Transcript Slide 1

NYU School of Medicine
Coding and Reimbursement Seminar Series
ICD-9 Coding for Physician Practices
Presented by the Office of Reimbursement Compliance
Gretchen L. Segado, MS, CPC
Director of Reimbursement Compliance
NYU School of Medicine
316 East 30th Street
New York, NY 10016
(212) 263-2446
(212) 263-6445 fax
[email protected]
History of ICD-9 CM
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Originally developed by the World Health
Organization (WHO) to record morbidity and
mortality information for statistical purposes
Has been revised and updated to suit a
greater variety of needs and to capture
additional information.
International Classification of Diseases, 9th
revision, Clinical Modification (ICD-9-CM)
was issued in 1978
History of ICD-9 CM
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In 1988, Medicare Catastrophic Coverage Act
required physicians to report medical diagnosis
codes on each Medicare payment request.
April 1, 1989, HCFA (now CMS) required diagnosis
codes to be reported using ICD-9 CM
Purpose of ICD-9 CM
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Classifying morbidity data for reporting;
Compiling and comparing health care data;
Evaluating the appropriateness and timeliness of
medical care provided, which can be used in
determining "medical necessity";
Analyzing payments for health care; and,
Conducting epidemiological and clinical research.
Who must use ICD-9 CM?
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All physicians and non-physician
practitioners are required to use ICD-9 CM
diagnosis codes with the exception of
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Ambulance providers
Durable medical equipment suppliers
Nonphysician directed
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Independently practicing PTs, OTs
Independently practicing psychologists
Audiologists
Other Coding Systems
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Morphology of neoplasms “M Codes” are in
ICD-O (International Classification of
Disease-Oncology)
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not acceptable for Medicare
DSM-IV-R for psychiatric illnesses
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Cannot be used for Medicare purposes
Diagnosis coding transforms verbal
descriptions into numbers.
In order to utilize the ICD-9-CM to its fullest level, the
coder must:
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Understand medical terminology
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Have a working knowledge of how to use a medical
dictionary; and
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Know how the ICD-9-CM text is organized
Three Volumes to ICD-9 CM
Volume 1-DiseasesTabular List
Volume 2-Diseases Alphabetical List Volume 3Procedures Used for Hospital
Inpatient coding
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Physicians only use Volumes 1 & 2
Diagnosis codes must be valid for the date of service
reported
Volume 2: The Alphabetical List
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Provides detailed instructions which assist
the coder in determining if a diagnosis may
require the use of additional or alternate
codes.
is found in the front half of the ICD-9-CM.
It is best to consult the Alphabetic List FIRST
before deciding whether a three-, four- or
five-digit code best represents the patient's
disease, sign or symptom.
Volume 2: The Alphabetical List
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Organized by "main terms" which are printed
in bold-faced type for ease of reference.
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Diseases–Influenza or Bronchitis
Conditions–Fatigue, Fracture or Injury
Nouns–Disturbance or Syndrome
Adjective–Double, Large or Kink
Volume 2: The Alphabetical List
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Anatomical sites are not used for Main terms.
Example: Bronchial asthma will be found
under the disease term asthma rather than
the anatomical site bronchial. It is located in
the Alphabetical Index to Diseases where, in
bold-faced type, the entry "Asthma,
Asthmatic" appears.
Volume 2: The Alphabetical List
Many conditions can be found in more than one place
Examples:
Obstetrical conditions may be found under the name of the condition
and under the entries for Delivery, Pregnancy and Puerperal (after
delivery.)
Complications of medical and surgical care are indexed under the
Name of condition and under Complications.
Eponyms (diseases named for persons)
 often located alphabetically by the person's name and by the
common name.
– For example Vincent's disease (trench mouth) can be found
under Vincent's, Disease and Trench.
Volume 1: The Tabular List
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Contains the Classification of Diseases and
Injuries.
Contains the three-, four-, and five- digit
codes that are used on the claims form to
indicate the patient's disease, signs or
symptoms.
