medical practice catalog it’s time to order your 2016...

It’s time to order your 2016 code books!

MEDICAL PRACTICE CATALOG

W W W . C O D I N G B O O K S . C O M | T O L L - F R E E 1 - 8 5 5 - C A L L - D H 1

CODEFASTER!

See p. 8

Save 30% on coding bundles!See p.3

Give your practice a critical head start for 2016

A wave of change is about to crest. Position your practice or facility to ride

out the ICD-10 transition, CPT® and HCPCS changes, and a myriad of

compliance mandates with the resources you’ll find in DecisionHealth’s

2016 Product Catalog.

Be sure to ready your team and supercharge your ICD-10 training with the

everyday ICD-10 coding tools they’ll need with DecisionHealth’s PIVOT to

ICD-10 training courses and desk reference guides, including the original

ICD-9 to ICD-10 Code Mappers and the Plain English Descriptions of

ICD-10-CM Codes.

And, we’re doing more of what we do best — supercharging the relevancy

of revenue cycle guidance by producing specialty-specific content — with

new product launches in orthopedics, cardiology, ophthalmology, OB/GYN

and general surgery.

NEW! The 2016 Illustrated Coding & Billing Expert product series (see

page 6) provides essential CPT-to-ICD-10 crosswalks, plus the payment

and coverage specifics — AMA guidelines, procedure definitions, RVUs,

NCCI edits, Pub. 100 references — to ensure you can optimize your CPT

code selection for full reimbursement.

Use these resources and more with DecisionHealth 2016 CPT, ICD, and

HCPCS code books. Not only are we unveiling an exciting new cover

design as the final celebration of the DecisionHealth integration of Contexo

Media, the DecisionHealth family of products offers your staff an array of

unique features, proprietary tips and enhancements that customers rave

about, including:

Documentation Finder – This industry-exclusive feature designed for

today’s audit-intensive environment sets DecisionHealth’s Procedural

Coding Expert manual apart! (pg. 4)

Code-specific illustrations – New full-page anatomy illustrations

added to all 2016 ICD-10-CM and HCPCS code manuals (pg. 5) build

on the hundreds of code-specific detailed, color illustrations included in

every code book.

Coding Tips – find nearly 400 tips, more than any other code book,

in our 2016 ICD-10-CM Expert coding manuals (pg. 5). Just one of the

reasons you don’t want to rely on ICD-10 draft manuals.

Give your practice a critical head start for 2016. With ample time to prepare

and adjust to new compliance requirements, you’re sure to prosper.

Table of Contents

Core Coding Bundles .... 3

CPT & HCPCS ............4-5

New! Illustrated Coding & Billing Expert ............................ 6

Plain English Descriptions .................. 7

SelectCoder ............. 8-10

ICD-10 .....................11-15

eLearning ................ 16-17

FeeCalc ....................... 18

Medicare Billing ........... 19

E/M .............................. 20

Compliance ................. 21

Newsletters ................. 22

Hospitals ..................... 23

Upcoming Events ........... Back Cover

CPT IS A REGISTERED TRADEMARK OF THE AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

2 D E C I S I O N H E A L T H M E D I C A L P R A C T I C E C A T A L O G

2016 Complete Physician Coding Bundle

MPP-ALLBUND-16 | $334.85 $241

2016 Procedural Coding Expert

2016 ICD-10-CM Expert for Physicians

2016 HCPCS Level II Expert

2016 Complete Hospital Coding Bundle

MPP-HOSPBUND-16 | $434.80 $304


2016 ICD-10-CM Expert for Hospitals/Payers


2016 ICD-10-PCS Expert

2016 Medical Necessity Coding Bundle

MPP-ESSNBUND-16 | $222.90 $154



2016 Procedural Coding Bundle

MPP-PCEBUND-16 | $224.90 $171


2016 Plain English Descriptions for Procedures

2016 All Purpose Coding Bundle

MPP-ALLPURPS-16 | $334.85 $234

AMA CPT® 2016 Professional Edition



2016 Basic Procedural Bundle

MPP-BASICPRO-16 | $339.85 $238

AMA CPT® 2016 Professional Edition



Save up to 30% on core coding bundles!

3W W W . C O D I N G B O O K S . C O M | T O L L- F R E E 1 - 8 5 5 - C A L L- D H 1 | P R O M O C O D E M U L 1 5 P H 2

2016 AMA CPT® books also available!

AMA CPT® 2016 Standard

MPBR-CPTSTND-16 | $89.95 2016 EDITION: SHIPS OCTOBER


AMA CPT® 2016 Professional

MPBR-CPTPRO-16 | $114.95 2016 EDITION: SHIPS SEPTEMBER


MPB-PCE-16 | $114.95 2016 EDITION: SHIPS DECEMBER

Designed to make CPT® coding as

accurate as possible, this is hands-down

the best procedural coding resource in its

class. Elegant in design, it now features an

exclusive Documentation Finder to highlight

necessary coding requirements, plus

reimbursement aids including a High Risk

Denial alert icon, Medically Unlikely Edits

(MUE), and RVUs noted at the code level.

