Infusion Coding – Always Confusion

Injections and Infusions coding is always confusing. Through this post will try to make the things clear in infusion coding and give a quality infusion coding. The basic rule while coding hydration, intravenous push, and IVPB is that there should be only one initial service code per encounter, unless there is a mention of two different IV routes. Selection of the initial code depends on the record and also the sequencing as per CPT. Will discuss in detail throughout this post.

Infusing normal saline only or with electrolytes is considered to be hydration. As per CPT, we have two hydration codes

Hydration

96360: This is an initial code. This is a first hour hydration code, which needs to be given more than 30 minutes and up to one hour. Hydration less than 30 minutes is ignored and not coded.

96361: This code is used for each additional hour of hydration more than 30 minutes.

For Ex:
Normal saline given for 55 minutes is coded to only 96360.
Normal saline given for 90 minutes is coded to only 96360 because the next hour is only for 30 minutes and cannot be coded for the extra hour.
Normal given for 93 minutes can be coded to 96360 and 96361 as there is an additional 33 minutes, which can be taken as additional hour.

Intravenous Push (IVP)
Intravenous push is an administration of therapeutic substance through IV route for less than or for 15 minutes. Even for IVPs, we have initial IVP and each additional IVP codes.

96374: This is an initial IVP given
96375: This is coded for each additional IVP of different drug or substance.
96376: This is coded for the IVP of the same substance given after the 30 minutes after the same substance administration. If the same substance is given within the 30 minutes of the same substance given, it is not coded.

For Ex:
Morphine IVP is coded to 96374
Morphine IVP and Pepcid IVP is coded to 96374 and 96375
Morphine IVP is given at 12.00 and next morphine is given at 12.10 and Pepcid is given at 12.15, then only 96374 and 96375 (for Pepcid) is coded. The second morphine is not coded, as there is only 10 minutes difference.

IVPB
Infusions of therapeutic substance through IV for more than 15 minutes are coded to IVPB. There are initial, subsequent, concurrent codes for coding these.

96365: This is coded to initial hour of infusion
96366: This is coded to each additional hour of infusion.
96367: This is coded to additional subsequent infusion.
96368: This is coded to concurrent infusion. This is coded only once per encounter.

For Ex:

· Zofran IVPB given for one hour coded to 96365.
· Zofran IVPB given for two hours is coded to 96365 and 96366. The second hour infusion should be more than 30 minutes to be coded as additional hour code.
· Zofran IVPB given from 12.00 to 1.00 and Pepcid from 2.00 to 3.00, the initial hour 96365 is coded and also 96367 is coded for subsequent infusion.
· Both Zofran IVPB and Pepcid given from 12.00 to 1.00. The initial 96365 and 96368 are coded showing both are running concurrently.

IM/SQ Injections:
We have only one code for IM/SQ injection.

96372 is coded to IM/SQ injection and can be used for each injection.

Medical Coding Scenerios with answers

Case 1
Chief complaint: Multiple dog bites to face.
HPI: 4 year old female who was over at a friend's house when she went to pet their dog and was accidentally bitten. She sustained a 2.5cm laceration to the left upper eyelid and eyebrow, a smaller, more superficial puncture wound to the right cheek measuring approximately 1 cm and an additional puncture wound of the lower cheek measuring 5mm.
PMH: Non-contributory.
Allergies: None
Medications: None
PE: Well-developed white female, alert and oriented. HEENT: Multiple abrasions and scratches to left cheek with lacerations as described above. The left upper eyelid, eyebrow laceration will require primary repair. The puncture wounds are best left cleaned and allowed to close secondarily and these will be revised at a later date if nece3ssary. There is no injury to the orbit itself and extraocular muscles are intact.
Procedure note: The wound was prepped and draped in the usual sterile fashion and infiltrated with 1% lidocaine with epinephrine. The wounds were thoroughly irrigated. Next, the lid laceration was debrided and closed with 6-0 Vicryl and 6-0 Prolene sutures. All wounds were dressed with Polysporin ointment.
Disposition: The patient will be discharged on Augmentin 250 mg po tid and she will be seen back in follow-up in five days for suture removal and reassessment of remaining wounds.
Codes: _________________________________________________________________

Case 2
Chief Complaint: Smashed left thumb
HPI: Patient complains of an injury to the right thumb a few hours ago. The patient states that he got his finger smashed in a machine at work. Last tetanus over 5 years ago.
Allergies: None
Medications: None
ROS: The review of systems is otherwise unremarkable for major signs and symptoms of acute illness or injury for constitutional, HEENT and other significant systems reviewed, except as noted above.
PMH: Generally well.
Social History: The patient smokes 1 ½ packs a day, non-drinker.
Family History: None pertinent to the present complaint.
PE: Vital signs: Review Nurse's notes.
Finger: Left thumb. There is a laceration vertically through the 1/3 or the lateral nail involving a small portion of the tip of the finger. Nonswollen. Range of motion: full. No deformity. Neurovascular status: normal.
Treatment section:
X-ray: Left thumb: tuft fracture.
The affected area was prepped with Betadine. 0.25% Sensorcaine without epi digital block. Nail was removed. The laceration was explored to its base. There was no foreign body in the wound. Irrigated and scrubbed with normal saline and Betadine. Wound repaired with 4-0 nylon and 4-0 Vicryl. Vaseline gauze applied. Sterile dressing and aluminum finger splint applied. Ancef 1 gram IM given.
Codes: _________________________________________________________________

Case 3
Preop Dx: Basal cell carcinoma of the nasal tip.
Postop Dx: Basal cell carcinoma of the nasal tip.
Procedure performed: Wide excision of basal cell carcinoma, frozen section control of the margins and dorsal nasal flap coverage.
Anesthesia: General
Description of Procedure: Following suitable general anesthesia Lacri-Lube was placed in both eyes. The area was marked for excision, prepped with Betadine and draped sterilely. Infiltrated with Marcaine and epinephrine. After suitable waiting period, this was incised circumferentially of the 12 and 3 o'clock position marked and sent for frozen section. Frozen section revealed the margins to be clear. Following this, the dorsal nasal flap based on the right nasal labial crease vessels was marked, extended into the glabella in a V type fashion, carried down to the nasal periosteum and elevated in a left to right fashion with bleeding points being grasped and elevated. It was rotated into position and then temporarily closed. The defect was then closed with buried interrupted 4-0 undyed Vicryl followed by interrupted 5-0 Prolene. After the frozen section revealed the areas to be clear, it was then inset with 4-0 Vicryl. The margins were then trimmed and closed with 5-0 Prolene. All layers were cleansed with saline and dried. The patient tolerated the procedure well.
Codes: _________________________________________________________________

Case 4
Preoperative diagnosis: Pyloric stenosis
Postoperative diagnosis: Same with esophageal stenosis
Operative procedure: Video EGD and balloon dilation of the pylorus and esophageal dilatation to 46 with straight dilator.
Procedure: The patient was given Demerol, 50; Phenergan, 12 ½ and Versed, 2mg and Cetacaine spray. The scope was passed down with little difficulty. The GE junction was at 42 cm. The scope was advanced and had difficulty getting through the pylorus. I thought it was strictured. I was able to finally get through it and get around to the second portion of the duodenum. I then passed the 54 French balloon into the pylorus and dilated it for 30 seconds. After I removed the balloon, I could then easily pass through the pylorus. I felt there might be a slight stricture at the distal part of the esophagus. A picture was taken of it and dilated the esophagus to 54 over a guidewire. Pictures were then taken of the GE junction, also retroflexed. No other lesions were seen. The patient tolerated the procedure well and went to recovery in satisfactory condition.
Note: The French scale is not identical to the metric system of measurement. Each French unit is equal to 1/3mm; for example, a 24 French sound is equal to 8mm in diameter.
Codes: _________________________________________________________________

Case 5
Preop Dx: Right knee torn medial meniscus and proximal tibial lesion.
Postop Dx: Torn medial and lateral menisci; chondcromalacias, grad 3 of medial femoral condyle, lateral femoral condyle, and patella; proximal tibial lesion; loose body.
Procedure Performed: Diagnostic arthroscopy with debridement of partial torn lateral and partial torn medial menisci; chondroplasty of medial and lateral femoral condyles of patella; removal of loose body and fluoroscopically controlled biopsy of proximal tibia.
Anesthesia: General
Description of Procedure: The arthroscope was introduced with the scope in the anterolateral portal and the probe in the anteromedial portal. The joint was investigated, and she was found to have synovitis throughout the knee. She had grade 2 and 3 chondromalacia over most of the surface of the patella. The medial and lateral femoral condyles ahd grade 3 lesions with some delamination. There was a parrot beak type tear in the posterior horn of the medial meniscus and a degenerative type tear in the lateral meniscus. There was also a loose body in the lateral compartment which was removed with a pituitary rongeur. The motorized cutter and the Arthrocare wand were then used to take the chondral defects on the medial and lateral femoral condyles down to stable cartilage base and rim. Excess carbonization was removed with the motorized cutter. Medial and lateral menisci were then trimmed back to a stable cartilage base and rim. The opening for the lesion on the position tibia near the posterior cruciate ligament insertion was not visible from inside the joint. Chondroplasty was also performed on the patella and was taken down to stable cartilage base and rim.
The arthroscopic portion was then terminated and through an open incision, a guide pin was placed into the tibia, and under fluoroscopic control, was angled into the cystic lesion. A 6.5mm drill was then drilled just short of this, and a Craig needle was used to take a biopsy of the lesion. This was sent to pathology. The knee was instilled with 27 cc of 0.25% Marcaine with epinephrine, and she was placed in a bulky bandage. She was awakened and returned to the recovery room in satisfactory condition. Estimated blood loss was none. There were no complications.
Codes: _________________________________________________________________

Case 6
Procedure: ECCE
After routine prep and drape, a small fornix-based conjunctival flap was raised superiorly. Bleeding points were cauterized. A 7mm step incision was made above. The anterior chamber was entered under the flap with a 5531 blade. The anterior capsule was removed under Healon with a cystotome. The nucleus was emulsified in the posterior capsule. Cortex was removed with the I&A tip. The posterior capsule was vacuumed. Healon was placed in the anterior chamber and capsular bag. The wound was extended to 7mm. A 23.5 diopter, 3161B lens was positioned in the bag horizontally. The wound was closed with a shoelace 9-0 nylon suture. After the Healon was removed from the anterior chamber with I&A tip, intracameral Miostat was injected. The wound was tested for water tightness. Superior rectus suture was removed. Vasocidin ointment was applied along the lid margins. An eye shield was applied. The patient tolerated the procedure well and was taken to the recovery room in good condition.