The Tabular list is arranged in 17 chapters.
Volume 1: The Tabular List
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Arranged in numerical sequence.
Chapter headings are always in BOLD CAPS.
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Three-digit code numbers always refer to sections.
Four-digit code numbers refer to categories
Five-digit code numbers denote sub-categories.
Note: 5th digits can appear:
At the beginning of a chapter
At the beginning of a section
At the beginning of a 3-digit category
Within a 4th-digit sub-category
Coding Conventions
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Always use the most recent version of the
ICD-9-CM, and other coding manuals such
as CPT and the HCPCS for the current year.
If you use an old codebook with outdated
codes, your payment may be denied,
delayed or underpaid.
Coding Conventions
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Notes: further define terms, clarify
information or list choices of additional
diagnosis
Format: Subterms are indented to the right
of the term to which they are linked
Excludes: Terms following the excludes
instruction are to be coded elsewhere
Coding Conventions
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Abbreviations
– NEC Not elsewhere classifiable. The category
number for the term including NEC is to be used
only when the coder lacks the information
necessary to code the term to a more specific
category.
– NOS
Not otherwise specified. This abbreviation
is the equivalent of “unspecified.”
Coding Conventions
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Punctuation
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[ ]
Brackets are used to enclose synonyms,
alternative wordings, or explanatory phrases.
( )
Parentheses are used to enclose supplementary
words which may be present or absent in the statement of a
disease or procedure without affecting the code number to
which it is assigned.
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Colons are used in the Tabular List after an
incomplete term which needs one or more of the modifiers
which follow in order to make it assignable to a given
category.
Coding Conventions
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Format:
ICD-9-CM uses an indented format for ease in
reference.
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Sequencing:
Code, if applicable, any causal condition
first (A code with this note may be principal if no causal
condition is applicable or known)
Instructional Notations
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Includes:
This note appears immediately under a threedigit code title to further define, or give example of, the contents
of the category.
Excludes: Terms following the word “excludes” are to be coded
elsewhere. The term excludes means “DO NOT CODE HERE”.
Use additional code:
This instruction is placed in the Tabular
List in those categories where the user will need to add further
information (by using an additional code) to give a more
complete picture of the diagnosis or procedure.
Code first underlying disease: This instructional note is used
for those codes not intended to be used as a principal diagnosis,
or not to be sequenced before the underlying disease. The note
requires that the underlying disease (etiology) be recorded first
and the particular manifestation recorded secondarily. This note
appears only in the Tabular List.
The Golden Rule
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Always code the primary reason that
the patient is interacting with the
medical professional
Correct Steps for Choosing a
Diagnosis Code
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Review the medical record to extract the
pertinent written description of the disease
or symptoms
Look up the disease, signs and symptoms
or condition in Volume 2, Alphabetic Index
and locate the corresponding code
Look up corresponding code in Volume 1
and choose most specific code that
accurately describes the patient’s condition
Start with the Alphabetic List
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Code the disease, sign, or symptom.
There are only 2 circumstances when it
would be appropriate to code directly from
the Alphabetic list.
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Table of Hypertension
Table of Neoplasms
After Selecting The Appropriate Codes From The
Alphabetic List, Go To The Tabular List
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Make sure that all appropriate fourth or fifth
digits are captured in the code.
This is referred to as "coding to the highest
degree of specificity."
If you fail to code to the highest specificity,
claims will usually be rejected.
Verify each payer's billing requirements to
avoid denied claims.
Coding to the Highest Degree of
Specificity means:
1) Code up to the 5th digit whenever possible,
2) Only use a 4-digit code when no 5-digit code
exists and,
3) Only use a 3-digit code when no 4- or 5-digit code
exists.
Most ICD-9-CM books have some sort of indicator,
for example: a red dot or a "5," that are placed next
to codes which are not considered highest degree of
specificity.
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Often patients cannot be specific about their symptoms or, the
physicians are not specific in their documentation. In this
situation, do not automatically use a 4-digit code. There may
be a 5 digit code where, one of the digits corresponds to the
meaning of "unspecified," "without complication," or some
other catch-all phrase.
