPC uses this example. Modifier 26 is appended to codes with a professional and technical component to indicate the provider you are coding for only performed the professional component. If the question/scenario indicates the procedure is performed in the hospital setting, the coder will be alerted that modifier 26 should be appended to radiology procedures and medicine procedures that apply. If the code description includes a professional component (e.g. 93010), you wouldn’t append modifier 26. 
  • Answer all questions: There is a 1 in 4 chance of getting the correct answer and choosing any answer is better than not answering. 
  • Save the 10 cases for last: Cases are worth the same 1 point as any other question but take longer to answer so we suggest you save them for the end.

Know the Official Code Guidelines 

The guidelines provide instructions for proper code selection. Coders should read their code books from cover to cover and pay special attention to guidelines. 

  • Review guidelines for each code set — and review often, particularly the challenging guidelines. 
  • The goal is not to memorize guidelines but to understand them. You need to know how to interpret and apply what you read. You should be able to recognize the rationale, purpose, logic, and intent of the guidelines by exam day.
    To help learn how a guideline is applied, review codes that the guideline applies to. And practice! 
  • Get the basic applications down. Be sure you can respond accurately to Includes, Excludes, Code First, Code Also, And, etc, without a second thought. 
  • Be sure you can follow sequencing rules. This is heavily factored into the CPC exam (as in real-world coding). You’ll want to practice sequencing. The guidelines have sequencing rules. Make a notation near these codes where they can be located in the guidelines.
  • Know where to find specific guidelines. Here, too, you don’t need to memorize where every guideline is. You only need to tab and mark your books. 
  • Know what topics are covered in chapter-specific guidelines. This will alert you when you should check a guideline before making a code selection. 
  • Don’t forget to review coding conventions, and notations, excludes notes for ICD-10 and parenthetical notes for CPT®. 

Prep Your Medical Coding Manuals

Coding Clarified students get access to the instructor’s audio files for each chapter to implement notes into their manuals.

Circle category codes in the same group heading (a parent code with child and add on codes as appropriate.

Highlight the differences between codes in the same category groupings.

Make a note of a page or a guideline where a resource can be located in the manual pertaining to those codes in the manual

Make notes for things you want to remember or struggle with next to the codes they pertain to.

 The more you know your manuals, the better you can manage your time on exam day. 

Get your manuals organized with tabs.

The goal is to quickly locate anything and everything — codes, guidelines, tables, instructions, illustrations, appendices, etc. — so continue familiarizing yourself with all the parts of your manuals. 

  • Tabbing your books will help you identify pages you need to access quickly and frequently to execute time management. Most people reserve tabbing for guidelines and chapters in the tabular lists, but anything you need extra help with is an area you might want to tab. You might also want to tab things you don’t normally search for. Some students tabbed the Alphabetic Index.
    These are your manuals, so tab and mark them according to your needs. Some people feel that tabs get in the way, and others examinees feel they are essential during the exam. Do what works for you. Purchase stiff tab dividers so they do not curl making them useless during the exam.

Tabbing and Marking Code Books for AAPC Exams 

  • Be strategic when marking your books. You don’t want to lose important notes in the chaos of too many notes. The same goes for highlighted text. Try to keep your notations relevant to the exam. Make notes where you can find them. Some students prefer to write short notes near the codes versus filling blank pages with notes. Choose whatever approach helps you quickly locate what you need. 
  • You may not add writing surface to your books. Taping, gluing, or stapling anything into your code books is prohibited. This includes sticky notes. 
  • Tips for adding notes in your books are recommendations others found helpful. Choose only what makes sense for you. 
  • For codes with guidelines that give you trouble write the guideline next to code. Some people also do the reverse — adding code examples next to the guideline. 
  • Draw an E/M table to help you determine E/M services (CPT®). https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
  • Mark out-of-sequence codes (CPT®). 
  • Write definitions of procedures next to the codes in CPT® or highlight differences between codes with subtle variations of body parts or layers (e.g., integumentary). 
  • Write main terms, prefixes, and suffixes on your anatomical illustration pages next to corresponding body parts.  
  • Conventions: Code first notes use, additional code notes, codes that are excluded from a category. Conventions to code: Alphabetic list of procedures, organs, and conditions. Boldface main terms may be followed by descriptions and groups of indented terms. Some code descriptions are indented to show that they include a common entry from above and refer to the “parent” code above. The words in the description of the parent code that precedes the semicolon are common to all the indented “child” codes below.   Important Coding conventions used frequently: + sign = add on code Empty circle with middle dot = includes moderate sedation Empty circle with a slanted slash through = modifier 51 exempt # = resequenced code
  • Group codes in the same heading parent and child codes
  • Highlight differences between codes in the same groupings (bubbles) Make a note of the page where a guideline or resource in a manual can be found about those codes.

