TABLE OF CONTENTS
CHAPTER 1: THE CODING PROCESS
Introduction
Classification Systems
The Coding Process
Purpose of Coding
CHAPTER 2: ICD-10-CA
Introduction
General Principles of ICD-10-CA
Structure and Presentation of ICD-10-CA
Locating Codes in ICD-10-CA
Guidelines for Coding with ICD-10-CA
CHAPTER 3: CCI
Introduction
General Principles of CCI
Structure and Presentation of CCI
Locating Codes in CCI
Intervention Attributes
Application of CCI
CHAPTER 4: APPLYING THE CODING PROCESS
Introduction
Coding from the Source Document
Diagnosis Type
Diagnosis Prefix
Diagnosis Cluster
Intervention Pre-Admit Flag
Coding Process Step by Step
Searching Folio Views
Accuracy and Consistency in Classification
CHAPTER 5: NEOPLASIA
Introduction
Neoplasia Classification
Locating Codes for Neoplastic Disease
Special Rules
Classification of Secondary Malignant Neoplasms
Classification of Other Behaviour Types
Specific Circumstances of Encounters
Other Chapter XXI Codes Related to Neoplasia
Lymphomas and Leukemia
CHAPTER 6: MULTISYSTEMIC OR UNSPECIFIED SITE INFECTIONS
Introduction
Drug-Resistant Organisms
Sepsis and SIRS
Tuberculosis
Fever of Unknown Origin
Viral Illness
CHAPTER 7: SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS
Introduction
Cellulitis, Skin Ulcers and Skin Infections
Other Skin Disorders
Surgical Interventions
Breast Disorders
Breast Interventions
CHAPTER 8: MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS
Introduction
Arthropathies
Joint Replacement Surgery
Torn Ligaments and Tendons
Internal Derangement of Knee
Dorsopathies
Osteoporosis
Pathological Fractures
Hallux Valgus and Bunion
Contracture of Palmar Fascia
Orthopedic Aftercare and Status
Sequelae of Injuries
CHAPTER 9: CARDIAC DISORDERS
Introduction
Hypertension
Ischemic Heart Disease
Interventions for Coronary Artery Disease
Arrhythmia and Conduction Disorders
Heart Failure
Heart Valve Disorders
Pulmonary Embolism
CHAPTER 10: VASCULAR DISORDERS
Introduction
Peripheral Vascular Disease
Aneurysm
Phlebitis and Thrombophlebitis
Central Venous Catheters
CHAPTER 11: BLOOD AND HEMATOPOIETIC DISORDERS
Introduction
Red Blood Cell Disorders (Anemia)
Postoperative Anemia
Anticoagulation Therapy
Transfusion Reactions and Complications
Admission for Blood Transfusion
CHAPTER 12: RESPIRATORY DISORDERS
Introduction
Lower Respiratory Tract Infection
Asthma
Emphysema
Chronic Obstructive Pulmonary Disease (COPD)
Respiratory Neoplasia
Acute Respiratory Failure (ARF) and Acute Respiratory Distress Syndrome (ARDS)
Vaping-related Disorders
Related Interventions
CHAPTER 13: DIGESTIVE DISORDERS
Introduction
Gastrointestinal Hemorrhage
Gastroenteritis and Diarrhea
Irritable Bowel Syndrome (IBS)
Inflammatory Bowel Disease (IBD)
Appendicitis
Hernias
Gastroesophageal Reflux Disease (GERD)
Neoplasia
Diverticulosis and Diverticulitis
Ulcers
Intestinal Obstruction
Adhesions
Fistula
Hemorrhoids
Related Interventions
CHAPTER 14: HEPATOBILIARY & PANCREATIC DISORDERS
Introduction
Biliary Disorders
Viral Hepatitis
Alcoholic Liver Disease
Malignancy in the Liver
Pancreatitis
CHAPTER 15: HIV INFECTIONS
Introduction
HIV Positive
Opportunistic Infections
AIDS-Associated Cancers
Other Associated Diseases
Multiple Conditions
Other Related ICD-10-CA Codes
Unconfirmed Diagnosis of AIDS
CHAPTER 16: EYE DISORDERS
Introduction
Cataracts
Retinal Disorders
Glaucoma
Corneal Disorders
CHAPTER 17: EAR, NOSE, MOUTH AND THROAT DISORDERS
Introduction
Tonsils & Adenoids
Croup
Sinusitis