While it may seem that the addition of the fifth digit does not
significantly enhance the meaning of the code, the use of a 4digit code would be considered incorrect where an
appropriate five-digit code exists.
Always check the information following a main term, or
indented beneath a main term. This may enhance or change
the meaning of the main term and therefore play a vital role in
determining the final code selected.
Examples
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Chronic obstructive pulmonary disease is
assigned code 496, chronic airway
obstruction, not elsewhere classified.
There is no 4th or 5th digits for 496
Examples
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Essential hypertension, 401, has fourth digits
that describe the type of hypertension.
It would be incorrect to report code category
401 without a fourth digit
For this code category, there is a 4th digit
provided to use when no information about
the type of hypertension is available
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401.9 unspecified site
Examples
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Gastric Ulcer, 531 has fourth digits assigned
to provide information such as whether there
is hemorrhage or perforation
A 5th digit is available to describe whether or
not there is an obstruction.
It would be incorrect to leave off the fifth digit
DO NOT!!!!!!
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Do not code diagnoses documented as
“probable”, “suspected”, “questionable” or
“rule out’ as if they are established.
Code the condition(s) to the highest degree
of specificity known at the time of the
encounter
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symptoms, signs, abnormal test results or other
reasons for the visit
Diagnosis Coding for Surgical Services
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Code the diagnosis for which the surgery
was performed
However, when the claim is filed, if the
postoperative diagnosis is known to be
different from the preoperative diagnosis,
select the postoperative diagnosis for coding
Code all exisiting documented conditions that coexist at
the time of the encounter and that require or affect
patient care
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Do not code conditions previously treated
and no longer exisiting
Do not code conditions which the patient has
unless they are the reason for the service
Coding pre-existing conditions that are no
longer being treated may affect medical
necessity determinations
The Tabular List Also Contains Two
Supplementary Classifications
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Supplementary Classification of Factors
influencing Health Status and Contact with
Health Services, commonly referred to as the "Vcodes."
External Causes of Injuries and Poisoning.
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These are very rarely used in physician billing as
most payer systems, including Medicare, do not
accept them for non-hospital claims.
“E-codes”
Supplementary Classification:V-Codes
V01-V82.9 Factors influencing Health Status & Contact
with the Health Service
(Circumstances other than a disease of injury classified to
categories)
"V-codes" are generally used in three instances:
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When a physician identifies a circumstance or problem in a
person who is not currently sick but has, nonetheless, come in
contact with health services (to receive a prophylactic
vaccination or routine health check, for example).
When an ill or injured patient requires specific treatment (such as
chemotherapy for malignancy or removal of pins or rods).
When a problem or circumstance that influences the patient's
health is not itself a current illness but may affect future medical
treatment."
Reporting V-Codes
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Usually, V codes should only be reported as
supplementary codes and should not be reported as
the primary reason for the encounter
Diagnostic tests can be reported with a routine
diagnosis code (V70.0-70.9 and V72/0-V72.9)
HOWEVER
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When the only diagnosis code listed is one of the codes
listed above, the service will be denied as a routine service
V-Codes will be used frequently by radiologists and
pathologists
Examples
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A specimen is referred to a pathologist
A time claim is submitted, if there is an established
dx (eg malignant neoplasm 195.3) this dx code
should be reported first to describe the reason for
the service
Dx Code V72.6 laboratory examination should be
reported as a secondary code
If the diagnosis had not been established, the
pathologist should report at least one of the signs or
symptoms
A Physician refers a patient to a
radiologist…..
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For a chest x-ray with the reason for the
exam identified a cough and fever, rule-out
pneumonia. The x-ray is normal.
The radiologist reports diagnosis code 786.2
(cough) and/or 786.6(fever) as the reason for
the service. Dx code V72.5 (radiological
exam not elsewhere classified) can be
reported as a secondary code
A Physician refers a patient to a
radiologist…..