CPT® highlights 

  • Keywords in the subsection guidelines (e.g., new and established patient definitions in the E/M section) 
  • Keywords in the Repair (Closure) guideline section define simple, intermediate, or complex repairs.  
  • Guidelines for services included with Adjacent Tissue Transfer or Rearrangement procedures. 
  • Keywords in the Musculoskeletal System guidelines define surgical procedures, such as closed, opened, percutaneous skeletal fixation, or manipulation. 
  • All parenthetical notes are found in the code description or following the code. 
  • Make note of procedures performed percutaneously, with any type of scope (endoscope, laparoscope, etc.), or by open technique (meaning the doctor had to cut into the patient to perform the procedure)  

Practicing for the CPC Exam 

 Once you’ve studied, you’ll want to take advantage of as many practice exams as possible. 

  • Treat practice exams like real tests. Study for them, follow time constraints, and note which questions you answered incorrectly. Go back and review the areas you struggled with. Retest and repeat. 
  • Keep practicing time management. This will allow you to complete the CPC exam in the allotted 4-hours. Good time management is answering questions in about 2.4 minutes or less. Practice like an athlete to improve your pace. 
  • Keep practicing for test-taking skills. Eliminating answers is an effective strategy for both accuracy and time management. Practice using what you’ve learned to eliminate answers. 
  • Keep practicing for accuracy. Keep practicing until you score 80% minimum. 
  • Do not schedule your exam before you are prepared. You do not want to fail or pay and take the exam for a second time.

Exam Week 

  • Read your guidelines before the exam so they’re fresh in your mind. 
  • Verify the start time and examination address a few days prior to your test date. If you’re unfamiliar with the exam site, consider mapping your driving directions in advance. Factor potential delays en route and arrive 10 to 15 minutes early. 
  • Gather items you’ll be taking to the exam — manuals,  photo ID, and AAPC member ID. It’s also a good idea to bring a wristwatch to remain aware of the time. You may highlight, underline, and make brief notations on the printed side of the ICD-10-CM Official Guidelines. Long passages of information are not permitted on the blank pages of the printout**Smart watches or anything that can connect to the internet are not allowed. Confirm what exam materials are allowed during the CPC exam.
  • Test your camera and be sure to confirm which materials are permitted. a printed copy of the ICD-10-CM Official Guidelines is not allowed nor is a whiteboard.

Certification Exam Eve 

Close your manuals. You’re done studying. If you’re taking the online exam, set up your webcam and test area, and try to have a good night’s sleep.

Stay positive. Breathe. Repeat your mantra — I am prepared. I can do this.   

Tips for Taking the CPC Exam 

To pass the CPC exam, you need a score of 70% accuracy on 100 questions. Perfection is not required. Choose the answers that best answer the questions.

Test-taking tips and advice from those who have passed the CPC exam can dramatically boost your test score. Below are the strategies CPCs consider most effective. 

  • Listen carefully while the proctor reads the instructions. Ask questions if you don’t fully understand something. 
  • Request a last call. Whether or not you brought a watch to track your progress, it’s a good idea to ask your proctor to call time when 15 minutes remain. This heads-up will allow you to go to flagged questions you’ve left blank. 

The 2-Minute Goal 

Most coding students preparing for the CPC exam say their biggest concern is time. Four hours gives you roughly 2 minutes and 40 seconds to answer a question. If you can keep a 2-minute pace, and don’t allow yourself to get stuck on too many questions, you’ll be able to answer all 100 questions without resorting to last-minute random answer picks. 

  • Keep an eye on the clock. This will show you how much time you’ve spent on each question and urge you to move on if you’re past the 2-minute mark. 