And it’s loaded with proprietary coding tips,

Medicare coverage rules, modifiers, and

global billing information that are integral to

code on a daily basis.

Go beyond the regular CPT manual;

choose the code book with exclusive

tips, indicators and features that will

allow greater coding clarity, optimize

reimbursement and lessen denials.

Finally, code books that support documentation and reimbursement.


Finally, code books that support documentation and reimbursement.


MPB-HCPCS-16 | $109.95 2016 EDITION: SHIPS DECEMBER

Ensure you’re using the most up-to-date HCPCS Level II codes and properly

submit claims to the DME or Part B MAC. If you’re billing for durable medical

equipment (DME), injections, Medicare services, drugs and medical supplies,

this resource will immediately help you identify the correct HCPCS Level II code

and identify which codes are on the Medicare DME fee schedule and paid by

the DME MAC.


MPB-MICD10-16 | $109.95 | SHIPS SEPTEMBER


MPB-ICD10HP-16 | $109.95 | SHIPS SEPTEMBER


MPB-ICD10PCS-16 | $109.95 | SHIPS AUGUST

Code-Ready Features:

All codes listed

with placeholder Xs

done for you!

More than 350

Coding Tips!

ICD10 Guidelines

excerpted at the code!

More than 100

Code Definitions!

40 full-page, color

anatomy illustrations!

Icons and color coding!


New! Specialty Illustrated Series

2016 Illustrated Coding and Billing Expert

$179.95 | SHIPS DECEMBER

This all-in-one resource is the perfect companion when using

CPT® codes in a specialty practice setting. Plain English

descriptions of each CPT code, CPT to ICD-9-CM crosswalks,

CPT to ICD-10-CM crosswalks, illustrations, guidelines, RVUs,

CCI edits, and make claims coding more efficient than ever. This

is the code book you’ll be reaching for again and again for use on

a daily basis.

Specialty Item #

Anesthesia/Pain MPB-MEDANEST-16

Cardiology MPB-MEDCARD-16

General Surgery MPB-MEDGENSU-16

OB/GYN MPB-MEDOB-16

Ophthalmology MPB-MEDOPHTH-16

Orthopedics, Upper Body & Spine MPB-MEDORTU-16

Orthopedics, Lower MPB-MEDORTL-16



458 l New Code s Revised Code CPT © 2014 American Medical Association. All Rights Reserved. © 2014 DecisionHealth

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2015 Plain English Descriptions for Procedures66020-66030 – 66184-66185

66020-66030 66020 Injection,anteriorchamberofeye(separateprocedure);airorliquid 66030 Injection,anteriorchamberofeye(separateprocedure);medicationThe anterior chamber of the eye is the area between the iris (outer layer of the cornea) and the endothelium (inner layer of the cornea). The anterior chamber is filled with clear gelatinous fluid called the aqueous humor. In 66020, air or liquid is injected into the anterior chamber. The patient is positioned supine with head and neck supported. A topical ophthalmic anesthetic applied and the eye is then cleansed with antiseptic. An eyelid speculum is placed and injection site marked. A fine needle with attached syringe is inserted through the cornea toward the mid-vitreous cavity. Air or liquid is then injected into the cavity. The needle is withdrawn, antibiotic eye drops instilled and the eye may be patched. In 66030, medication is injected into the anterior chamber using the same technique described above.

66130 66130 Excisionoflesion,scleraLesions of the sclera are usually benign in nature. They can include pingueculae found most often in the open space between the eyelids and characterized by a yellowish color and slight elevation. Pigmented lesions that arise from melanocytes and non-melanocytes can be acquired or congenital. Scleral lesions may be removed for cosmetic reasons or when they become enlarged and cause discomfort. A topical ophthalmic anesthetic is applied and the eye is prepped with an antibacterial solution. An eyelid speculum is inserted and the lesion is excised. Separately reportable tissue grafting may be performed to repair the surgical defect resulting from the excision. At the conclusion of the procedure, the cytotoxic (anti-cancer) drug Mitomycin C may be applied briefly to reduce scarring and then flushed away.

66150 66150 Fistulizationofscleraforglaucoma;trephinationwithiridectomyThe physician creates a new drainage tube for eye fluids through the fibrous covering of the eye. This is done to treat a condition in which fluid drains from the front chamber of the eye slower than new fluid is produced. The physician uses a small cylindrical saw to create the passage and removes a portion of the iris.