_________________________________________________________________

Answers:

Case 1
870.0; 873.42?; 873.41; 910.0; E906.0-not CCS; E849.0-not CCS; 86.59; 12011
Case 2
927.3; 816.02; E919.9—not CCS; 86.23; 11730; 86.59?; 12001?
Case 3
173.3; 11640; 21.32; 14060?; 86.70?
Case 4
537.0; 530.3; 42.92; 44.22; 43245; 43248
Case 5
836.0; 836.1; 717.7; 717.6; 733.90; 29883; 29877-51; 20225-51; 76003; 81.47; 80.86; 80.16; 77.47
Case 6
366.9 but no pre and pst dx given!; 13.41; 13.71; 66984

Evaluation and Management Template

Ó GENERAL MULTI-SYSTEM


PT TYPE: OFC/NEW_____ OFC/EST _______
Hosp Obs____ Hosp Obs w/ Adm & DC ______ ER ________ CONSULT OFC/OP _________Consult Initial IP______
Consult FU IP______ Consult Confirm_______
Nursing facility Initial Comprehensive Assessment_____
Nursing facility Subsequent______

CC_____________

HISTORY

HISTORY of Present Illness:
____Location diffuse/localized, unilateral/bilateral, fixed/migratory
____Duration How long? 20 min, onset 3 yrs ago, since last Friday, for approx 2 months, since yesterday
____Quality sharp, dull, burning, gnawing, fullness, aching, throbbing, stabbing, radiating, color of sputum, non-productive, asymptomatic etc. Laceration jagged/straight. Sore throat scratchy
____Context What was going on at time symptoms occurred, exercise, big meals, dairy products, spicy foods, etc. What were they doing when it occurred, MVA, running down steps, sitting in chair, playing sports.
____Severity Rank of pain on pain scale 0-10, severe, slightly, worst I’ve ever had, mild, moderate, 0 pain, increase, decrease, progressive, well, major, poor, significant, complicated (must be ranked; can’t just say “pain in my leg”
____Modifying Factors What makes better or worse, any meds helping, rest or eating, affected by spicy foods, ice pack or quiet room for MHA, coughing irritates the pain, OTC or prescribed meds have been attempted, etc What were the results?
____Timing Onset, night, day, continuous, occasional, episodic, AM, PM, constant, recurrent, seldom, frequently, off and on, morning, evening, intermittent, transient.
____Signs/Symps Associated with…, Negative Responses will count

Document of at least 3 chronic/inactive conditions_____

REVIEW OF SYSTEMS:
Negative, Normal, WNL can count in any/all systems
_____Constitutional – Activity, appearance, appetite, exercise, fatigue, fevers, mood, sweats, weakness, wt change, chills
_____Eyes - Blurred vision, drainage, dryness, flashing, pain, photophobia, redness, tearing, vision change
_____ENT & Mouth - Airway, balance, bleeding, discharge, hearing, pain, ringing, smell, swallowing, taste, voice
_____CV - Chest pain, diaphoresis, dizziness, exertional pain, irregular beats, leg cramps, orthopnea, palpitations, peripheral edema, radiation, SOB
_____Respiratory - Allergies, cough, dyspnea, hemoptysis, pain, SOB, sputum, wheezing
_____GI - Appetite, Change in bowel habits, constipation, diarrhea, heartburn, hemetemesis, indigestion, nausea, pain, rectal bleed, swallowing, thirst, vomiting
_____GU – Burning, discharge, dribbling, frequency, hematuria, incontinence, menopause, nocturia, odor, pain, pregnancies, starting, stopping, urgency, dyuria
_____All/Imm – Allergies to meds, chemo, hay fever, HIV/AIDS, hives, immune suppression, immunizations, sweating
_____MS - Limitation of activity, pain, redness, stiffness, swelling, weakness
_____Skin – bleeding, color change, cyanosis, dryness, growths, jaundice, rash
_____Neuro – blackout, HA, memory loss, numbness, seizure, syncope, tingling, tremors
_____Psych – Anxiety, delusion, depression, hallucination, insomnia, nervous, panic, personality, phobia, suicidal
_____Endocr – Change hair pattern, heat/cold intolerance, polydiipsia, polyphagia, polyuria, sweating
_____Hem/Lym – bleeding, bruising, gland swelling, menses, nodes
_____Documentation of adequate ROS & all others negative


PFSH
_____Past Medical History
Surgeries
Any item labeled as PMH may only be used for that. This is true for even chronic problems. Don’t try to count them for HPI or ROS elements
Diagnostic tests, even when they appear in the HPI area, can only be used as PMH. Don’t try to count them as something else
_____Family History
_____Social History
Smoking, Alcohol, Marital status
____Unable to do comprehensive history due to patient condition






PHYSICAL EXAM

CONSTITUTIONAL (2) –
____BP, Pulse, Respiration, Temp, Ht, Wt Measurement of any 3 of
the above VS. (May be measured/recorded by staff person)
____GENERAL APPEARANCE – Development, Nutrition,
Body habitus, Deformities, Grooming
EYES (3)–
____ Conjunctivae, Lids
____ Pupils and Irises PERRLA
____ SCOPE EXAM, Optic discs, C/D ratio (Cup to Disk
Ratio), Size, Appearance
Posterior segments,Vessel changes, Exudates,
hemorrhages
EARS, NOSE, MOUTH, THROAT (6)
____External auditory canals, TM’s
____EARS & NOSE – Appearance, Scars, Lesions, Masses
____Hearing, Whispered voice, Finger rub, Tuning Fork
____NOSE - Mucosa, Septum, Turbinates
____MOUTH – Lips, Teeth, Gums
____THROAT/OROPHARYNX – Oral mucosa, Salivary glands,
Hard and soft palates, Tongue, Tonsils, Posterior pharynx
NECK (2)
____NECK – Masses, Appearance, Symmetry, Tracheal
position, Crepitus
____THYROID – Enlargement, Tenderness, Mass
RESPIRATORY (4) –
____Effort, Retractions, Muscles, Movement
____Percussion, Dullness, Flatness, Hyperresonance
____Palpation, Fremitus,
____Auscultation, Breath sounds, Rubs
CARDIOVASCULAR (7) –
____Palpation, Location, Size, Thrills
____Auscultation, Abnormal sounds, Murmurs
ARTERIES –
____Carotid, Pulse, Bruits
____Abdominal Aorta,Size, Bruits
____Femoral, Pulse, Bruits
____Pedal Pulse
____Extremities, Edema, Varicosities
CHEST/BREASTS (2)–
____Breasts, Symmetry, Nipple discharge
____Breasts and axillae, Mass, Lump, Tenderness
GI/ABDOMEN (5) –
____Abdomen, Mass, Tenderness
____Liver, Spleen
____Hernia
____Anus, Perineum, Rectum, Sphincter tone, Hemorrhoids,
Rectal mass
____Occult blood


GU, FEMALE (6)–
____External genitalia, Appearance, Hair distribution, Lesions,
____Vagina, Appearance, Estrogen effect, Discharge,
Lesions, Pelvic support, Cystocele, Rectocele
____Urethra, Mass, Tenderness, Scarring
____Bladder, Fullness, Mass, Tenderness
____Cervix, Appearance, Lesions, Discharge
____Uterus, Contour, Position, Mobility, Tenderness,
Consistency, Descent or Support
____Adnexa/Parametria, Mass, Tenderness, Organomegaly,
Nodules
GU, MALE (3)–
____Scrotum, Hydrocele, Spermatocele, Tenderness of cord,
Testicular mass
____Penis, phallus
____DRE of prostate for Size, Symmetry, Nodules, Tenderness
LYMPHATIC (4) - Nodes, ____Neck, ____Axillae
____Groin, ____Other
MS (26) –
____Gait, Station, Romberg, Ambulatory??
____Nails/Digits, Clubbing, Cyanosis, Inflammation,
Petechiae, Ischemia, Infection, Nodes
HEAD AND NECK
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion, EOMI
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
SPINE, RIBS, AND PELVIS
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
EXTREMITIES,
RUE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
LUE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
RLE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
LLE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements

SKIN (2) –
____Inspection, Rash, Lesion, Ulcer
____Palpation, Induration, Nodule, Tightening

NEURO (3) –
____Cranial deficits
____DTR, Babinski
____Sensation, Touch, Pin, Vibration, Proprioception

PSYCH (4) –
____Judgement, Insight
____AO x 3
____Memory, recent and remote
____Mood and affect, Depression, Anxiety, Agitation





MEDICAL DECISION MAKING:

Dx: Types of problem:
_____Self-limited or minor
_____Established same/improving ____ Established, worsening
_____New, no additional workup ____New, with additional workup

_____Are any of the above illnesses a severe exacerbation, progression or side effect of treatment?

Management Options:
_____OTC Meds ____Phys/Occ Therapy
_____Prescrip/IM meds ____Closed Fx/dislocation w/o
_____IV meds manipulation
_____IV meds w/ additives ____Minor surg w/o risk factors
_____High Risk meds ____Minor surg w/ risk factors
_____Telemetry ____Major surg w/o risk factors
_____Respiratory treatments ____Major surg w/ risk factors
_____Nuclear Medicine ____Major emergency surger
____Decision not to resuscitate
----------------------------
_____Decision to obtain old medical records and/or obtain Hx from someone other than patient
_____Review and summ of old records and/or obtain Hx
from someone other than patient
_____Discussion of case with another health care provider

Time spent in minutes w/ patient or family_____________


Labs:
_____CBC/UA ____Cardiac enzymes
_____Flu/Strep/Monospot ____ABG
_____PG test _____PT/PTT
_____Amylase _____T&C
_____BUN/Creat _____Superficial Bx
_____Electrolytes _____Deep/incisional Bx
_____ETOH/Drug screen ____Other labs 0-9
_____Chem profile
----------------------
_____Independent visualization of test
_____Discussion w/ performing
physician

X-ray/Radiology
_____Chest ____GI/Gallbladder series
_____Extremities ____IVP
_____Abdomen ____CAT scan
_____Hip/Pelvis ____MRI
_____C-spine ____Vascular studies w/o risk
_____Diagnostic US ____Vascular studies w/ risk
_____Discography ____Other X-ray 0-9
_____T/L spine
--------------------------
_____Independent visualization of test
_____Discussion w/ performing physician

Other diagnostic tests:
_____EKG ____Nuclear scan
_____Holter ____Lumbar puncture
_____Treadmill/stress ____Thoracentesis
_____EEG/EMG ____Culdocentesis
_____Vectorcardiogram ____Endoscope w/o risk
_____Doppler flow ____Endoscope w/ risk
_____Pulmonary
---------------------
_____Independent visualization of test
_____Discussion w/ performing
physician


Ó

Medical Coding Quiz CCS/ CCS-P

CPC OR CCS-P CODING PREP QUIZ

1. Complete the following statement, “Medically necessary services are . . . “

a. Consistent with the symptoms or diagnosis of the illness or injury being treated.
b. Reasonable. That is, in line with mainstream medical practice.
c. Reasonable and necessary for the patient’s condition and not performed primarily for the convenience of the patient, the attending physician, or the supplier.
d. All of the above.