Strategies for Dealing with Questions 

  • Start with the easy anatomy questions Then perhaps terminology and HCPCS. These straightforward questions are quick but count the same toward your score. By tackling them first, you’ll have time to answer all of them and can then work on the case study questions with a better sense of time remaining, as well as less pressure. 
  • Read the question before reading the long operative report associated with the question. Sometimes a question will refer to only a small part of the report, such as if a modifier is needed or not, and knowing this in advance can save you substantial time. 
  • Make a mental note or use the notepad to help you when looking up the code. Note words such as the diagnosis, and procedure, as well as words like “time, and level for E/M codes as these are often pivotal in determining the correct answer. You’ll also want to eliminate in the case anything that’s not relevant to the question. This could help you to eliminate answers. 
  • Code notes are used to define terms, clarify information, or list choices for additional characters. Pay close attention to them when looking up codes, as this provides valuable information and can prevent you from making errors. And don’t forget about placeholder X and which visit initial, or other.
  • Don’t second-guess yourself. Go through a question as quickly as you can and trust your first educated answer. The last thing you want is to get trapped in overthinking. Remember — keeping the pace means answering more exam questions, which means a better score. 
  • Take your best guess. If you get stuck on a difficult question, make a logical deduction and move on. Tab the question so you can come back to it if you have time. 
  • Skip tough questions. You don’t want to spend so much time on one question that you’re unable to answer many questions. Tab obstinate questions and come back to them later. 
  • Never leave a question unanswered. A blank answer is wrong, whereas you could get lucky with a guess. But save guessing for when you have no option, typically in the last 15 to 20 minutes of the CPC exam. 

Narrow Down Your Answers 

You will need to manage your time wisely. You can’t look up every code in all 4 multiple-choice answers. Take a strategic approach and eliminate as many answers as possible. If two can be eliminated, then you only need to confirm which of the two remaining answers is correct. 

The process of elimination for the AAPC CPC exam involves:
  • Reading the question first
  • Scanning the case for keywords
  • Eliminating two answers
Here are some tips for using the process of elimination:
  • Read the guidelines
  • Highlight the guidelines
  • Take notes
  • Look for keywords
  • Check the first character of the code
  • Run straight to the answers
  • Look at the heading
  • Look for “with or with outs”:
  • Look for “do not report”
  • Does the 1st character of the code align with the correct code range? If a question pertains to the musculoskeletal system, for example, you can eliminate all CPT® codes that don’t begin with the numeral 2. 
  • Check sequencing. Is a secondary code listed as a primary code? If so, eliminate this answer. 
  • Can
  • Read notes under the codes. You can often eliminate answers based on note details. 
  • Is a code mentioned in two answers? If so, go directly to that code to see if it fits the op notes and eliminate two answers based on what you find. 

If you can eliminate two answers, you’re halfway to the correct answer and only need to check the guidelines for the CPT® and ICD-10-CM codes in the remaining answers. 

With any exam time you have left, check to see if you’ve answered every question. If you still have time, revisit your best guesses to see if you can come up with a more solid answer. 

General Exam Day Advice 

Block out distractions. People may finish before you but don’t allow that to stress you. Stay calm and carry on, as the saying goes. Use all the time available to you. 