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For a chest x-ray with the reason for the
exam identified as cough and fever, rule out
pneumonia. The x-ray demonstrates
bronchopneumonia.
The dx code 485 (bronchopneumonia)
should be reported as the reason for the
service
V72.5 can be reported as a secondary code
A Physician refers a patient to a
radiologist…..
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For a chest x-ray with the reason for the exam
identified only as rule out pneumonia. The x-ray is
normal
The radiologist should use a code for undiagnosed
disease (eg 799.9, other unknown and unspecified
cause) to indicate the patient has some condition,
but it is not clearly defined.
Diagnosis V72.5 can be reported as a secondary
code
Supplementary Classification:
E-codes"—E800-E999
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External causes of Injury and Poisoning
(environmental events, circumstances and
conditions)
"E-codes" are not normally used on Part B
claims. However, check with your carrier to
determine which, if any E codes they will
allow.
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Frequently used for accident and worker’s
compensation claims
USING THE TABLE OF NEOPLASMS
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A neoplasm is defined as an abnormal growth of
tissue.
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A growth may be a lesion, tumor, cyst or mass. A neoplasm
is not always a malignancy.
Growths behave in different ways. Behavior refers to
the capacity of the neoplasm to invade surrounding
tissue.
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It may remain benign (non-cancerous) or become
cancerous but remain in one designated area (malignant,
cancer in situ).
Categories Of A Neoplasm Depending
On Its Behavior
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Malignant Primary:Identifies site of original cancerous
neoplasm
Malignant Secondary:Identifies secondary cancerous
neoplasm appearing at a body site other than the original
site. Malignant, secondary should be used for all
secondary cancers, even when the primary malignancy
appears to have been arrested.
Malignant Cancer in situ:Identifies cancerous
neoplasms that are confined, or "noninvasive" in nature.
Categories Of A Neoplasm Depending
On Its Behavior
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Benign:Identifies neoplasm that is non-cancerous.
Benign neoplasms do not invade normal tissue and
remain localized at the primary site.
Uncertain Behavior:This means the tumor cells do not
look normal but there are not enough changes to
designate malignancy. It is borderline, indicating that the
pathologist cannot determine whether this growth is
benign or malignant or that this behavior is unpredictable.
Unspecified:So many changes have occurred that it
is impossible to tell the origin of the tumor. The
nature of the neoplasm is undetermined with no way
to tell where the cancer began.
Neoplasm Table—An example
PRIMARY
SECONDARY
CANCER
in Situ
BENIGN
Uncertain
Behavior
174.9
198.81
233.0
217
238.3
Neoplasms are categorized as follows:
140-195.8 Malignant neoplasms of specific sites, stated or
presumed to be primary except lymphatic and hematopoietic
tissue.
196-198.89 Malignant neoplasms of specified sites, stated or
presumed to be secondary.
199-199.1 Malignant neoplasms, without specification of site.
200-208.9 Malignant neoplasms of lymphatic and hematopoietic
tissue, stated or presumed to be primary.
210-229.9 Benign neoplasms.
230-234.9 Carcinoma – in-situ.
235-238.9 Neoplasms of uncertain behavior
239-239.9 Neoplasms of unspecified nature.
Examples
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Metastatic carcinoma of colon to the lungs
Code: Colon as Primary (e.g 153.9) and Lungs as Secondary (e.g.
197.0) depending on the specificity of the documentation in the
record.
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If a primary malignant neoplasm previously excised or eradicated by
radiation or chemotherapy recurs, code it as primary malignancy of the
stated site unless the Index directs otherwise. If you are not sure, check
with your payer to see how they would like it coded.
Recurrence of cancer in Mastectomy site. For example, a
cancerous Skin lesion recurs at same site where a lesion has been
removed. Code: 173.8 (or 173.9 depending upon the documentation
in the record).
You should find the same code for the same diagnosis even if you
look it up under different headings on the neoplasm table.