2. In the SOAP format of medical record documentation, what term describes the section of the medical record that contains the notes for the physician’s examination of the key components of the E/M codes (what the physician observes)?

a. Subjective
b. Objective
c. Assessment
d. Plan

3. Referring to the SOAP format, the following statement would be found in what section of the medical record: “The patient is a 10-year-old female who has experienced right ear pain starting last night after dinner.”

a. Subjective
b. Objective
c. Assessment
d. Plan

4. In what portion of the medical record would you find the following statement: “Patient to apply ice pack around ankle three times a day to prevent further swelling; Tylenol as needed to relieve pain.”

a. Subjective
b. Objective
c. Assessment
d. Plan



5. The intentional misrepresentation by either providers or beneficiaries to obtain or receive payment for services is referred to as:

a. Unbundling
b. Fraud
c. Limiting Charges
d. All of the above

6. The prefix “path-“ means:

a. System
b. Organ
c. Disease
d. Cell

7. One of the three bones that constitutes the pelvic girdle is called:

a. Ileum
b. Lunette
c. Coccyx
d. Ilium

8. A laryngoscopy is:

a. A visual examination of the larynx
b. The inflammation of the larynx
c. The defective development of the larynx
d. An instrument used to examine the membrane of the larynx

9. The term “carcinoma in situ” refers to:

a. A malignant neoplasm found at the original site
b. A secondary or metastasized neoplasm
c. Malignancies that are confined or noninvasive
d. Tissue that is beginning to exhibit neoplastic behavior

10. A 6-year-old girl fell on the playground at school. An x-ray revealed a distal radial fracture. Where is this located?

a. Thumb side of lower forearm
b. Outside lower leg
c. Just below elbow on the thumb side
d. Lower part of the upper arm



11. Which term describes the most important reason for the care provided to the patient; that is, the first diagnosis code listed on the insurance form?

a. Complications
b. Adverse effect
c. Primary diagnosis
d. Symptoms

12. The term “adverse effect” means:

a. Secondary diagnosis code used to identify the external cause for a condition for which the patient is being seen
b. A morbid phenomenon or departure from the normal structure, function, or sensation experienced by the patient and indicative of the disease
c. The term denoting name of the disease or syndrome a person has or is believed to have
d. None of the above

13. Which of the following is a FALSE statement?

a. When only ancillary services are provided, list the appropriate V code first and the problem or condition second.
b. Code the primary diagnosis code first followed by the secondary, tertiary, and so on. Code any co-existing conditions that affect the treatment of the patient for the visit or procedure as supplementary information.
c. Only code a chronic diagnosis once, as it is not applicable to the patient’s current treatment.
d. Identify the service(s) or visit(s) for circumstances other than the disease or injury such as follow-up care

14. The symbol [ ] indicates:

a. Synonyms, alternate wording, or explanatory phrases
b. Supplementary words that may be present or absent without affecting the code assignment
c. A series of terms, each of which is modified by the statement appearing to the right
d. The code is specified


15. Which reference manual contains a listing of “V” and “E” codes as well as a numerical listing that classifies groups of disease and injury codes according to etiology and organ system?

a. CPT
b. HCPCS
c. ICD-9-CM VOL I
d. ICD-9-CM VOL II


16. A 16-year-old female was admitted to the ER for abdominal pain, nausea and vomiting, and diarrhea. Upon discharge, she was diagnosed with a ruptured ovarian cyst.

a. 789.0
b. 620.2
c. 789.03
d. 620.2, 789.03

17. A superficial burn to the right shoulder.

a. 942.04
b. 943.40
c. 943.15
d. 692.71

18. A four-week-old infant who is admitted for pyloric stenosis.

a. 750.5
b. 537.0
c. 779.3
d. 536.2

19. HCPCS is the acronym for:

a. Health Care Procedure Coding System
b. Health Coding Procedural Counting System
c. HCFA Common Procedure Coding System
d. Hospital Coding Procedural Care Services


20. Chose the appropriate HCPCS code for a semi-rigid, thermoplastic foam, two-piece cervical collar.

a. L0120
b. E0943
c. E0942
d. L0172

21. What is the HCPCS code for 1 cc of Testosterone Cypionate 50 mg?

a. J1090
b. J1060
c. J0900
d. J3140

22. Which modifier indicates diagnostic mammogram converted from screening mammogram on the same day?

a. –59
b. –58
c. –AT
d. –GH

23. What is the HCPCS code for wound closure using tissue adhesive(s) only?

a. A6250
b. G0168
c. A6265
d. G0170

24. Which of the following is the correct HCPCS code for 250 mg of Cyclosporin, parenteral?

a. J7502
b. J7516
c. K0121
d. J7515

25. Which modifier is used to describe a CLIA waived test?

a. QP
b. QW
c. GA
d. SG


26. In the CPT-4 text, what does the bullet symbol (•) represent?

a. Revised codes
b. New codes
c. Add-on codes
d. Service includes surgical procedure only

27. When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding which of the following modifiers?

a. –54
b. –66
c. –59
d. –62

28. When a patient is in a postoperative period and returns to the operating room for an unrelated procedure by the same physician, which of the following modifiers would you attach to the procedure being performed?

a. –59
b. –24
c. –78
d. –79

29. Evaluation and Management services were performed on an established patient in which the decision to perform a major surgery scheduled for the following morning was made. The patient was counseled for 15 minutes regarding treatment options, risks, and projected outcome. Which of the following modifiers would be appended to the service performed?

a. –56
b. –52
c. –50
d. –57

30. In the CPT-4 text, what does the following symbol represent (+)?

a. Revised codes
b. New codes
c. Add-on codes
d. Service includes surgical procedure only


31. The index in the CPT-4 text is arranged with main term entries. These main term entries will fall into one or more of four categories. Identify the four categories.

a. The procedure or service performed; the anatomical site involved; the condition; the modifying term.
b. The procedure or service performed; the organ or anatomical site; the code range; the synonym, eponym, or abbreviation.
c. The procedure or service performed; the organ or other anatomical site; the condition; the synonym, eponym, or abbreviation.
d. The modifying terms; the anatomical site; the disease; the synonyms, eponyms, or abbreviations.

32. A three-year-old established patient presents to her pediatrician for an earache and abdominal pain. The physician documented the chief complaint, a brief HPI, and problem pertinent system review. An examination of the respiratory system and the abdomen was performed. The physician prescribed an antibiotic and clear liquids for gastroenteritis. Select the E/M service code for this visit.

a. 99212
b. 99202
c. 99213
d. 99203

33. An out-of-state patient came to visit a Nephrologist to establish temporary care. The patient filled out a detailed history form, which was reviewed by the MD and his documentation recorded in the patient’s chart. The Nephrologist performed a detailed exam and made arrangements for local dialysis care. This history, exam, and medical decision-making took approximately thirty minutes. In addition, the physician spent 40 minutes with the patient and a family member discussing the new treatment options available for Chronic Renal Failure by addressing the patient concerns regarding the medical treatment he is receiving from his own Nephrologist. Code this encounter.

a. 99244
b. 99203-21
c. 99203, 99354
d. 99291

34. A routine E/M visit to stabilize a patient in ICU/CCU utilizes what code range?

a. 99234-99236
b. 99231-99233
c. 99291-99292
d. 99271-99275
35. The descriptors for the levels of E/M services recognize seven components in defining the levels of E/M services. Which components are considered the key components in selecting an E/M level of service?

a. Counseling, Time, and Examination
b. History, Examination, and Medical Decision Making
c. History, Time, and Medical Decision Making
d. Time, Examination, and Medical Decision Making

36. In the case where a patient is held in observation for more than two calendar dates, the physician must bill subsequent services furnished prior to the discharge utilizing which code range?

a. 99211-99215
b. 99201-99205
c. 99234-99236
d. 99231-99233

37. A physician is requested to stand by during a high-risk delivery of a newborn. The physician was on standby for forty-five minutes. Which code would be billed for this standby service?

a. 99436
b. 99360
c. 99360 x 2
d. 99431

38. What code would be reported for the delivery and discharge of a newborn on the same day?

a. 99431
b. 99432
c. 99435
d. 99238

39. Spinal anesthesia is defined as:

a. An injection of a local anesthetic solution into the subarachnoid space of the lumbar region to block the roots of the spinal nerves
b. The spinal nerves are blocked with injected local anesthetic agent into the epidural space of the spinal cord
c. When muscular relaxation occurs throughout the body, the muscles lose their tone; ocular movements cease; the pupils are centrally fixed.
d. None of the above


40. Continuous epidural analgesia for labor and a cesarean delivery

a. 00857-P1
b. 00955-P1
c. 59514-47
d. 88050-P1

41. Which of the following is not needed when billing for Monitored Anesthesiology Care (MAC)?

a. Modifier –QS
b. Total minutes of anesthesia service
c. Modifier –66
d. Documentation