66155 66155 Fistulizationofscleraforglaucoma;thermocauterizationwithiridectomyThe physician creates a new drainage tube for eye fluids through the fibrous covering of the eye. This is done to treat a condition in which fluid drains from the front chamber of the eye slower than new fluid is produced. The physician uses a heat probe to burn a hole through the eye to the cornea, and also removes a portion of the iris.

66160 66160 Fistulizationofscleraforglaucoma;sclerectomywithpunchorscissors,

withiridectomyThe physician creates a new drainage tube for eye fluids through the fibrous covering of the eye. This is done to treat a condition in which fluid drains from the front chamber of the eye slower than new fluid is produced. The physician uses scissors or uses a special instrument to create the passage and remove a portion of the iris.

66170-66172 66170 Fistulizationofscleraforglaucoma;trabeculectomyabexternoinabsence

ofprevioussurgery 66172 Fistulizationofscleraforglaucoma;trabeculectomyabexternowith

scarringfrompreviousocularsurgeryortrauma(includesinjectionofantifibroticagents)

The physician creates a new drainage tube for eye fluids through the fibrous covering of the eye. This is done to treat a condition in which fluid drains from the front chamber of the eye slower than new fluid is produced. The physician removes some of the tissue connecting the iris to the fibrous membrane that surrounds the eye, leaving a passage for fluid to drain into the space between the fibrous membrane and the other structures of the eye. Code 66172 if this procedure is performed after a previous eye surgery to reduce scar tissue.

66174-66175 66174 Transluminaldilationofaqueousoutflowcanal;withoutretentionofdevice

or stent 66175 Transluminaldilationofaqueousoutflowcanal;withretentionofdeviceor

stentTransluminal dilation of the aqueous outflow canal (Schlemm’s canal) without retention is performed to treat open angle glaucoma. This procedure is also referred to as glaucoma canaloplasty or enhanced viscocanalostomy. The procedure reduces intraocular pressure (IOP) in patients with glaucoma by forcibly opening Schlemm’s canal to restore natural drainage of fluid from the eye. A scleral flap is created. The canal is exposed and

deroofed. The scleral flap may be extended to expose Descemet’s membrane and a window (Descemet’s window) is created. The canal is then intubated with a flexible hollow microcatheter with a lighted tip. The lighted tip illuminates the canal as the microcatheter is advanced. A viscoelastic, such as high viscosity sodium hyaluronate, is instilled to dilate the canal and facilitate advancement of the microcatheter. After it has been passed through the entire length of the canal, the microcatheter is withdrawn. The scleral flap is closed. Use 66174 when the procedure is performed without retention of a device or stent. Use 66175 when transluminal dilation of the aqueous outflow canal is performed with retention of a device or stent. The procedure is performed as described above except that a device, such as a suture, or a stent is left in the canal. After the microcannula has been passed through the entire length of the canal, either a flexible stent or a suture is advanced along the path of the microcannula through the full length of the canal as well. The flexible stent or suture is left in the canal and the microcannula is withdrawn. If a suture is used to permanently open the canal, the suture is tied off and left in place. The suture cinches and stretches the trabecular meshwork inward and opens the canal.

66179-66180s 66179 Aqueousshunttoextraocularequatorialplatereservoir,externalapproach;

withoutgrafts 66180 Aqueousshunttoextraocularequatorialplatereservoir,externalapproach;

withgraftNormal outflow of vitreous fluid begins at the aqueous humor and passes through the trabecular meshwork, enters Schlemm’s canal (a space lined with endothelial cells) finally draining into the collector channel and the aqueous veins. An aqueous shunt to extraocular reservoir (Molteno, Schocket, Denver-Krupin) bypasses the trabecular meshwork and Schlemm’s canal. The shunt is used to reduce intraocular pressure (IOP) when traditional medical (pharmacological) or surgical (trabeculectomy) therapy have failed. This procedure is most often implemented when increased intraocular pressure (IOP) is caused by iris swelling, abnormal vessel formation or iridocorneal endothelial (ICE) syndrome. With the patient supine and under general anesthesia, a small silicon tube is implanted into the anterior chamber of the eye allowing vitreous fluid to drain through the tube and collect in a tiny plate sutured on the anterior eye between the sclera and the conjunctiva (usually in the area of the upper eye lid). After collecting in the plate, the vitreous fluid is then absorbed by blood vessels on the surface of the anterior eye. In 66180, a scleral or corneal patch graft from donor tissue may be placed over the plate to keep it in position and reduce the incidence of conjunctival ulceration. At the conclusion of the procedure, the cytotoxic (anti-cancer) drug Mitomycin C may be applied briefly to reduce scarring and then flushed away. A contact lens bandage may be applied and antibiotic and/or steroid drops may be instilled. The eye is then patched.