Example: 230.7 CA in situ of the ileum
230.7 CA in the intestines (small)
V – codes Associated with Neoplasms
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V10-V10.9 Personal history of malignant neoplasm
V58.0 Radiotherapy
V58.1 Chemotherapy
V66 Convalescence
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V67Follow-up Examination
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V66. 1 following Radiotherapy
V66.2 following Chemotherapy
V67. 1 following Radiotherapy
V67.2 following Chemotherapy
V71. 1Observation for suspected malignant neoplasm
Tips for Coding
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Code the condition that brought the patient in today. Some patients
present with a complaint of pain. This can be a valid reason for
office visits.
The first diagnosis code listed should be the primary diagnosis for
that day's service. Do not just depend upon what's in the computer
system from the last visit.
Never begin your initial search in the Tabular List (Volume 1) – this
leads to errors. The range of code choices should always be
explored.
Check all indentations to ensure you have coded the most
appropriate code.
Do not code "rule-out" or "suspected" diagnoses, or one that is
possible or probable. Code based on the patient's symptom or
condition, unless you can document a confirmed diagnosis, which
can then be utilized.
Tips for Coding
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Do not code a diagnosis for a condition a patient no longer has, unless it
has a significant importance relative to the claim being billed. For example,
do not code for cancer of the uterus (233.2) if the patient has had a
hysterectomy.
It is acceptable to use repeatedly a chronic diagnosis as often as necessary.
Do not embellish or modify a valid diagnosis on subsequent visits. If you are
unsure if a code applies to a chronic illness that can be used in repeated
visits, contact your payer for direction.
When a patient undergoes a surgical procedure, code the diagnosis for the
procedure that is being performed (e.g. uterine cancer for hysterectomy).
DO NOT USE a code that is not specifically documented in the record.
Do not use mental health diagnosis codes for Medicare when discussing
medical issues. Cancer patients often have complaints of fatigue or
insomnia, which are sometimes mistakenly referred to as depression.
Symptoms of fatigue or insomnia are valid medical diagnoses.
Tips for Coding
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Do not use "E-codes" from the ICD-9-CM for Medicare purposes
unless the Carrier's payment policy specifically directs you to do so.
Do not use "history of " when treating the patient for current disease.
This term usually refers to patients who are confirmed as 'disease
free'. This can mean that the tumor area is confirmed pathologically to
be free of disease.
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Some oncologists prefer not use this until the patient has been out of
treatment for a specified period (6 months to one year). Check with your
doctor and/or payer before using these codes.
Do use a definitive diagnosis for lab tests—for example V58.1
(Encounter for chemotherapy). Chemotherapy is a reason for checking
the patient's lab values, in some instances.
Avoid vague terms like "uncertain behavior". Check to see if there is a
Pathology Report before using this diagnosis.
Test Your Coding Skills
Using your current ICD-9-CM, assign diagnosis codes for the
following statements. Some may require more than one code.
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5.
6.
Abnormal cervical Pap smear_____
Metastatic Ca to the lung from the breast (surgery performed
2 years prior with no local recurrence)_____
Follow-up exam after surgery_____
Nasopharyngeal polyps_____
Cancer in situ of the Ovary_____
Hodgkin's sarcoma of the intra-abdominal lymph node_____
Test Your Coding Skills
7. Breast mass scheduled for biopsy_____
8. Abnormal thyroid scan_____
9. Cancer of the sigmoid colon removed five years ago with no
recurrence_____
10.Metastatic carcinoma of the liver originating in the stomach body_____
11.Abnormally heavy menstruation and severe abdominal pain -possible
uterine tumor_____
12.A 45-year old female patient sees her physician for her annual
mammogram and is found to have bilateral microcalcifications_____
13.The physician sees a patient requiring a breast biopsy. The biopsy
results from the pathologist confirm the existence of a malignant tumor.
The tumor, a primary cancer, is located within the upper-outer
quadrant of the right breast._____
14.A patient with cancer of the upper and lower breast is seen for
metastases to the liver._____