  • Terminology: (4 questions)
    These questions will assess your knowledge of medical terminology for all systems in the human body. Since coding requires knowing the names of medical procedures and basic human anatomy, this section covers how medical terms are formulated. Emphasis is placed on the meanings of various prefixes and suffixes as various root words used in naming medical conditions and procedures.
  • Anatomy: (4 questions)
    These questions will assess your knowledge of anatomy for all systems in the human body. (Remember you have anatomy illustrations in your manuals).
  • Compliance And Regulatory: (3 questions)
    This section will test your knowledge of compliance and regulations that pertain to services covered under Medicare Parts A, B, C, and D; applying coding to payment policy; place of service reporting; fraud and abuse; NCCI edits; NCDs/LCDs; HIPAA; ABNs; and RVUs.
  • Coding Guidelines (7 questions)
    This section will address the ICD-10-CM Official Guidelines for Coding and Reporting, CPT® coding guidelines and parenthetical notes, and modifier use. Mostly these questions are around the ICD codes.
  • ICD-10-CM: (5 questions)
    This area will test your proficiency in diagnosis coding within all the chapters of ICD-10-CM, as well as a thorough knowledge of the ICD-10-CM Official Guidelines for Coding and Reporting. Additionally, diagnosis questions will appear in other sections of the exam from the CPT® categories. 
  • HCPCS:  (3 questions)
    This section will test your knowledge on HCPCS Level II coding and includes questions focusing on modifiers, supplies, medications, and professional services for Medicare patients. Modifiers by type, explain the difference between global package modifiers, E/M-only modifiers, and the number of surgeon modifiers. Medical supplies and durable medical equipment used in treating patients. Medical transport (ambulance). Splints and orthotic devices. Pathology and laboratory procedures. Medicare and Non-Medicare codes. Medicaid-only codes. Letter = designated codes (F codes, Q codes, etc.) Drug codes. (using the appendix of your coding manual)
  • 10000 series codes: (6 questions) The 10000 series CPT® part of the exam relates to surgical procedures performed on the integumentary system, which includes skin, subcutaneous, and accessory structures, as well as nails, pilonidal cysts, repairs, destruction, and breast. Know when to add codes together and when to report them separately. Understand that an intermediate repair is not just for layered repairs. Know breast procedures. 
  • 20000 series codes: (6 questions)
    Surgical procedures performed on the musculoskeletal system from head to toe. Specifically, these areas include the head, neck, back and flank, spine, abdomen, shoulder, arm, hand and fingers, pelvis and hip, leg, foot, and toes.
  • 30000 series codes: (6 questions)
    Focuses on surgical procedures performed on the respiratory system, the cardiovascular system, the hemic and lymphatic systems, and the mediastinum and diaphragm. Surgical procedures performed on the musculoskeletal system from head to toe. Specifically, these areas include the head, neck, back and flank, spine, abdomen, shoulder, arm, hand and fingers, pelvis and hip, leg, foot, and toes. This video covers dislocation and fracture coding when you can code for casts and strapping, bunionectomy coding, and wound exploration procedures. The video also demonstrates the “stacking” technique for coding spine procedures. 
  • 40000 series codes (6 questions)
    Your knowledge of the 40000 series CPT® section covers surgical procedures performed on the digestive system, which will focus on these areas: lips, mouth, palate and uvula, salivary gland and ducts, pharynx, adenoids, tonsils, esophagus, stomach, intestines, appendix, rectum, anus, liver, biliary tract, pancreas, abdomen, peritoneum, and omentum.
    Covers conditions of the esophagus, stomach small and large bowels, and the rectum. After a brief anatomy review, you will be taken to the digestive section of the CPT® manual and be shown the areas that tend to be the area of focus for the CPC® certification exam. Scope procedures dominate this section. You’ll see some key notes you’ll want to write in your CPT® manual so they jump out at you when you are taking the CPC® certification exam. 
  • 50000 series codes (6 questions)