66183 66183 Insertionofanteriorsegmentaqueousdrainagedevice,withoutextraocular

reservoir,externalapproachInsertion of an anterior segment aqueous drainage device is used to treat chronic or progressive open angle glaucoma. Using an external approach, which may also be described as non-penetrating deep sclerectomy, the conjunctiva is incised and a scleral flap is created with the base of the flap located at the corneoscleral junction (limbus). An incision is made into the anterior chamber and aqueous flow is established. A miniature drainage device (shunt), about the size of a grain of rice, is implanted between the anterior chamber and under the scleral flap in order to facilitate drainage of aqueous humor from the anterior chamber to the space under the conjunctiva. The scleral flap is secured with sutures and the conjunctival incision is closed.

66184-66185s 66184 Revisionofaqueousshunttoextraocularequatorialplatereservoir;without

grafts 66185 Revisionofaqueousshunttoextraocularequatorialplatereservoir;with

graftA number of conditions may require revision of aqueous shunt to extraocular plate reservoir. With the sudden drop in intraocular pressure (IOP) from the newly created drainage system, the anterior chamber may decrease the amount of fluid it produces. This can be treated by priming the pump with a viscoelastic fluid to raise IOP in the anterior chamber and stimulate the production of vitreous humor. However, some conditions require revision of the shunt, including corneal damage, small cataracts, infection, and bleeding. The most common problem requiring revision of the aqueous shunt is the build up of scar tissue at the posterior plate. An incision is made in the conjunctival tissue over the plate. The scar tissue is then removed. Once the scar tissue is removed, the conjunctival incision is sutured closed. In 66185, a scleral or corneal patch graft from donor tissue may be placed over the plate to keep it in position after the revision and reduce the incidence of conjunctival ulceration. At the conclusion of the procedure, the cytotoxic (anti-cancer) drug Mitomycin C may be applied briefly to reduce recurrence of scarring and then flushed away. A contact lens bandage may be applied and antibiotic and/or steroid drops may be instilled. The eye is then patched.

Gain coding clarity with Plain English guidance2016 Plain English Descriptions for ICD-10-CM

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Increase ICD-10-CM coding accuracy with added clarification.

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illustrations and thorough information on the Official Coding

Guidelines help to broaden understanding of what you’re coding

and why. This book mirrors the numerical arrangement of the official

ICD-10-CM code set for easy identification.

2016 Plain English Descriptions for Denial Codes

MPB-PEDDENY-16 | $129.95 2016 EDITION: SHIPS OCTOBER | 2015 EDITION: AVAILABLE NOW

Decipher denied claims, develop solutions and appeals, and train

your staff to avoid the problems that caused the denials in the first

place. Inside you’ll find Plain English explanations for Remittance

Advice codes and more, plus the action steps to quickly resolve the

issues delaying your reimbursement.

2016 Plain English Descriptions for Procedures

MPB-PEDCPT-16 | $129.95 2016 EDITION: SHIPS DECEMBER | 2015 EDITION: AVAILABLE NOW

Increase coding accuracy with Plain English descriptions for more

than 8,000 CPT® codes, complete code descriptions, detailed

anatomy illustrations and procedure illustrations. Get the clarification

you need to choose the correct code, every time.

Take a look

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Get started today!

Call toll-free 1-855-885-0192 or visit

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Code faster Simple screens let

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CPT IS A REGISTERED TRADEMARK OF THE AMERICAN MEDICAL ASSOCIATION.

OCT1OCT1

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Documentation Finder ™ – Medical record essentials; terminology synonyms, supporting tests essential to medical necessity, and target words auditors seek.

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Coder’s Scope™ Descriptions – Procedure descriptions offering dual vantage points of clinical synopsis and steps needed to decide appropriate codes

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Denial Risk Monitor – Code-level trends show payment risks based on real Medicare Claims processing data3

DecisionHealth articles tipsheets and expert answers to real-world coder questions indexed at the code level.4

Empower your coding decisions with exclusive guidance you won’t find in any coding application:

Discover the SelectCoder differencewww.decisionhealth.com/selectcoder


Expert ICD-10

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One stop for all your coding answers

Bonus: 4 tools for faster, more accurate coding: AMA Official Guidelines,

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Cardiology

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CPT® HCPCS, ICD-9-CM, ICD-10-CM and Modifiers:

Quickly search to find codes, descriptions and

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ICD-10-CM mappings, guidelines and conventions: Get a

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Fees, RVUs for facility & non-facility: GPCI-adjusted to

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Modifier crosslinks: At-a-glance modifier eligibility to gain

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LCD/NCD policies, covered ICD-9-CM/ICD-10-CM &

validation tool: Up tp date MAC-specific coverage policies

Medicare CCI edits with code bundling validation:

At-a-glance code pair restrictions

Coders Scope™ definitions: Advanced procedural descrip-

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Denial Risk Monitor: Payment risks based on real claims

filing and denial data

Coder’s Pink Sheet™ Specialty articles, tips and guidance

DocumentationFinder™: Crosswalk clinician documentation

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Get started today! Call toll-free 1-855-885-0192 or visit www.decisionhealth.com/selectcoder for a free demo!