42. A patient required an epidural in place for four days. The anesthesiologist checked it every day. How would daily visits be coded for an anesthesiologist when the patient’s primary physician also saw the patient?

a. 00700
b. 00850
c. 01996
d. 11760

43. When an anesthesiologist is utilized to provide services to a patient with a broken fibula requiring cast repair, the anesthesia services are reported with code(s):

a. 01462
b. 27780-47
c. 01490
d. 01999

44. Anesthesia complicated by emergency conditions would require the use of what modifier or CPT code?

a. –23
b. P5
c. 99100
d. 99140

45. Code the cryosurgery of a 1.5 cm pre-malignant lesion on the left forearm:

a. 17000
b. 17250
c. 17304
d. 17262

46. What would define the removal of an entire lesion for pathological review:

a. Destruction
b. Biopsy, incisional
c. Biopsy, excisional
d. Shaving

47. A patient, suffering from a hypertrophic breast condition, presents to the surgeon’s office surgical suite to have breast tissue removed due to her back pain this condition has caused. The physician removes 221 grams of tissue from the right breast and 284 grams of tissue from the left breast. Select the appropriate code(s) for this procedure.

a. 19316 x 2
b. 19324-50
c. 19324
d. 19318-50

48. Debridement is the process of removing dead tissue, eschar, dirt, foreign material, or debris from all except:

a. Burns
b. Wounds
c. Orifices
d. Infected skin

49. Code the excision of a 2.5 cm malignant lip lesion and two malignant lesions of the chest, each 1.5 cm in diameter.

a. 11643, 11602-51 x 2
b. 11403, 11402-51 x 2
c. 11643, 11602 x 2
d. 11200

50. Code the destruction of three benign facial lesions.
a. 17000, 17003 x 2
b. 17000 x 3
c. 17260 x 3
d. 11305 x 3
51. “No man’s land” is:

a. the palm of the hand
b. the middle bone of the fingers to the wrist
c. the crease in the palm closest to the fingers and the middle bone of the fingers
d. the crease in the palm closest to the fingers and the wrist

52. Code the closed treatment of a carpal bone fracture (not scaphoid), with manipulation.

a. 25635
b. 25624
c. 25645
d. 25628

53. Code a repeat closed treatment of a femoral shaft fracture with manipulation by the same physician who performed the initial treatment.

a. 27502-77
b. 27506-76
c. 27507-77
d. 27502-76

54. Code a knee amputation of the right leg just above the knee.

a. 27598
b. 27590
c. 27290
d. 28825

55. Code an arthocentesis into the acromioclavicular joint of the left shoulder.

a. 20550
b. 20610
c. 20605
d. 20600

Medical Coding Test 2

Answer using both 1997 and 1995 guidelines assign all codes and modifiers that apply

On Dec 5, patient fell from a ladder while at work. He was taken to the ER where x-rays were taken noting a comminuted fracture of the distal fibula. Orthopedist, was called in by the ER doctor in consultation to evaluate the patient & discuss treatment options The Orthopedist obtained an expanded problem focused history and performed a detailed examination. His decision making was of moderate complexity identifying the need for immediate surgery. The patient was admitted and taken to the OR where a closed treatment (without manipulation) was performed. Patient is in the postoperative period of an arthroscopy of the shoulder performed 2 weeks ago. The Orthopedist performed both the surgeries. Assign the appropriate ICD-9-CM and CPT codes for the December 5 case by the orthopedist and the ER doctor.



12. Patient presents to her psychiatrist’s office for a 45-minute supportive psychotherapy service that included review of recent lab work and adjustment of her medication. Her diagnosis was noted as: severe bipolar disorder in depressed state displaying psychotic behavior. Assign the appropriate ICD-9-CM and CPT codes for this case.



Patient presents to Outpatient Surgery Department with a suspicious skin lesion involving the upper trunk. Lesion measures 2.8 cm and the margin required to adequately excise the lesion includes 0.2 cm from both sides. Pathology is negative for cancer noting actinic keratosis. Assign the appropriate ICD-9-CM diagnosis code(s) and CPT procedure code(s) for the surgeon.



A six-year old boy fell while riding his bike in his backyard. He had numerous cuts and was brought to the ER by his mother. The ER physician obtained a brief HPI, pertinent ROS and pertinent past medical, social & family history. He performed an expanded problem focused examination. Medical decision making was of low complexity. Physician performed a layered closure of a 5.0 cm laceration of the forehead, a 1.5 cm layered closure of the left external ear and a simple repair of a 2.5 cm laceration of the lip. Assign the appropriate ICD-9-CM diagnosis code(s) and CPT procedure code(s).



An established patient with known diagnosis of hypertension returns to the office for a blood pressure check by the nurse. The physician did not see the patient during this visit. Assign the appropriate ICD-9-CM diagnosis and CPT procedure codes.



A doctor is requested by another doctor to evaluate his patient that is hospitalized. He. sees the patient on 1/5 . He obtains a detailed history, performs a comprehensive examination and medical decision making was of moderate complexity. He has ordered several tests to be performed and will schedule a follow-up appointment with the patient in his office to go over the results. The patient was discharged home on 1/7. The patient sees the. doctor in his office on 1/12 to discuss the results of the tests. He obtains an expanded problem focused history, performs an expanded problem focused examination and provides medical decision making of moderate complexity.

Identify the E&M code for the 1/5 visit in the hospital

Identify the E&M code for the 1/12 visit in the office


Patient presents to OP surgery for insertion of a dual chamber pacemaker into the right atrium and ventricle including transvenous placement of electrodes. A subcutaneous pocket for the pulse generator was also created. Patient has long-standing atrial fibrillation with minimal improvement from medications. Assign the appropriate ICD-9-CM diagnosis and CPT procedure codes.



Patient has recently moved to the area and presents to Dr. Peters office to establish care and for evaluation of long-standing diabetes and hypertension, currently doing well per patient. A detailed history was obtained and a detailed exam was performed. Medical decision making was of moderate complexity, including renewal of medications. Doctor ordered a baseline EKG, which was performed by the nurse. The results were interpreted by Dr. Peters as normal. The patient requested evaluation of several skin tags that were rubbing against his shirt collar. Following examination, patient agreed to have them removed. Eight skin tags were successfully removed. Assign the appropriate ICD-9-CM diagnosis and CPT procedure codes.



A patient had a biopsy of skin lesion performed on 10/2/05. Results were positive for malignant melanoma and patient was taken back to the operating room on 10/5/05 for a wide excision with adjacent tissue transfer to ensure no further tumor is present. What two-digit modifier should be appended to the surgical procedure?


CT scan of the cervical spine without contrast material followed by contrast material with additional sections taken. You are the biller for the radiologist who supervised, interpreted & dictated the report for this test. Assign only the appropriate CPT procedure code.


Via femoral approach, an arch aortogram and bilateral selective common carotid arteriogram were performed. Assign the CPT codes for both the surgery and the radiologic (professional component only) portions of the procedure.



Patient was taken to the Operating Room for a repeat excision of Baker’s cyst from the popliteal space of the right knee. Assign the appropriate ICD-9-CM diagnosis and CPT procedure code for the second procedure.


Anesthesiologist personally provided anesthesia service for patient undergoing spinal surgery including laminectomy and insertion of Harrington rods. The patient is relatively healthy other than the spinal condition. Assign only the CPT code along with the appropriate physical status modifier and modifier identifying the provider.


Patient was admitted on January 10 for planned surgical repair of left carotid artery stenosis. He was taken to the OR where Dr Peters performed a thromboendarterectomy of the left carotid artery with patch graft. He was stable while in recovery and was transferred to the surgical ward when a bed was available Dr Peters stopped by to see the patient later in the evening on the 10th. He stopped by the morning of the 1/11 and noted that the patient was doing well and could be discharged later in the day. The patient was discharged home on the 11th with instructions to follow-up with Dr. Peters on the 18th. Assign the appropriate ICD-9-CM and CPT codes for the following:

January 10:

January 11:


Dr. Peters sees an established patient in his office for evaluation of end-stage renal disease due to insulin-dependent diabetes mellitus. In addition to a problem focused history, he performs an expanded problem focused exam that includes a limited exam of the genitourinary, immunologic, skin and musculoskeletal systems and documents all positive and negative findings. The patient’s status does not seem to have changed and medical decision making is of a low complexity. Dr. Hawthorne discusses with the patient his insulin dosage, diet, exercise and will see patient again in 6 months. Assign the appropriate ICD-9-CM and CPT codes.



Patient was brought to the ER following a car accident yesterday evening in which she was a passenger. The accident was minor and she and her husband drove home with no complaints noted at the time of the accident. When she woke up this morning, she complained of neck pain especially with movement. She tried a heating pad for an hour with no relief. She has no complaints of dizziness or headache, abdominal or other musculoskeletal pain or nausea. The patient has no known allergies and takes Zocor for her hypercholesterolemia. Doctor performed an expanded problem focused examination. The ER doctor, Dr. Smith, ordered complete cervical spine x-rays including oblique & flexion views. Radiologist, Dr. Jones completed the x-ray report noting cervical sprain. Dr. Smith instructed the patient to apply heat to alleviate the cervical sprain. Assign the appropriate ICD-9-CM and CPT codes for both Dr. Smith & Dr. Jones (professional component only).

Dr. Smith:

Dr. Jones:
Patient presents to her doctor’s office with complaint of dizziness and headache for the past week. Her regular doctor is on vacation and she is seen by his partner, Dr. Sullivan. Doctor obtains a problem focused history and performs an expanded problem focused exam noting tachycardia. Patient has a history of atrial fibrillation and has been on Digoxin for the past year. Venipuncture is done to assess the quantity of Digoxin in the blood. Results showed elevated Digoxin. Patient was called and dosage was adjusted. Patient will return to the office in one week for follow-up. Final diagnosis: Digoxin toxicity and atrial fibrillation. Assign the appropriate ICD-9-CM and CPT codes.



Patient presents to the lab department for the following blood tests: serum potassium, calcium, carbon dioxide, chloride, creatinine, serum sodium, BUN & glucose. Assign the appropriate CPT code(s) for these tests.