    The 50000 series CPT® section tests your knowledge pertaining to surgical procedures performed on the urinary system, the male reproductive system, the female reproductive system, including maternity and delivery, and the endocrine system. Coding for kidney, bladder, and urinary tract conditions. Specifically, urodynamics, kidney procedures, ureter and bladder procedures are discussed. After a brief anatomy review, you will be taken to the urinary section of the CPT® manual and be shown the areas that tend to be the area of focus for the CPC® certification exam. Also In this segment, the male and female genital system procedures are discussed with emphasis on prostate procedures, tricky definitions related to vulvectomies, hysterectomy coding, and maternity coding.
  • 60000 series codes (6 questions)
    The 60000 series CPT® section involves surgical procedures performed on the nervous system and will include codes pertaining to the skull, meninges, brain, spine, spinal cord, extracranial nerves, peripheral nerves, and autonomic nervous system. Specifically, eye removal, keratoplasty coding, cataract coding, and ocular adnexa coding are discussed for the eye. For the ear, emphasis is on ear tube surgery (tympanoplasty)
  • Radiology SectionRadiology codes (6 questions)
    These questions will focus on both diagnostic and interventional radiology, including diagnostic ultrasound, radiologic guidance, mammography, bone and joint studies, radiation oncology, and nuclear medicine. This section is about X-rays and diagnostic imaging, including MRI and PET scans.
  • Path & Lab Section: (6 questions)
    This section will test your knowledge of organ and disease panels, drug testing, therapeutic drug assays, evocation/suppression testing, consultations, urinalysis, molecular pathology, MAAA, chemistry, hematology and coagulation, immunology, transfusions, microbiology, anatomic pathology, cytopathology, cytogenetic studies, surgical pathology, in vivo and reproductive.  Codes for diagnostic laboratory procedures from blood chemistry to surgical biopsies. The highlights of this video are pathology consults, surgical pathology, panels, the difference between qualitative and quantitative tests, and more.
  • Medicine Section6 questions) This will cover numerous specialty-specific coding scenarios, as well as immunizations, biofeedback, dialysis, central nervous system assessments, health and behavior assessments, hydration, medical nutrition, therapeutic and diagnostic administration, chemotherapy administration, photodynamic therapy, osteopathic manipulative treatment, patient education and training, non-face-to-face nonphysician services, and moderate sedation. Covers general medical conditions infectious diseases and prescription medications. 
  • E&M Section:  (6 questions)
    This area will assess your coding proficiency related to place and level of services, such as office/other outpatient, hospital observation, hospital inpatient, consultations, emergency department, critical care, nursing facility, domiciliary and rest homes, and home services. It will also include questions directed at preventive medicine, non-face-to-face services, neonatal and pediatric critical care, intensive care, prolonged services, chronic care, transitional care, case management, and care plan oversight.
    If the patient or an inpatient. How to code a consultation? What are critical care codes? What defines a nursing facility, what exactly is an emergency department, etc? 
  • Anesthesia Section: (4 questions)
    The questions related to anesthesia will pertain to time reporting, qualifying circumstances, physical status modifiers, and anesthesia for surgical, diagnostic, and obstetric services. You should understand the difference between general, regional, and local anesthesia and how to code them as well as conscious sedation. You will know what to do if there is more than one procedure performed during an operative session.
    Anesthesia has its own modifiers that correspond to a patient’s health condition: P1- Normal, Healthy Patient P2- Patient with Mild Systemic Disease P3- Patient with Severe Systemic Disease P4- Patient with Severe Systemic Disease That is a Constant Threat to Life P5- Moribund patient who is not expected to survive without the operation P6- Declared brain-dead patient whose organs are being removed for donor purpose. 
  • Cases (10 cases, 1 question each) multiple choice until AAPC implements fill-in-the-blank coming soon but no firm date is set for this change).
    Each case will test your ability to accurately code medical record documentation using CPT®, ICD-10-CM, and HCPCS Level II codes. AAPC announced earlier this year that the cases will change from multiple choice to fill-in-the-blank. No date for this change was announced but practice exams are already seeing this change. 