Plan and Prepare focused training

� Build awareness by specialty

� Conduct baseline skills gap assessment to target training

Implement training

� Introduce coders and clinicians to the language and logic of ICD-10

� Establish new documentation specificity with physicians

Validate ability to apply knowledge

� Test readiness of coders and clinicians

� Provide opportunity for scenario practice and dual coding

Operate in a daily ICD10 coding workflow

� Introduce ICD-10 codes to daily workflow

� Dual code records to get used to using new codes, ramp productivity

� Update superbills and other coding cheatsheets

� Conduct pre-billing audits on dual coded claims

rack coding accuracy and compliance

� Track use of unspecified codes and documentation to support code selection

� Monitor and manage claims denials with remedial training

� Continue periodic staff assessments to identify skills gaps and need for remedial training

� Monitor ICD-10 developments, clarification and best practice guidance

Guarantee a seamless,

efficient and cost-effective

transition to ICD-10 with

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Look for the logo on the products and services on the next few pages and begin to

build your PIVOT program. Or call us toll-free at 1-855-CALL-DH1 and a PIVOT representative

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The transition strategy, tools and resources you need to be ready for ICD-10

Plan. Implement. Validate. Operate. rack.


Save 30% with ICD-10 training bundles!

Ultimate Training Package

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2016 Advanced Anatomy and Physiology for ICD-10-CM/PCS Trainer

2016 ICD-10-CM Documentation Trainer

2016 ICD-10-CM Workbook Trainer



Companion Package

MPP-COMPANIO-16 | $319.90 $224



ICD-10 Essentials for Hospitals

MPP-I10BOOKB-16 | 379.85 $270




Documentation Booster Package

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2015 ICD-10-CM Workbook Trainer

ICD-10-CM Essentials for Medical Practices

MPP-CORECOD1-16 | $269.90 $189



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MPP-DIAGBUND-16 | $239.90 $168

2016 Plain English Descriptions for ICD-10-CM


Train today and save! Visit www.codingbooks.com to order.


Ensuring proficiency in anatomy and physiology will be

essential for coding in ICD-10. Unlike other anatomy &

Physiology books, this guide is written specifically for coders

to empower coding decisions.

Inside you’ll find full-page illustrations to help you understand

laterality and specificity, detailed reviews of each body

system, quizzes at the end of every chapter, hundreds of

coding practice exercises, and comparisons of ICD-10-CM

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Keep your ICD-10 training focused

This is the ideal tool for coders of all levels to sharpen

their ICD-10-CM coding skills. This book includes coding

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encounters to help both students and experienced coders

apply their understanding of correct ICD-10-CM coding. In

all exercises, coders will need to apply the pertinent coding

principles, conventions and guidelines in code selection

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Dozens of new scenarios added!


MPB-API10-16 | $159.95 2016 EDITION: SHIPS SEPTEMBER 2015 EDITION: AVAILABLE NOW

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The ability to properly and fully assign more detailed

ICD-10-CM codes hinges on solid documentation. In this

how-to guide for coders and physicians, you’ll find all the

tools required for an effective documentation analysis

and a corrective action plan, including:

Comprehensive review of each ICD-9-CM chapter

and the corresponding ICD-10-CM chapter

An ICD-9-CM to ICD-10-CM comparison of code cat-

egories and subcategories

Condition-based crosswalks of ICD-9-CM to

ICD-10-CM codes

Scenarios showing required documentation in

ICD-10-CM

End of chapter quizzes

Specialty-specific documentation checklists

Updated for new ICD-10 Guidelines!


ICD-9-CM to ICD-10-CM crosswalks

2016 ICD-9-CM to ICD-10-CM Diagnostic Code Mappers for Specialties

$28.95 | 2016 EDITIONS: SHIP SEPTEMBER | 2015 EDITIONS: AVAILABLE NOW

Each specialty diagnostic code mapper has four full pages containing the top reported ICD-9-CM diagnoses codes, mapping

them to ICD-10-CM codes for each specialty. These fast, convenient and reliable tools are perfect for training!