Patient is status post right hip replacement and presents to the outpatient physical therapy department for rehab as per the treatment plan approved by the physician. The following services were provided by the PT assistant under the direction of the physical therapist: 15 minutes of whirlpool therapy, 8 minutes of ice packs and 10 minutes of therapeutic massage. The patient is doing very well and able to complete 5 minutes more therapeutic exercises compared to last week. Patient is instructed to continue with home exercises until next visit. Assign the appropriate ICD-9-CM and CPT codes.



Patient presents with spinal stenosis. He was taken to the OR where a laminectomy with exploration and decompression of spinal cord at L1, L2 and L3. Assign the appropriate CPT code(s) only.

Medical Coding Resources

A medical coder always needs to have his knowledge updated and need to continue his education throughout the career. As we know, every year on Oct 1, the ICD-9 CM gets updated and on Jan 1 of every year CPT and HCPCS gets updated.

All Medical coders need to follow Coding Clinics and CPT Assistants where you can have your knowledge updated.

The coding edge magazine from AAPC is also a very good magazine to follow. The journals from both the AHIMA and AAPC are valuable and knowledge gaining.

There are many blogs and forums over net where you can be part of them and share your knowledge with them. Keep reading articles on coding whenever you have time.

Some of the coding resources:

http://health-information.advanceweb.com/

http://www.justcoding.com/

http://www.hcpro.com/

http://www.ahima.org/coding/coding_resources.asp

http://www.cms.hhs.gov/

http://www.aapc.com/

http://www.pharma-lexicon.com/

http://www.coderyte.com/

http://www.zhealthpublishing.com/

http://www.stedmans.com/

Medical Coding Schools

Medical Coding is assigning numeric values for the procedures and/or diagnoses documented in the medical record. For being a medical coder, you need to undergo training and then need to get certification, which makes you a qualified coder, which inturn increases your chances of getting a better job. There are many online coding scools and classroom schools where you can undergo training. The training can be completed in 3-6 months period of time. For Certification, please check our post on coding certifications.

Here are the list of the schools which give medical coding training.
http://www.andrewsschool.com/
http://www.codingcert.com/
http://online.allenschool.edu/
http://www.earnmydegree.com/online-education/health-care/medical-billing-and-coding.html
http://www.lincolnonline.edu/programs/online-associate-degrees/online-medical-coding-and-billing
http://www.codemedschool.com/

Tags: Medical coding training, medical coding courses, medical coding colleges, medical coding job, medical coding specialist.

Remote Medical Coding- Working From Home

Experienced and certified Medical Coders are in great demand and many companies are offering work from home.
These are some of the companies, which provide work to home.

www.maximhealthinformationservices.com/remote-coding-services.aspx
www.completecodingsolutions.com/remotecoding.html
www.lexicode.com/remoteathome.html
www.carecommunications.com/careers.html
www.precysesolutions.com/precyse-careers.asp
www.himoncall.com

Medical Coding Test/Practice

1. Which of the following identifies the key component(s) of an Evaluation and Management Services code?
a. Review of Systems, Nature of Presenting Problem and Examination
b. History, Medical Decision Making and Assessment
c. History, Examination and Medical Decision Making
d. Time and Counseling

2. Which of the following is a true statement regarding modifier 51:
a. Modifier 51 should ONLY be used with “add-on” codes.
b. Modifier 51 is appended to a code indicating that service was reduced in some way.
c. Modifier 51 is appended to a code indicating the procedure is distinct from others performed on the same day.
d. None of the above.

3. Which of the following describes an endoscopic examination of the rectum and sigmoid colon per the CPT manual?
a. Sigmoidoscopy
b. Colonoscopy
c. Proctosigmoidoscopy
d. Anoscopy

4. A total abdominal hysterectomy with bilateral salpingo-oophorectomy. The following codes were submitted to the insurance company (58150 and 58720), but the claim was rejected. Which of the following identifies the reason for the rejection:
a. Codes are accurate. Insurance company error.
b. Modifier 50 should have been appended to code 58720 indicating a bilateral procedure.
c. Procedures were unbundled.
d. None of the above.

5. On March 1, 2006 patient returns to his surgeon’s office for a postoperative follow-up visit following a cholecystectomy performed on February 15, 2006. Patient has no complaints. The wound site looks good with no drainage noted. Patient was instructed to call the office with any complaints. Which of the following describes the appropriate coding of the March visit.
a. Assign an established patient E&M visit code based on the extent of the documentation.
b. Assign code 99024 indicating a postoperative visit.
c. NO code is assigned since the patient is within the global period of the original procedure.
d. Assign a code for the original procedure and append with modifier 55 (postop care).


6. Patient was admitted for stabilization of glucose levels. He has long-standing type 1 DM, COPD and hypertension. This is the 4th day of hospitalization and his doctor was called by the nurse reporting several elevated glucose readings. The patient has no complaints other than a slight headache. The doctor documents that the patient is progressing well with the exception of his diabetes. Repeat glucose tests are 250, 275 and 240. The physician adjusts the insulin dosage and enters an order for Accu-checks to be performed every 4 hours with repeat glucose in 8 hours. Exam included: BP is 140/90, Heart – normal, Lungs – clear. Given this documentation, which of the following identifies the most appropriate CPT code for the service rendered by Dr. Green?
a. 99222
b. 99232
c. 99253

7. Which of the following terms does CPT define as a service that is provided by a physician whose opinion or advice regarding a diagnosis or treatment is requested by another physician?
a. Referral
b. Consultation
c. Attending Physician
d. New Patient Office Visit

8. Which of the following describes a new patient per the CPT Manual?
a. Patient that has been seen by the same doctor or one within the same specialty within the past 3 years.
b. Patient that has not been seen by the same doctor or one within the same specialty within the past 3 years.
c. Patient that has been seen by the same doctor or one within the same specialty within the past year.
d. Patient that has not been seen by the same doctor or one within the same specialty within the past year.

9. A patient was seen by her obstetrician in the office for evaluation of her gestational diabetes. Her glucose levels required that she be placed on insulin. Which of the following identifies the correct code assignment?
a. 648.83
b. 648.03
c. 648.83; 250.01
d. 648.03; 250.01

10. Which of the following describes a selective catheterization?
a. Aortogram
b. Superior venogram
c. Insertion of catheter into arteriovenous shunt for dialysis
d. Cerebral arteriogram via the right femoral artery

Heart / Cardiac Catheterization Coding Left/Right

Right Heart Catheterization
This is the introduction of a catheter(s) into the right atrium, right ventricle and pulmonary artery. It includes hemodynamic measurements, cardiac output determination, shunt determinations, blood sampling, and hydrogen arrival time, as part of the procedure. Placement of catheter(s), repositioning, and replacement with other catheters are included as part of the procedure. Cannulation of the coronary sinus is included in this procedure.
Indications for Right Heart Catheterization

Right heart catheterization is indicated to evaluate:
· Valvular heart disease
· Congestive heart failure
· Congenital heart disease
· Cor pulmonale
· Pulmonary hypertension
· Intracardiac shunts
Limitations for Right Heart Catheterization

This procedure is done in a cardiac catheterization laboratory or interventional radiology laboratory, and does not include a "bedside placement" of a flow directed (Swan-Ganz type) catheter.
There is no additional reimbursement for a right heart catheterization done for reasons other than hemodynamic evaluation. Studies done in conjunction with electrophysiologic tests, HIS bundle studies, pacing studies, temporary pacemaker insertion and endomyocardial biopsy are not separately payable. Right heart catheterization with hemodynamic measurements done at the same time as these above-mentioned procedures will still have to meet the requirements of medical necessity.
There is no additional reimbursement for leaving a catheter in place for monitoring at the conclusion of a right heart catheterization or for the introduction of a Swan-Ganz type catheter at the time of a right heart catheterization, or for its subsequent removal.
Right heart catheterization is not indicated for:

· Atherosclerotic heart disease without heart failure
· Angioplasty or other interventional procedures
Swan-Ganz Catheterization
This procedure commonly includes insertion of a flexible, balloon-tipped catheter into the pulmonary artery for hemodynamic monitoring of the critically ill patient. Although Swan-Ganz catheterization is considered an invasive procedure, it may be safely performed at the bedside in an intensive care unit setting, using continuous EKG and blood pressure monitoring. In brief, this technique involves cannulation of a large vein, such as the subclavian or internal jugular vein. A flow-directed catheter is advanced through the central venous system into the right atrium (RA), right ventricle (RV), and pulmonary artery (PA). If desired, the catheter may be further "wedged" briefly into a small pulmonary artery branch. Direct pressure measurements are obtained in the respective cardiac chambers and pulmonary artery. An indirect measurement of left atrial filling pressure is obtained when the catheter is "wedged". In addition, other hemodynamic parameters may be easily measured, such as the cardiac output, systemic vascular resistance (SVR), mixed venous oxygen saturation, and intrapulmonary shunt fraction.
Indications for Swan-Ganz Catheterization
Swan-Ganz catheterization is indicated in the following situations:
· Acute myocardial infarction with hemodynamic instability
· Severe hypotension of unknown etiology, especially if the response to initial therapy is inadequate (e.g., volume loading)
· Selected cases of septic shock
· Adult respiratory distress syndrome, to confirm the diagnosis of noncardiogenic pulmonary edema (normal "wedge" pressure) and to aid in subsequent fluid and ventilator management
· Suspected cases of cardiac tamponade, to confirm the diagnosis, monitor hemodynamics during pericardiocentesis, and follow response to therapy
· Suspected papillary muscle rupture
· Possible ventricular septal defect or atrial septal defect following myocardial infarction
· Congestive heart failure responding poorly to diuretics, especially when intravascular volume status is uncertain
· Intraoperative monitoring of patients undergoing open heart surgery, particularly coronary artery bypass procedures involving multiple vessels; patients undergoing abdominal aortic aneurysm repair may also benefit from PA catheterization perioperatively
· Drug overdose, especially when the risk of acute lung damage is high (e.g., heroin, aspirin)
· Exacerbations of chronic obstructive lung disease requiring intubation; hemodynamic monitoring may detect occult or superimposed causes of respiratory failure not suspected clinically (e.g., left ventricular dysfunction)
· End-stage liver failure with deteriorating renal function
· Suspected cases of pulmonary hypertension
· Intraoperative and hemodynamic perioperative monitoring of patients with significant heart disease, undergoing non-cardiac surgery
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management.
Limitations for Swan-Ganz Catheterization
This procedure is done at the bedside in the critical care unit or the operating room.
There is no additional reimbursement for a Swan-Ganz catheterization done for reasons other than hemodynamic evaluation. Studies done in conjunction with electrophysiologic tests, HIS bundle studies, pacing studies, temporary pacemaker insertion and endomyocardial biopsy are not separately payable. Swan-Ganz catheterization with hemodynamic measurements done at the same time as these above-mentioned procedures will still have to meet the requirements of medical necessity.
There is no additional reimbursement to leave a catheter in place for monitoring at the conclusion of Swan-Ganz catheterization.
Swan-Ganz catheterization is not indicated for:
· Atherosclerotic heart disease without heart failure
· Angioplasty or other interventional procedures