More Tips/Notes:

  • Abortion-/Pregnancy/ Childbirth: Chapter 15 Codes take Sequencing Priority, Only on Mothers Record-Final Character for Trimester 7th Character for Fetus Identification, Routine Prenatal Z34, High-Risk O09, Normal O80, Outcome of Delivery Z37, Hypertension O10, Diabetes O24, HIV O98.7, Gestational O24.4, Postpartum Care Z39.0, Complications O94?
  • Activity Codes: Activity at Time of Injury
  • Acute vs Chronic: default to Acute which is sequenced first when both are present.
  • Adjacent Tissue Transfers: Benign or Malignant, Measurements –Types-Closures
  • Adverse effects/Poisonings/Underdosing/Toxic Effects: (I.C.19.e.5) Table of Drugs and Chemicals
  • Alcohol/Drug: Level 1=Use, Level 2 =Abuse, Level 3 =Dependence, Code to highest Level Only. Remission
  • Anemia: Chemotherapy – Coded 1st Other- What Kind Due to-In, Coded 2nd
  • Anesthesia: Types, Level-Base & Time Units Provider, P Modifier
  • Asthma: Intermittent or Persistent, Acute Exacerbation, Status Asthmaticus
  • Bronchitis: More than 1 site =Lower, Tobacco? Inflammation vs Infection
  • Burns: Location, Severity Extent, External Cause, (Rule of 9’s) Degrees: 1st =Damage to the Epidermis, Erythema. 2nd =Blistering with Damage Extending into the Dermis. 3rd =Full Thickness Tissue Loss Complete Destruction of Both Layers.
  • Cardio: Angina, Bypass, Disease, Failure MI-(NON-STEMI Evolves to STEMI Assign STEMI If STEMI Converts to Non-STEMI Still Coded STEMI) New AMI Within 4 Weeks Rule! Pacemaker
  • Casual Relationship: Section I. A.15, says, “The classification presumes a causal relationship between the two conditions linked by these terms [i.e., “with”] in the Alphabetic Index or Tabular List.” In other words, you may presume a relationship between two conditions if those conditions are linked within the ICD-10-CM Alphabetic Index or Tabular List — even if the documentation does not explicitly state that the two conditions are related.
  • Chemotherapy: Only Z51.0
  • CKD: Stage? Hypertension, Dialysis (Z99.2), ESRD (N18.6)
  • COPD: Infection? Exacerbation? Asthma? Bronchitis? Other Factors? (Smoking or Exposure)
  • Complications: Documented as such?
  • COVID-19: Code Only Confirmed U07.1 1 st NOT Confirmed Report Signs and Symptoms (no confirmation needed Inpatient) Acute Respiratory Infections as Additional Diagnosis- 2nd Pneumonia J12.89 Acute Bronchitis J20.8, Lower Respiratory Infection J22, Acute Respiratory Distress Syndrome J80, Acute Respiratory Failure J96.0, NON-Respiratory Exposure = Screening Z20.828, Signs and Symptoms: Cough R05,SOB R06.02, Fever R50.9, Personal History Z86.19, Resolved Follow Up Z09, Antibody Testing Z01.84.
  • Diabetes: no type given defaults to Type ll.
  • Death: NOS –R99, Do not Resuscitate Z66D
  • Dehydration: Treated only/neoplasm- malignant code 1st
  • Depression: Episode-single or recurrent. Severity- Mild = at least 5 symptoms Moderate = 7-8 symptoms Severe = Most or all symptoms
  • Dominant /Non-Dominant: – Ambidextrous =Dominant- Left Side =Non-Dominant- Right Side =Dominant
  • Clinical Status: Partial or full remission
  • Diabetes: Type Secondary Long Term Drug (LTD), Insulin Z79.4, Oral drugs Z79.84, Pump failure T85.6, l.C.4.a
  • E/Mhttps://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
  • External Causes: Never Principal DX
  • Fractures: Pathological? Type Displaced or Nondisplaced, and Open or Closed, Fracture open or closed unknown default to closed, which encounter, Complication, Displaced or Nondisplaced Fracture default to Displaced
  • Grafts: Donor? Measurements Sq cm
  • Types: Allograft-From Donor, Autograph-From Patient, Xenograft-From Animal, Split Thickness-One Layer and Some Partial, 2 nd Layer Full Thickness- Both Layers