Specialty Item #

Allergy MPL-MAPALLG-16

Anesthesia MPL-MAPANES-16

Behavioral Health MPL-MAPBEHAV-16

Cardiology MPL-MAPCARD-16

Dermatology MPL-MAPDERM-16

Emergency Medicine MPL-MAPEMED-16

Endocrinology MPL-MAPENDO-16

Family Practice MPL-MAPFAMP-16

Gastroenterology MPL-MAPGASTR-16

General Surgery MPL-MAPGENSR-16

Gynecology MPL-MAPGYN-16

Internal Medicine MPL-MAPIMED-16

Neurology MPL-MAPNEURO-16

Specialty Item #

Neurosurgery MPL-MAPNEURS-16

Obstetrics MPL-MAPOB-16

Oncology MPL-MAPONC-16

Oncology – Blood Disorders MPL-MAPBLOOD-16

Ophthalmology MPL-MAPOPHT-16

Orthopaedics – Lower MPL-MAPORTL-16

Orthopaedics – Upper MPL-MAPORTU-16

Orthopaedics – Spine MPL-MAPORTS-16

Otorhinolaryngology MPL-MAPOTO-16

Pain Medicine MPL-MAPPAIN-16

Pulmonology MPL-MAPPULM-16

Urology MPL-MAPURO-16

Train today: 2015 Editions available now! Visit www.codingbooks.com to order.


Quick references for I-10 coding clarity

Specialty Item #

Cardiology MPL-CCCARDIO-16

Family Medicine MPL-CCFAMMED-16

Gynecology MPL-CCGYN-16

Internal Medicine MPL-CCINTMD-16

Obstetrics MPL-CCOB-16

Orthopaedics – Lower MPL-CCORTL-16

Orthopaedics – Spine MPL-CCORTS-16

Orthopaedics – Upper MPL-CCORTU-16

ICD-10-PCS for Root Operations MPL-CCROOT-16

2016 ICD-10-CM Compact Coders

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Hone in on the ICD-10-CM code you need with these specialty-specific, quick reference tools. Each specialty 2015 ICD-10-CM

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The fastest, easiest and most convenient path to ICD-10 readiness

Comprehensive training customized for every member of your organization

Clinicians. We know how hard it is for busy physicians

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CMEs/CNEs available

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Compliance Pathway. Keep your practice compliant

with this 6-hour pathway that includes instruction on the OIG

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E/M Coding Pathway. The Evaluation and

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covering each of the different types of codes available,

the elements required for each of the types, and the

modifiers that may be included when submitting claims for

reimbursement.

DecisionHealth University provides pre-approved

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Why choose

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Learn at your own pace

Training by subject matter experts

Validate skills at the end of each course

Earn CEUs from AAPC, AHIMA, BMSC

Affordable and risk-free


The fastest, easiest and most convenient path to ICD-10 readiness

ICD-10-CM Coding PathwaySample courses include:

Understanding and Preparing for ICD-10-CM

ICD-10 Preparation for Healthcare Professionals:

The CM Guidelines

Anatomy and Terminology Essentials from an ICD-10-CM

Perspective

ICD-10-CM Documentation and Compliance

Fundamentals for Healthcare Professionals

Common Coding Scenarios: A Practicum in ICD-10-CM

Coding and Documentation

ICD-10-CM Specialty Coding PathwaySample courses include:Mastering Anesthesia for ICD-10-CM

Mastering Cardiology for ICD-10-CM

Mastering ENT for ICD-10-CM

Mastering Orthopedics for ICD-10-CM

Mastering General Surgery for ICD-10-CM

Mastering OB/GYN for ICD-10-CM

Mastering Pain Management for ICD-10-CM

Compliance PathwaySample courses include:

OIG Overview and Work Plan

HIPAA

Auditing and Monitoring

Compliance Planning

Medicare PathwaySample courses include:

National Correct Coding Initiative (NCCI)

Medicare Physician Fee Schedule (MPFS)

Medicare Provider Enrollment

Medicare Preventative Services

ICD-10-PCS Coding PathwaySample courses include:

Understanding and Preparing for ICD-10-PCS

ICD-10 Preparation for Healthcare Professionals:

The PCS Guidelines

Anatomy and Terminology Essentials from an ICD-10-PCS

Perspective

Coding from the Operative Report: a Practicum in

ICD-10-PCS Coding and Documentation

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Complete training pathways or single courses to suit your individual needs

Visit www.codingbooks.com or call I-855-885-0192 for course details

Clinician PathwaySample courses include:

Behavioral and Psychological Disorders

Cardiovascular Diseases and Disorders

Vascular Diseases and Disorders

External Causes

Metabolic and Nutritional Diseases and Disorders

Neoplasms

Other Injuries – Part I

Pregnancy, Delivery and Pueperium


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Ensure competitive charge-setting Using FeeCalc, you can compare your charges against local peers to set your

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Improve out-of-network patient revenue Charge data helps determine how much the provider is paid for seeing

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Empower contract negotiations The charge amount is often the starting point that payers and providers use

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Stay on top of Medicare coding and payment rules

2016 Physician Charge Benchmarks

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This comprehensive training

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Capture PQRS incentives,

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decipher Modifiers, and

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Medicare National Correct Coding Sourcebook

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Keep updated on the

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E/M Documentation Quick Reference Card Set

MPL-EMCARD-16 | $69 SHIPS NOVEMBER

Uncertainty around the proper selection of E/M service codes is

the most common cause of up coding and down coding exposing

your practice to greater audit and OIG scrutiny.