Left Heart Catheterization
Indications and Limitations for Left Heart Catheterization
This is the introduction of catheter(s) into the aorta, left ventricle and left atrium and includes cannulation of the coronary arteries and bypass grafts. It includes hemodynamic measurements, blood sampling and shunt determinations as part of the procedure. Placement of multiple catheters and their repositioning or replacement is included in this procedure. Injection procedures for selective opacification of arteries and conduits are separately reimbursable.
There is no additional reimbursement for a left heart catheterization done for reasons other than hemodynamic evaluation or angiography. Therefore, left heart catheterization is not separately reimbursed with studies such as electrophysiologic or pacing studies, or endomyocardial biopsies (unless there is medical necessity).
Angiography
Indications and Limitations for Angiography
Angiograms of the individual cardiac chambers will be reimbursed based on medical necessity. Coding must utilize the most all-inclusive procedure description. Each procedure may be reimbursed only once regardless of the number of views or actual pictures taken.
Aortography is reimbursable only for diagnoses of aortic root disease, valvular heart disease or congenital heart disease. It is not reimbursable for atherosclerotic heart disease. Angiograms to visualize the coronary ostia are included as part of coronary angiography. A diagnosis of "rule out (valvular lesion)" is not reimbursable.
Coronary angiography includes arteriograms of all the coronary arteries and their branches, regardless of the number of vessels visualized. Coronary angiography includes angiograms done with the administration of medications for diagnostic purposes (e.g., ergonovine, nitroglycerine) as part of the procedure. The procedure may be reimbursed only once regardless of the number of views, films or whether medications were administered. Replacement and repositioning of catheters are considered as part of the procedure, and are not reimbursable separately. The selective injection procedures may be performed without a formal left heart catheterization.

Angioplasty/Stent Placement/Atherectomy
Indications and Limitations for Angioplasty/Stent Placement/Atherectomy
The interventional procedures - percutaneous transluminal angioplasty, coronary stent placement and atherectomy are described under the interventional cardiology policy. These are separately reimbursable procedures.
Diagnostic cardiac catheterization with coronary angiography performed prior to an interventional procedure is reimbursable whether done on the same day or on a previous day, when used as a diagnostic tool to evaluate the need for the intervention, but only once prior to the interventional procedure. When the interventional procedure and cardiac catheterization with angiography are done on the same day, the multiple surgery pricing will apply (payment in full for the higher of two procedures and 50% for the second, etc.). Angiography to evaluate results of the interventional procedure and to guide the catheter(s) (to assist with the interventional procedure) is considered incident to the procedure and is not separately reimbursable.
General Limitations
The completion of the diagnostic cardiac catheterization and the interventional procedure on the same day is increasingly the standard of practice. While there may be legitimate reasons for delaying the interventional procedure (e.g., transfer from a community hospital to a tertiary center), Medicare strongly discourages the separation of these procedures to circumvent the multiple surgery pricing.
Cardiac catheterization requires personal (in person) supervision of its performance by a physician. When performed in a teaching setting, the teaching physician must be present with the resident throughout the procedure. The performance by the resident alone would not establish a basis for fee schedule payment for such services.
Vascular closure of the puncture site is an inherent part of all procedures for arterial access. As such, it is included in the arterial access codes for all angiographic and catheterization procedures, and may not be billed separately.
Extra Cardiac Angiography performed with Cardiac Catheterization.
Extra Cardiac Angiography is sometimes reported with cardiac catheterization. These services include interrogation of the abdominal plus iliofemoral artery, abdominal aorta, carotid and renal arteries.
However, such services are generally not indicated and will be denied unless there are specific conditions that warrant selective investigation. Examples of specific clinical syndromes are: subclavian steal syndrome, TIA (transient ischemic attack), renal artery stenosis, hypertensive patients with pulmonary edema and renal failure.
These extra angiographic services must be specifically requested by the treating physician.





Other Non-covered Procedures During Catheterization
· Prophylactic insertion of temporary transvenous pacemaker
· Assistant at surgery
· Right heart catheterization for the purpose of inserting a temporary pacemaker or performing electrophysiologic studies
· Standby anesthesia or surgeon during angioplasty
· Repositioning and replacement of catheters
· Administration of medications during catheterization
· Percutaneous vascular closure (e.g., Perclose)
· Anesthesia