  • Hernia: Mesh, Laparoscopic hernia Included, open repair NOT included, Manually reducible? (Incarcerated-Physician cannot reduce manually)
  • History/Family: Personal : Personal: Indicates the person no longer has the condition and is not receiving treatment Condition can reoccur Family: Cause of death of a family member that may affect care from a provider Disease related to patient diagnosis and may affect the care from a provider Hereditary diseases that may put the patient at more risk.
  • HIV: Code Only Confirmed=B20 Always on every encounter subsequently Exception Inpatient Unrelated Condition Admission Code + B20 2 nd Asymptomatic Z21, inconclusive R75, Pregnancy O98.7 +B20, Testing Z11.4
  • Hypertension: Essential I10 Heart Failure (HF) I50? Kidney (I12?) Kidney- Stage or Failure (N18?) Due to? Both Heart and Kidney (I13?) Involvement is Assumed Casual Relationship (No Documentation Needed) Transient= Elevated Blood Pressure R03.0
  • Infections: Identify Organism Antibiotic Resistant?
  • Influenza: Type Due to?
  • Immunizations: Vaccine Z23, Child Z00.121 over 298 Days Z00.129
  • Lab Panels: For Multiple tests
  • Late Effects: Sequela Residual Effect (condition produced) AFTER the acute phase of an illness or injury has terminated (No Limit to Occurrences)
  • Lesions: Anatomic Location (same grouped together) Simple, Intermediate, Complex Code Each, Multiple Modifier 59, Benign or Malignant
  • Mastectomy: (Simple means Total)
  • Modifiers: CPT Appendix A. Understand when each modifier should be applied.  Procedure has both a professional and technical component Service is performed by more than 1 physician and/or in more than 1 location. Service has been increased or reduced. Only part of a service was performed.  An adjunctive service was performed. Service or procedure was provided more than once. Unusual events occurred. Service was provided during a global period but is NOT included as part of the global reimbursement.
  • MOHS: Surgeon and Pathologist are Same Location.  How many Stages/Blocks? Code Each Separately
  • Neoplasms: Neoplasm Table Primary Code 1st Secondary Treatment Only Code 1st Malignant/Benign, Personal History Z85,  Table l.C.2. c.1 /Pain l.C.6.
  • Pain: G89 Pain Control Only, Central Pain Syndrome G89.0, Chronic Pain Syndrome G89.4, Chronic G89.2, No Pain Code if Diagnosis Causing Pain is Being Treated, Post Op or Routine Not Coded, Neoplasm Pain Management-G89.3, Acute or Chronic
  • Place of Occurrence: Location of Patient
  • Pneumonia: Infection Coded 1st – Which lobe? Lungs Lobes (2 left 3 Right)
  • Repairs: Anatomical Location Size of Each What Type of Closure Repairs-Simple-Intermediate-Complex: Simple-Superficial- 1 layer closure. 37 Intermediate- 2 layers closure. Complex- More than a layered closure
  • Respiratory: Acute Chronic or Both Exposure to or Use/Dependence.
  • SIRS/Sepsis/Septic Shock: Infection or Organism Severe? = 2 Codes 1 st Underlying + 2 nd Severe R65.2 +3 rd Shock T81.12 Never Principal.
  • Spine: How many Segments or Interspace? Location =Cervical/Thoracic/Lumbar/Sacral/Coccygeal Pathology Graft? Approach: Anterior Posterior Lateral Extracavity Percutaneous/ Instrumentation Implants
  • Ulcers: Pressure Gangrene? Stages: 1=Edema 2=Partial Skin Thickness Loss 3= Full Skin Thickness Loss 4=Necrosis
  • Vaping: U07.0
  • Vascular families: Appendix L
  • Wounds: Anatomical Sites Length of wound Graft vs Flap? Mesh? The same body area and the same type of closure are coded as one
  • Z Codes: Indicate Reason for Encounter Contact Exposure Immunizations Vaccinations Status History of Screening Observation Aftercare Follow-up Reproductive Services Donor Counseling Routine Exams Organ Removal List of Allowed 1st Listed