Ensure the most appropriate level of service is selected and coded

correctly with increased emphasis on the patient’s presenting

problem. Each compliance-ready laminated card clearly — and

quickly — spells out the rules for documentation complexity levels

for easy reference. It’s the perfect pocket-reference for physicians!

Outpatient

E/M Documentation Guide

Outpatient - New Patient POS = 11 or 22 HX

EXMDM Time

99201 1 minimal or stable problem

PFPF

SFD 10 min

99202 Minimal problem(s)

EPF EPF SFD 20 min

99203 Acute uncomplicated or multi-stable prob(s) DET DET LOW 30 min

99204 Acute complicated or multi prob w/1 exacerbated COMP COMP MOD 45 min

99205 Life threatening or severely unstableCOMP COMP HIGH 60 min

Outpatient - Established Patient POS = 11 or 22

99211 Nursing visit

5 min

99212 1 minimum or stable established problemPF

PFSFD 10 min

99213 Acute uncomplicated or multi-stable prob(s) EPF EPF LOW 15 min

99214 Acute complicated or multi prob w/1 exacerbated DET DET MOD 25 min


Outpatient - Consult POS = 11, 22 or 23


PFPF

SFD 15 min

99242 Minimal problem(s)

EPF EPF SFD 30 min

99243 Acute uncomplicated or multi-stable prob(s) DET DET LOW 40 min

99244 Acute complicated or multi prob w/1 exacerbated COMP COMP MOD 60 min


Emergency Department POS = 23


PFPF

SFN/A

99282 Acute uncomplicated

EPF EPF LOW N/A

99283 Acute complicated

EPF EPF MOD N/A

99284 Acute complicated - urgent

DET DET MOD N/A

99285 Life threatening or severely unstableCOMP COMP HIGH N/A

History

Exam ( Based on 1995 Guidelines )

HPI

Location, quality, severity, timing,

duration, context, associated signs,

modifying factors

Exam Body AreasExam Organ Systems

Abdomen, axillia,

back/spine,

chest/breast,

genitalia,

head/face, neck,

URE, ULE, LRE, LLE

Const (recommended 3),

CV, ENMT,

eyes, GI, GU,

hem/lymph/imm,

musculo, neuro,

psych, resp, skin

ROS

Const, allergy/immuno, CV, endo,

ENMT, eyes, GI, GU, hem/lymph,

musculo, neuro, psych, resp,

integ (skin/breast)

PF HPI = 1

PF = 1

EPF HPI = 1, ROS = 1

EPF = 2-7

DET HPI = 4, ROS = 2, PFSH = 1DET = 2-7 with 1 system detailed

COMP HPI = 4, ROS = 10, PFSH = 3

COMP = 8 organ systems must be examined.

If body areas are examined and counted, they must be

over and above the 8 organ systems. (1995)

Disclaimer: Numbers listed for the expanded problem-focused and detailed examinations are

recommendations by consultants and may be considered more aggressive than the non-specific

language provided by CMS and the AMA for 1995 examination guidelines.

Medical Decision-Making

SFD Num Dx/mgt options = Minimal, Amt/complexity of data = Minimal, Risk = Minimal

LOW Num Dx/mgt options = Limited, Amt/complexity of data = Limited, Risk = Low

MOD Num Dx/mgt options = Multiple, Amt/complexity of data = Moderate, Risk = Moderate

HIGH Num Dx/mgt options = Extensive, Amt/complexity of data = Extensive, Risk = High

Medicare no longer recognizes consultation codes.