**Please Check CPT guidelines before coding

Abbreviations related to Eye

A
Applanation tension
AA
Amplitude of accommodation
AACG
acute angle closure glaucoma
ABK
aphakic bullous keratopathy
ABMD
ant. basement membrane dystrophy cornea 371.52
AC
anterior chamber
AC/A
accomodative convergance/accommodation ratio
ACA
anterior cerebral artery
acc
accommodative
ACG
angle closure glaucoma
ACIOL
anterior chamber intraocular lens
ACS
anterior cortical
ACT
alternate cover test(ACT' = near)
add
Added power for near vision
AES
anterior eye segment
AET
alternate esotropia
AFGE
air fluid gas exchange
AFIP
armed forces institute of pathology
AHC
acute hemorrhagic
AHF
anterior hyaloid face
AHM
anterior hyaloid membrane
AION
ant. ischemic optic neuropathy
AK
astigmatic keratotomy
AKC
allergic keratoconjunctivitis
AL
axial length
ALK
automated lamellar
ALT
argon laser trabeculoplasty
AMD
age related macular degeneration
AMPPE
acute multifocal placoid pigmaent epitheliopathy
AMT
amniotic membrane
ANS
autonomic nervious system
Ant Vit
anterior vitrectomy
AO
american optical company
AO-HRR
American Optical's Hardy-Rand-Rittler color vision plates
APCT
alternate prism & cover test
APD
afferent pupillary defect
App
applanation tonometry
Appl
applation tension
AR
axenfeld-reiger syndrome
AR
autorefractor
ARC
abnormal retinal correspondence
ARG
Angle recession glaucoma
ARM
age-related maculopathy
ARMD
age related macular degeneration
ARN
acute retinal necrosis
ARNS
atropine retinoscopy
ASC
anterior subcapsular cataract 366.13 (senile vs juvenile)
ASCC
anterior subcapsular cataract 366.13 (senile vs juvenile)
ASO4
atropine
AT
applanation tonometry (measure IOP)
AV
arteriovenous (nicking) (fundus)
AXT
alternate exotropia
B
Betoptic
B4L
Binkhorst 4-loop IOL
BAO
branch artery occlusion
BC
base curve
BD
Base-down prism
BDR
background diabetic retinopathy
BFP
binocular fixation pattern
BI
base-in prism
BLR
bilateral lateral rectus
BMR
bilateral medial rectus
BO
Base-out prism
BRAO
branch retinal artery occlusion
BRC
Blind Rehab Center
BROS
Blind Rehab Outpatient Specialist
BRVO
branch retinal vein occlusion
BS
blond spot
BSCL
bandage soft contact lens (per Dr McCarty 7/2004)
BSS
balanced salt solution
BSV
binocular single vision
BU
base-up prism
BUT
(tear) break up time
BVA
best-corrected visual acuity
BVO
branch vein occlusion 362.36
BVO
branch vein occlusion
C
cornea
C&F
cell and flare
C/D
cup to disc ratio (part of OPTIC DISC exam)
C/D
cup to disc ratio
C/F
cell/flare(anterior chamber)
C/N
cyclogyl and neosynephrine
C/S
cornea sclera
C3F8
Perfluoropropane gas
CA
corneal abrasion
CACG
chronic angle closure glaucoma (365.23 2004)
CAG
conjunctival autograft
CAI's
carbonic anhydrase inhibitors
Cap
capsule(anterior or posterior)
CAT
computer access training
cat
cataract
Cat TRAB
combined cataract-trabeculectomy
cat.ext
cataract extraction
CB
ciliary body
CBB
cilary body band
cc
with correction
CCF
carotid cavernous fistula
CCS
carotid cavernous shunt
CCT
Computed coronal tomography
CDCR
canaliculodacryocystorhinostomy
CE
cataract extraction
CF
count fingers
CF
confrontation field
CFFF
criitical flicker fusion frequency
CG
ciliary ganglion
CHA
compound hypermetropic astigmatism (376.20 2004)
CHRPE
congenital hypertrophy of retinal pigment epithelium (743.56) 2004)
CjDCR
conjunctivodacryocystorhinostomy
CL
contact lens
CME
cystoid macular edema
CMG
combinde mechanism glaucoma
CN
cranial nerve
CNAG
chronic narrow angle glaucoma
CNDO
congential nasolacrimal duct obstruction
CNVM
choroidal neovascular membrane (362.16)
COAG
chronic open angle glaucoma
Conj
conjunctiva
CPC
central posterior curve
CPC
gas permeable contacts
CPEO
crh. progres. ext. ophthalmoplegia
CR
chorioretinal (as in "CR scar" 363.30
CRA
central retinal artery
CRAO
central retinal artery occlusion 362.31
CRET
constant right esotropian (monocular per Dr Stephens 2004 378.01)
CRRR
corneal rust ring remover
CRV
central retinal vein
CRVO
central retinal vein occlusion (362.35)
CSC,CSR
central serous (chorio)
CSM
central, steady, maintained
CSME
clinically significant macular edema
CSUM
central, steady, unmaintained fixation
CT
cover test(CT' = near)
CTL
contact lens
CUSUM
central, unsteady, unmaintained fixation
CV
color vision
CVF
confrontation visual field
Cx
cylinder (in diopters), axis (in degrees)
Cyl
cylinder(astigmatism) (367.20)
cyl
cylinder
D
disc
D
diopeter, the unit of refractive power
D
distance, distance vision
D/Q
deep and quiet
D-100
Farnsworth Panel D-100 color vision test
D-15
Farnsworth Panel D-15 color vision test
DA
dark adaptation
DCR
dacryocystorhinostomy
DD
disc diameter
DD
disc diameter
DDH
dissociated double hypertropia
DDVD
double dissociated vertical deviation
DES
Dry Eye Syndrome
DFE
dilated fundus exam
DHD
dissociated horizontal
Disp
dispensed
DM & NOU
dilate mydriacyl & Neo-Synephrine, both eyes
DMVP
disc, macula, vessels and periphery
DOD
dilate right eye
DOS
dilate left eye
DR
diabetic retinopathy
DRS
diabetic retinopathy study
DVD
dissociated vertical deviation
E
esophoria
EBMD
epithel. basement membrane dystrophy cornea 371.52
ECCE
extracapsular cataract extraction
EE
external examination
EKC
epidemic keratoconjunctivitis
EKF
epikeratophakia
EL
endolaser
ELISA
enzyme-linked immuno-absorbent assay
EMM
epimacular membrane
EMP
epimacular proliferation
Enuc
enucleation
EOG
electrooculogram
EOM (I)
extraocular movements (intact)
EOMB
extraocular musle balance
epi
epithelium
EPI
epinephrine
EPRP
endopanretinal photocoagulation
ERG
electroretinogram
ERM
epiretinal membrane 362.56 (macular puckering)
ERP
early receptor potential
ES
esophoria
ET
esotropia
ETDRS
early treatment diabetic retinopathy study
EW
Edinger-Westphal
EW
extended wear contact lens
EWSCL
extended wear soft contact lens
F + F
fix and follow vision
F&C
flare & cells
F&F
fixes and follows
FA
fluorescein angiogram
FAX
fluid-air exchange
FB
foreign body
FBS
foreign body sensation
FC
finger counting
FEF
frontal eye field
FEM
fast eye movements
FEVR
familial exudative vitreoretinopathy
FFA
fundus fluorescein
FFF
flicker fusion frequency fields
FGX
fluid-gas exchange
FK
flilamentous keratitis
FM 100
Farnsworth-Munsell 100-hue color vision test
FP
fibrous proliferation
fpa
far point of accommodation
FTA
fluorescent treponema absorption test
FTC
full to confrontation visual fields
FTFC
full to finger counting
FTG
full-time glasses
FTO
full-time occlusion
FTP
full-time patch
GAT
Goldman Applanation Tonometry
GHPC
giant helicoid peripapillary choroidpathy
GPC
giant papillary conjunctivitis
gtt
drop
gtts
drops
GVR
goldman visual field
H
hyperphoria
HCL
hard contact lens
heme
hemorrhage
HGC
horizontal gaze center
HK
herpes keratitis
HM
hand motions
HOT
hypotrophic
HOTV
HOTV vision test
HRC
high risk characteristic
HRR
Hardy Rand Rittler color plate
HSK
herpes simplex keratitis
HSV
herpes simplex virus
HT
hypertrophia
HVF
Humphrey Visual Field
HZO
herpes zoster ophthalmicus
I
iris
I & A
irrigation and aspiration
IC
infeior colliculus
ICCE
intracapsular cataract surgery
ICD
intercanthal distance
ICE
iridocornea enodthelial (syndrome)
IK
intersitiial keratitis
ILM
internal limiting membrane
INO
internuclear ophthalmoplegia
IO
inferior oblique
IOFB
interocular foreign body
IOL
intraocular lens
ION
ischemic optic neuropathy
IOOA
inferior oblique muscle overation
IOP
intraocular pressure
IOP
intraocular pressure
IP
intraoccular pressure
IPCV
idiopathic polypoidal
IPD
interpupillary distance
IR
inferior rectus
IRMA
intraretinal microvascular abnormalities
IVFA
intravenous fluorescien angiography
J1
Jaeger near reading acuity
J2, J3, etc
jaeger size print
JXG
juvenile xanthogranuloma
K
keratometric cornea readings
K
cornea
K (xx.xx/xx.xx)
keratometry (measurements of cornea)
K sicca
keratoconjunctivitis sicca
KCS
keratoconjunctivitis sicca
KM
kermatomileusis
KP
keratic precipitates
L
left
L
lens
L.L.c.P
light perception with projection
L/A
lids and adnexa
L/I
lens iris
LA
light adaption
Lac
laceration
LASER
Light Amplification by Stimulated Emission of Radiation
LASIK
laser in situ keratomileusis
LCT
lateral canthal tendon
LD
lattice degeneration
LDVD
left dissociated vertical deviation
LE
left esophoria
LE
left eye
LE(T)
intermittent left esotropia
LET
left esoptropia
LGB
lateral geniculate body
LGN
lateral geniculate nucleus
LH(T)
intermittent left hypertropia
LHT
left hypertropia
LI
laser iridotomy
LID
left inferior oblique
LIR
left inferior reectus
LK
lamellar keratoplasty
LKP
lamellar keratoplasty
LL
lower lid
LLL
left lower lid
LMR
left medial rectus
LOM
lens opacity meter
LP
light perception
LP + P
light perception and projection
LPCA
long posterior cillary artery
LPI
laser peripheral iridectomy
LPw/P
light perception with projection
LR
lateral rectus
LSO
left superior oblique
LSR
left superior rectus
LTG
low tension glaucoma
LTP
laser trabeculoplasty
LTP
laser trabeculoplasty
LUL
left upper lid
LV
low vision
LVA
low vision aids
LX(T)
intermittent left exotropia
LXT
left exotropia
M
macula
M
manifest refraction
M/N
mydracyl and neosynephrine
MA
microaneurysm
MB
muscle balance
MCA
middle cerebral artery
MCE
microcystic corneal edema
MCT
medial canthal tendon
MDF
Map-Dot-Fingerprint of cornea 371.52 (ABMD)
MEWDS
multifocal evanescent white dot syndrome
MG
marcus gunn defect (afferent pupillary defect)
MGD
Meibomian Gland Dysfunct. 259.9
MH
macular hole (362.54)
MLF
medial longitudinal fasciculus
MMG
mixed mechanism glaucoma
M/N
in regards to dilation means mydriacyl (tropicamide) & neophenylephrine (phenylephrine) & there is usually a time written next to it when drops instilled
MP
membrane peeling
MPP
massive preretinal proliferation
MPR
massive preretinal retraction
MR
manifest refraction
MR
medial rectus
MRD
marginal reflex distance
MS
multiple sclerosis
MVR
massive vitreous retraction
MVR
microvitreoretinal needle knife
N
near
NAG
narrow angle glaucoma
NDF
neutral density filter test
NdYAG
neodymium yittrium-aluminum-garnet laser
NE
non-exudative (as in NE-ARMD 362.51)
NFL
nerve fiber layer
NI
no improvement
NLD
nasolacrimal duct
NLP
no light perception
NMI
no manifest improvement
NO
near point
NPA near point of accomodation
NPC
near point of convergence
NPDR
non-proliferative diabetic retinopathy
NR
non-reactive
NRC
normal retinal correspondence
NS
nuclear sclerosis (366.16)
NSC
nuclear sclerotic cataract
NTG
normal tension glaucoma 365.89
NV
near vision
NVD
neovascularization of the disc
NVE
neovascularization elsewhere
NVG
neovascular glaucoma 365.63
NVI
neovascularization of the Iris
OA
overaction (eg. Muscle)
OA IO
overactive infeior oblique
OA IO OU
overactive inferior obliques, both eyes
OA SO
overactive superior oblique
OA SO OU
overactive supeior obliques, both eyes
OAG
Open angle glaucoma
OCT
optical coherence tomography (92135)
OD
right eye
ODM
ophthalmodynamometry
OHT
ocular hypertension
OKN
optokinetic nystagmus
O-M
orientation and mobility
ON
optic nerve
onh
Optic Nerve Head
ONSD
optic nerve sheath decompression
OR
over-refraction
ortho.
orthophoria
OS
left eye
OT
ocular tension (pressure)
OT
ocular tension
OT
orthotropia
OU
both eyes
OWS
overwear syndrome
P
periphery(fundus)
P
pupil
P + C
prism and cover test
PACG
primary angle closure glaucoma
PACT
prism and alternate cover
PAG
perennial allergic conjunctivitis
PAM
potential acuity meter
PAN
periarteritis nodosa
PAS
peripheral anterior synechiae
PAT
prism adaptation test
PBI
pritein bound iodine
PBK
pseudophakia bullous keratopathy
PC
posterior chamber
PC
peripheral curve
PC
post-cycloplegic
PC
Posterior capsule
PC
posterior chamber
PC
poserior commissure
PCA
posterior cerebral artery
PCF
pharyngoconjunctiival fever
PCIOL
posterior chamber intraocular lens
PCIOL
posterior capsule
PCO
posterior capsule opacity
PD
interpupillary distance
PDG
pigmetary dispersion glaucoma
PDR
proliferative diabetic retinopathy (250.5X + 362.0X)
pdt
photodynamic therapy (67221, 67225)
PE
phacoemulsification
PED
retinal pigment epithelial detachment
PED
persistent epithelial defect
PEE
punctate epithelial eorsion
PEO
progressive external ophthalmoplegia
PERRLA
pupils equal round reactive to light accommodation
PEX
pseudoexfoliation syndrome 366.11
PF
pred forte
PFCL
perfluorocarbon liquid
PFV
persistent fetal vascularture
PGC
pontine gaze center
PH
pin hole
Phaco
phacoemulsification
PHM
posteior hyaloid membrane
PHNI
pinhole: no improvement
PHPV
persistent hyperplastic of primary vitreous
PI
peripheral iridectomy
PK
penetrating keratoplasty
PKP
penetrating keratoplasty
PKU
phenylketonuria
PL
plano
PLCO
posterior lens capsule opacity
PLS
posterior lip sclerectomy
PLT
perferential looking technique
PMMA
polymethymetacrylate
PMR
POAG
primary open angle glaucoma
POHS
presumed ocular histoplasmosis syndrome
POZ
posterior optical zone
PP
pars plana
PP
pars Pplicate
PP
near point
PPA
perpapillary atrophy
PPA
near point of accomodation
PPC
near point of convergence
PPDR
preproliferative diabetic retinopathy
PPG
pilopine gel
PPL
plar plana lensectomy
PPMD
posterior polymorphous dystrophy
PPRF
pontine paramedian reticular formation
PPV
pars plana vitrectomy
PR
pneumatic retinopexy
PR
far point of accommodation
prba
Problems-Risks-Benefits-Alternatives
PRK
photorefractive keratectomy
PRP
panretinal photocoagulation
PRRE
pupils round, regular and equal
PS
posterior synechiae
PSC
posterior subcapsular cataract
PSCC
posterior subcapsular cataract 366.14 or 743.31
PTK
phototherapeutic keratectomy
PTN
pretectal nucleus
PTO
part time occlusion (patch)
PTP
part time patch
PTR
pterygium
PVD
posterior vitreous detachment 379.21
PVR
proliferative vitreoretinopathy
PXE
pseudoexamthoma elasticum 757.39 in 2004
PXF
pseudoexfoliation
PXG
pseudoexfoliation glaucoma 365.52
PXS
psedoexfoliation syndrome
R
right
R
retinoscopy
R
recession (of extraocular muscle)
R
refraction
R & R
recess and resect (muscle)
R&R
recess and resect (recess-resent)
R/R
resection and recession
RA
react to accommodation
RAPD
reverse afferent pupillary defect
RB
retinoblastoma
RBAC
Risk-Benefits-Complications-Alternatives
RBCA
Risk-Benefits-Complications-Alternatives
Rc
cycloplegic retinoscopy
RD
retinal detachment
RDE
random dot esterogram
RDVD
right dissociated vertical deviation
RE
right esophoria
RE
right eye
RE(T)
intermittent right esotropia
Ref
refraction
REM
rapid eye movements
RET
retinsocopy
RET
right esotropia
ret pig
retinitis pigmentosa
RGP
rigid gas permeable contact lens
RH(T)
intermittent right hypertropia
RHT
right hypertropia
RIO
right inferior oblique
RIR
right inferior rectus
RK
radial keratotomy
RLF
retrolental fibroplasia
RLL
right lower lid
RLR
right lateral rectus
ROP
retinopathy of prematurity
RP
retinitis pigmentosa
RPA
retinitis punctata albesens
RPDE
retinal pigment epithelium detachment
RPE
retinal pigment epithelium
RPED
retinal pigment epithelium detachement
RRD
rhegmatogenous retinal detachment
RSO
right superior oblique
RSR
right superior rectus
RUL
right upper lid
RVO
retinal vein occlusion
Rx
prescription (glasses)
Rx
right exophoria
RX(T)
intermittent right exotropia
RXT
right exotropia
S
sphere
S(T)
intermittent esotropia at distance
SAC
seasonal allergic conjunctivitis
SB
scleral buckle
SBP
scleral buckling procedure
SBV
single binocular vision
sc
without correction
SC
senile cataract
SCH
subconjunctival hemorrhage
SCL
soft contact lens
SCT
single cover test
SEM
slow eye movements
SEM
scanning electron microscopy
SF
scleral fixation
SF6
sulfur hexafluroide (gas)
SFP
simultaneous foveal perception
SG
Sheridan-Gardner visual acuity test
SI
sector iridectomy
SITA
Swedish Interactive Thresholding Algorithm
SK
striate keratopathy
SLE
slit lamp exam
SMD
senile macular degeneration
SMP
simutaneous macular perception
SO
silicone oil
SO
superior oblique
SO
sympathetic ophthalmia
SO
superior oblique
SOF
superior orbital fissure
SOI
silicone oil injection
SOV
superior opthalamic vein
SPCA
short posteior ciliary artery
SPCT
simutaneous prism & cover test
Sph
sphere
SPK
superficial punctate keratopathy
SR
superior rectus
SRF
subretinal fluid
SRH
subretinal hemorrhage
SRK
Sanders, Retzlaff, Kraff formula for IOL power
SRM
subretinal membrane
SRN
subretinal neovascularization
SRNVM
subretinal neovascular membrane
SRNVM
subretinal neovascularization
SS
scleral spur
SS
scleral spur
SSPE
subacute sclerosing panencephalitis
ST
esotropia at distance
ST
esotropia at near
T
ocular tension (pressure)
T
tension
TA
applanation tonometry(eye pressure)
TAC
teller acuity cards
TAP
tension by applation
Tapp
Applation tonometry
TBT
tear break up time
TBUT
tear break up time
TM
trabecular meshwork
TN
tension (ocular)
TOV
transcient obscuration of vision
TP
tono-pen (eye pressure)
Tp
tension by pneumotonometry
Tpen
tonopen, method used to perform tonometry (checking intraocular pressure)
TPI
treponema pallidum immobilization test
Tpn
tension by pneumotonometer
TPPL
trans pars plana lensectomy
TPPV
trans pars plana vistrectomy
Trab
trabeculectomy
TRD
total or tractional retinal detachment
TRIC
trachoma or inclusion conjunctivitis
Ts
tension Schiotz
TSCPC
transsleral cyclophotocoagulation
Tx
treatment
TX
trabeculectomy
UA
underaction (eg. Muscle)
UA IO
underactive inferior oblique
UA IO OU
underactive infeior obliques, both eyes
UA SO
underactive superior obliques
UCUSUM
uncentral unsteady unmaintained fixation
UGH
uveitis glaucoma hyphema syndrome
UL
upper lid
UPECCE
unplanned extracapsular cataract extraction
V
vitreous
VA
visual acuity
VA wc or cc
visual acuity with correction
VA sc
visual acuity without correction
VECP
visual evoked cortical potential
VEP
visual-evoked potential
VER
visual evoked response
VF
visual fields(confrontation; automated)
VGC
vertical gaze center
VH
vitreous hemorrhage
VISC
vitreous infusion suction
Vit
vitrectomy; vitreous
vit.
vitreous infusion suction
VKH
vogt-koyanaki-harada
VOD
vision right eye
VOR
vestibulo-ocular reflex
VOS
vision left eye
VOU
vision both eyes
W
wear (present glasses)
W4D
Worth 4-dot test
WGOA
wearing glasses on arrival
WTR
wearing patch on arrival
X
exophoria
x
axis
X (T)
intermittent exotropia
XT
exotropia
YAG
Yttrium, Aluminum, Garnet
A0.2
Brimonidine 0.2%
B
betaxolol
B1/2
Betaxolol 0.5%
B-s
Betaxolol 0.25% susp
C1
cyclopentolate (cyclogyl) 1% eye drops
C3
Carbachol 3%
C3
Cyclogyl
D250
Acetazolamide 250mg
D250
Diamox
D250
Diamox 250 mg
DFP
diisopropyl fluorophosphate
E1
epinephrine 1%
EDMA
ethylene glyco-dy-methacrylate
EDTA
ethylene diamine tetra acetate
F3T
trifluorothymidine
FML
Fluorometholone 0.1%
HA5
homatropine 5% eyedrops
I1/2
Apraclonidine 0.5%
IDU
idoxuridine
M1
Tropicamide 1%
M1
tropicamide (Mydriacyl) 1% eyedrops
N2.5
Neo-Synephrine 2.5%
N2.5
phenylephrine HCL (Neosynephrine) 2.5% eyedrops
N50
Methazolamide 50mg
N50
Neptazane 50 mg
P
Pilocarpine 2%
P0.1
Dipivefrin Hydrochloride 0.1%
P2
Pilocarpine 2%
PF 1
Prednisolone Acetate 1%
PI .25
Echothiophate iodide 0.25%
PI .25
phospholine iodine
PT
Trimethoprim Sulfate & Polymyxin B Sulfate
SF6
sulfur hexafloroide
SFG
sulfur hexafluoride gas
T 0.5
timolol maleate (timpotic) 0.5% eyedrops
T1/2
Timolol Maleate 1/2%
T2
Trusopt 2%
TFT
trifluorothymidine