Deviated Nasal Septum
Nasal Polyp
Foreign Body in Orifice
Epistaxis
Cleft Palate and Velopharyngeal Insufficiency
Obstructive Sleep Apnea
Otitis Media
Dental Extractions
CHAPTER 18: KIDNEY AND URINARY TRACT DISORDERS
Introduction
Urolithiasis
Upper Urinary Tract Infection
Lower Urinary Tract Infection
Acute and Chronic Kidney Disease
Bladder Malignancy
CHAPTER 19: MALE REPRODUCTIVE DISORDERS
Introduction
Nonmalignant Disorders of the Prostate
Prostate Malignancy
Testicular Malignancy
Infectious and Inflammatory Disorders
Hydrocele/Spermatocele/Varicocele
Contraceptive and Procreative Management
CHAPTER 20: FEMALE REPRODUCTIVE DISORDERS
Introduction
Related Interventions
Cervical Dysplasia/Neoplasia
Uterine Neoplasia
Ovarian Cysts and Neoplasia
Pelvic Organ Prolapse
Stress Incontinence/Urge Incontinence
Infectious/Inflammatory Disorders
Adenomyosis and Endometriosis
Menstrual Disorders
Contraceptive Interventions
CHAPTER 21: ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS
Introduction
Diabetes Mellitus
Obesity
Dehydration and Electrolyte Imbalance
Thyroid Disorders
CHAPTER 22: NERVOUS SYSTEM DISORDERS
Introduction
Cerebrovascular Disorders
Transient Ischemic Attacks (TIA)
Neurologically Determined Death
Seizures and Seizure Disorders
Carpal Tunnel and Peripheral Nerve Disorders
CHAPTER 23: MENTAL AND BEHAVIOURAL DISORDERS
Introduction
Organic Disorders
Psychoactive Substance Use
Schizophrenia, Schizotypal and Delusional Disorders
Mood Disorders
Neurotic, Stress-Related and Somatoform Disorders
Behavioural Syndromes Associated with Physiological Disturbances and Physical Factors
Disorders of Adult Personality and Behaviour
CHAPTER 24: POISONINGS, EFFECTS AND REACTIONS
Introduction
Adverse Effect
Poisoning
Allergic Reaction
CHAPTER 25: OTHER REASONS FOR HOSPITAL CARE
Introduction
Palliative Care
Medical Assistance in Dying
Other Factors Influencing Admission
Planned Interventions Not Carried Out
Investigation of Signs, Symptoms and Abnormal Findings
Homelessness
CHAPTER 26: BURNS
Introduction
Burns by Site and Thickness
Burns of Multiple Sites
Burns by Extent
Complications of Burns
CHAPTER 27: TRAUMA
Introduction
Multiple Injuries
External Causes of Trauma
Fractures
Dislocations
Intracranial Injuries
Injuries of Internal Organs
Open Wounds
Traumatic Amputations
Soft Tissue Injuries
Complications of Trauma
CHAPTER 28: POST-INTERVENTION CONDITIONS
Introduction
Definition of Post-Intervention Condition
Classification of Post-Intervention Conditions
Locating the Primary Code
External Cause Codes
Linking the Codes
Application in Specific Circumstances
Prefix 5 & 6
CHAPTER 29: PREGNANCY AND CHILDBIRTH
Introduction
Obstetrical Classification Principles
Abortive Outcome
Hypertensive Disorders in Pregnancy
Other Maternal Disorders
Maternal Care Related to Fetus, Amniotic Cavity and Possible Delivery Problems
Complications Related to Labour and Delivery
Complications Predominantly Related to the Puerperium
Interventions
CHAPTER 30: NEWBORNS
Introduction
Classification of Healthy Newborn
Classification of Morbidity in Newborns
Infants Born by Cesarean Delivery
Prematurity and Low Birth Weight
Maternal Factors and Complications of Labour and Delivery
Birth Trauma
Hypoxic Acidemia
Infant Respiratory Distress Syndrome
Transient Tachypnea of the Newborn
Perinatal Jaundice
Infections in the Newborn
Fetus Affected by Maternal Alcohol Intake
Stillborn
EXERCISE ANSWERS
REFERENCES
GLOSSARY
APPENDICES
INDEX
CHAPTER EXERCISES