Hospital Initial Visit POS = 21HX EX MDM Time

99221 Uncomplicated problem DET/COMP

DET/COMP SFD/LOW 30 min

99222 Complicated problem(s)COMP COMP MOD 50 min

99223 Life threatening or severely unstable COMP COMP HIGH 70 min

Hospital Subsequent Visit POS = 21 99231 Stable established conditionPF PF SFD/LOW 15 min

99232 Exacerbated condition(s)EPF EPF MOD 25 min

99233 New or severely unstable condition(s) DET DET HIGH 35 min

99238 Discharge - 30 minutes or less

< 30 min

99239 Discharge - greater than 30 minutes (specific clock time required)> 31 min

Inpatient - Consult POS = 21 or 3199251 1 minimal or stable problemPF PF SFD 20 min

99252 Minimal problem(s)EPF EPF SFD 40 min

99253 Acute uncomplicated or multi-stable prob(s) DET DET LOW 55 min99254 Acute complicated or multi prob w/1 exac-erbated

COMP COMP MOD 80 min99255 Life threatening or severely unstable COMP COMP HIGH 110 min

SNF Initial Visit POS = 31 or 3299304 Uncomplicated problem DET/

COMPDET/COMP SFD/LOW 25 min


99306 Life threatening or severely unstable COMP COMP HIGH 45 min

SNF Subsequent Care POS = 31 or 3299307 Stable established conditionPF PF SFD 10 min

99308 Minor complication(s)EPF EPF LOW 15 min

99309 Significant complication(s)DET DET MOD 25 min

99310 New problem or severely unstableCOMP COMP HIGH 35 min

99315 Discharge - 30 minutes or less

< 30 min

99316 Discharge - greater than 30 minutes (specific clock time required)> 31 min

Observation Admit POS = 2299218 Uncomplicated problem DET/

COMPDET/COMP SFD/LOW 30 min


99220 Possibly life threatening or severely unstable COMP COMP HIGH 70 min

Observation Subsequent POS = 2299224 Stable established conditionPF PF SFD/LOW 15 min

99225 Minor complication(s)EPF EPF MOD 25 min

99226 Significant complication(s)DET DET HIGH 35 min

Observation Admit/Discharge same day POS = 21 or 2299234 Uncomplicated problem DET/COMP

DET/COMP SFD/LOW N/A

99235 Complicated problem(s)COMP COMP MOD N/A

99236 Possibly life threatening or severely unstable COMP COMP HIGH N/A

99217 Observ care discharge day managementMedicare no longer recognizes consultation codes.

Inpatient E/M Documentation Guide

© 2014 Decisionhealth | www.decisionhealth.comPlease consult your CPT manual for full code descriptions.

CPT® is a registered trademark of the American Medical Association. H5662

Improve E/M coding accuracy, reduce risk

2016 E/M Coding & Billing Answers

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Includes detailed chart audit tools, real-life

visit notes, tips and hints, plain-English

definitions, even a skills test to validate

your understanding of E/M coding rules.

2016 E/M Bell Curve & Auditing Sourcebook

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This data-driven workbook and instructional guide

helps you quickly identify irregular E/M billing

patterns and target your chart auditing to ensure you

are billing at proper levels to minimize compliance

risk. Compare national Medicare statistics with your

own E/M utilization and payer mix, focus your chart

audits by targeting patterns that suggest over- or

under-coding, improve physician documentation

with real-world audit scenarios and sample notes.

Bonus CD: generate E/M bell curve graphs by

specialty with self-populating spreadsheets.


Coding and compliance references designed to address specialty coding challenges

2016 HIPAA Answers

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Presumptive Drug Screen Code Decision Tree (5-pack)

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ease of use to quickly find the information you need.

Keep your qualitative drug screen claims clean with this

new helpful coding guide. Eliminate confusion on new 2015

CPT® codes used by private payers (80300-80304) with

this quick reference chart that easily identifies the correct

presumptive drug screen code based on the presumptive

drug class and the method you use for testing.

2016 Orthopedic Coding Answers

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This must-have reference for coding

challenging orthopedic procedures

answers more than 100 questions

so you can navigate through the

coding scenarios your practice

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instant access to answers from top

coding and billing expert Margie

Scalley-Vaught.

2016 E/M Coding & Billing Answers

MPB-EMCODANS-16 | $199 SHIPS NOVEMBER

Code and document E/M services

(99201-99499) correctly and develop

protocols to handle ambiguity in the

guidelines that work in your internal

compliance plan — before an external

audit occurs. Includes detailed chart

audit tools, real-life visit notes, tips

and hints, plain-English definitions,

even a skills test to validate your

understanding of E/M coding rules.

2016 Pain Management Coding Answers

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Provides the information you need

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pain management coding examples,

sample scenarios and chapter

reviews, ICD-10 coding tips, medical

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Top practice insights for top performance

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Orthopedic Coder’s Pink Sheet

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Anesthesia & Pain Coder’s Pink Sheet

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Medical Practice Coding Pro

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Coding Answer Book

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Inside the Joint Commission

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The Quick Guide to the 2014 Environment of Care Standards

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Two Washingtonian Center 9737 Washingtonian Blvd., Ste. 200Gaithersburg, MD 20878-7364

Live training for every healthcare settingJoin us!

www.decisionhealth.com/ICD-10specialtycoding

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Advanced Anesthesia Coding, Compliance & Reimbursement S Y M P O S I U M

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