Certifications - Medical Coding AAPC/AHIMA

Certification is necessary to be a Qualified Medical Coder. As in todays, healthcare industry we can see a high demand for Qualified medical coders. Medical coders with certification and experience are in good demand and can earn good.

There are two main organization, where you can get certified AAPC and AHIMA.

AAPC stands for Americal Academy of Professional Coders. There are different certifications and you can go for the certification as per your requirement. You can visit the below link to he list of the certifications.

http://www.aapc.com/certification/

AHIMA stands for American Health Information Management Association, which provides different certifications. you can visit the below link to check for the certifications programs.

http://www.ahima.org/certification/

Some of the Certifications Listed below for your quick reference:

AHIMA CERTIFICATIONS
Certifications Available:
Registered Health Information Administrator (RHIA)
Registered Health Information Technician (RHIT)
Certified Coding Specialist (CCS)
Certified Coding Specialist—Physician-based (CCS-P)
Certified Coding Associate (CCA

AAPC
Certifications Available:
Certified Professional Coder (CPC)
Certified Professional Coder-Hospital (CPC-H)
CPC- A Apprentice
CPC-H Apprentice

Specialty Credential Examinations
The American Academy of Professional Coders offers specialty credentialing for:
Evaluation and Management Specialist (EMS)
General Surgery Specialist (GSS)
Obstetrics and Gynecology Specialist (OGS)
Orthopedics Specialist (OS)
Emergency Medicine Specialist (EDS)
Cardiology Specialist (CS


Radiology Certified Coders
The purpose of the RCCB® credentialing program is to:
Establish the body of knowledge for radiology coders
Assess the level of knowledge demonstrated by radiology coders in a valid and reliable manner
Encourage professional growth in the field of radiology coding
Formally recognize individuals who meet the requirements set by RCCB®
Serve the public and the medical community by encouraging quality radiology coding services

AACCA Clinical Coder and Auditor Certifications
AACCA Certification Categories
Certified RN-Coder®/Clinical Coder
Certified Medical Coder (CMC)® - Technical Coders (non-clinical)

Association of Registered Medical Professionals
Registered Medical Coder - Associate
Registered Medical Coder
Registered Medical Manager