Principal diagnosis/procedure:

  • The condition established after study which resulted in the patient’s admission.
  • If 2 conditions meet the principal diagnosis either condition may be sequenced first.
  • A procedure is performed as the definitive treatment of both principal diagnoses and secondary diagnosis sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure.
  • A procedure is performed as definitive treatment and diagnostic procedures are performed for both the principal diagnoses and secondary diagnosis sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure.
  • A diagnostic procedure was performed for the principal diagnosis and the procedure is performed for definitive treatment of a secondary diagnosis sequence, the diagnostic procedure as the principal procedure because the procedure most related to the principal diagnosis takes precedence.
  • A procedure performed was related to the principal diagnosis, but procedures were performed for definitive treatment or diagnostic procedures were performed for the secondary diagnosis sequence the procedure performed for definitive treatment of the secondary diagnosis as the principal procedure.
  • The principal procedure is that procedure performed for therapeutic rather than diagnostic purposes or that procedure performed which is most closely related to the principal diagnosis or that procedure performed to treat a complication. (Remember you select just 1 principal procedure for each inpatient record)
  • When the procedure is performed for definitive diagnosis

OP Checklist:

  • Pre-op/post-op diagnosis
  • Procedure described
  • Biopsies/specimens
  • Co-surgeons
  • Complications
  • Scopes
  • Anesthesia
  • Circumstances prolonging
  • Multiple procedures
  • Bundles
  • Modifiers
  • History
  • Labs
  • Major or Minor
  • Age
  • Sex
  • Anatomic site
  • Approach
  • Unilateral/Bilateral
  • Included or Excluded/ Contrast, Injections, Stents, Image Guidance, Closure

Inpatient Coding Guidelines:

  • Code other diagnosis that co-exists at the time of admission that develop subsequently, or that affect the treatment received and/or length of stay.
  • Code diagnosis that requires active intervention during the stay.
  • Code diagnosis of chronic systemic or generalized conditions that are not under active management when a provider documents them and that may have a bearing on the management of the patient.
  • Code status post previous surgeries or conditions likely to recur that may have a bearing on the management of the patient.
  • DO NOT code status post previous surgeries or histories of conditions that have no bearing on the management of the patient.
  • DO NOT code localized conditions that have no bearing on the management of the patient.
  • DO NOT code abnormal findings unless there is documentary evidence from the provider of their clinical significance.
  • DO NOT code the signs and symptoms that are characteristics of a diagnosis.
  • DO NOT code conditions in the social history section that have no bearing on the management of the patient.
  • DO NOT assign E codes except those that identify the causative substance for an adverse effect of a drug that is correctly prescribed and properly administered and/or poisoning.
  • DO NOT assign Morphology M codes.
  • DO NOT code procedures that fall within the code range 87.01 – 99.99. 40
  • DO NOT confuse diagnostic procedures with ancillary tests (labs, x-rays) as they are NOT coded for inpatients.
Outpatient Coding Tips:
  • Uncertain diagnoses are NOT reported in the outpatient setting. The signs, symptoms, abnormal test results, or other reasons for the visit would be reported.
  • Chronic diseases in the outpatient setting should be reported. If a condition is under current treatment it should be reported for each visit as long as the patient is receiving treatment for the condition. Remember though that there are chronic diseases that are systemic conditions and the patient will have them for the remainder of their life. Some of these are HTN, COPD, asthma, emphysema, and diabetes. It may be that some research is necessary to determine if the condition is one that has a cure or if it is one that they will have forever.
  • All outpatient orders should be reviewed to determine if additional signs, symptoms, or diagnoses are provided
  • Coders may report confirmed diagnoses on radiology and pathology reports (except for incidental findings)
  • “Z” codes help paint the entire health picture for the patient. If there is a specific code for a past or family condition, it will most likely always be reported
  • Code only confirmed diagnosis on outpatient encounters
  • Remember to report any long-term use of specific medications
  • Sometimes it is the “Z” codes that will help meet medical necessity for outpatient testing
  • Chronic conditions should be reported on each visit when they are under treatment or are systemic medical conditions
  • Chronic systemic conditions should be reported even in the absence of intervention or further evaluation. These conditions will affect patients for the rest of their lives or most of their lives and require continuous clinical monitoring and evaluation. Certain medications are not to be used if a patient has a certain condition or can’t be mixed when taking a certain medication. This should always be part of the physician’s medical decision-making process.
  • Coders may not assign a diagnosis code based on the up/down arrows on the order or MD note.
  • Coders should remember that additional diagnoses reported on claims can help in supporting the medical decision-making that went into treating this patient
  • Any diagnosis that requires treatment or monitoring would be reported regardless of if it is chronic or develops during the visit
  • Past medical conditions and diagnoses help improve communication with other healthcare providers and registries. The diagnoses are not just reported for payment but also statistics.
  • Signs and symptoms may be reported in addition to specific diagnosis codes if the physician has not clearly documented the link between signs/symptoms and the condition. This is due to limited documentation in outpatient records and the need for additional follow-up testing that may be necessary
  • Coders must review the entire outpatient encounter rather than only focusing on the reason for the visit. Diagnoses and symptoms may be found in radiology orders and impressions, orders for labs, anesthesia evaluations, history of present illness, a physical exam by the physician, past medical history, current medications, and the final impression. Not all of these will be present for every outpatient encounter, but they should be reviewed if present. Reviewing these areas will ensure that all pertinent secondary diagnoses and status codes are reported.

Good Luck! 

References http://AAPC.com 





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