Buck's Step-by-Step Medical Coding, 2025 Edition
- 1st Edition - September 11, 2024
- Imprint: Elsevier
- Authors: Elsevier Inc, Elsevier, Jackie Koesterman
- Language: English
- Paperback ISBN:9 7 8 - 0 - 4 4 3 - 2 4 8 7 8 - 8
- eBook ISBN:9 7 8 - 0 - 4 4 3 - 2 6 0 6 5 - 0
**Selected for 2025 Doody’s Core Titles® in Health Information Management**Take your first step toward a successful career in medical coding with guidance from the most trusted… Read more
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Take your first step toward a successful career in medical coding with guidance from the most trusted name in coding education! The bestselling Buck’s Step-by-Step Medical Coding is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. To reinforce your understanding, practice exercises follow the explanations of each coding concept. In addition to coverage of reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, an Evolve website includes 30-day access to TruCode® Encoder Essentials. No other book so thoroughly covers all coding sets!
Take your first step toward a successful career in medical coding with guidance from the most trusted name in coding education! The bestselling Buck’s Step-by-Step Medical Coding is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. To reinforce your understanding, practice exercises follow the explanations of each coding concept. In addition to coverage of reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, an Evolve website includes 30-day access to TruCode® Encoder Essentials. No other book so thoroughly covers all coding sets!
- Theory and practical review questions (located at the end of each chapter) focus on recalling important chapter information and application of codes.
- A step-by-step approach makes it easier to build your coding skills and remember the material.
- Learning objective and glossary review questions reinforce your understanding of key chapter concepts and terms.
- Coverage reflects the latest CPT E/M guidelines changes for office and other outpatient codes.
- 30-day trial to TruCode® Encoder Essentials gives you experience with using an encoder (plus access to additional encoder practice exercises on the Evolve website).
- UNIQUE! "Real-life" coding reports simulate the reports you will encounter as a coder and help you apply coding principles to actual cases.
- Online activities on Evolve provide extra practice with assignments, including coding reports.
- More than 450 illustrations help you understand the types of medical conditions and procedures being coded, and include examples taken directly from Elsevier's professional ICD-10 and HCPCS manuals.
- UNIQUE! Four coding-question variations — covering both single-code questions and multiple-code questions and scenarios — develop your coding ability and critical thinking skills.
- UNIQUE! Coders’ Index in the back of the book makes it easy to quickly locate specific codes.
- Official Guidelines for Coding and Reporting boxes show the official guidelines wording for inpatient and outpatient coding alongside in-text explanations.
- Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information.
- Valuable tips and advice are offered in features such as From the Trenches, Coding Shots, Stop!, Caution!, Check This Out, and CMS Rules.
- Sample EHR screenshots (in Appendix D) show examples similar to the electronic health records you will encounter in the workplace.
- Buck’s Step-by-Step Medical Coding, 2025 Edition
- Cover image
- Title page
- Table of Contents
- Copyright
- Dedication
- About the authors
- Acknowledgments
- Preface
- Development of this edition
- Introduction
- List of Illustrations
- List of Tables
- UNIT 1. Reimbursement
- 1. Reimbursement, HIPAA, and compliance
- Introduction
- Basic structure of the medicare program
- Quality improvement organizations (QIOS)
- Part A: Hospital insurance
- Part B: Supplementary insurance
- Part C: Medicare advantage organizations
- Part D: Prescription drugs
- Health Insurance Portability and Accountability Act
- Electronic transactions
- Code sets
- Privacy requirements
- Security requirements
- National provider identification
- Federal register
- Outpatient resource-based relative value scale (RBRVS)
- Relative value unit
- Geographic practice cost index
- Conversion factor
- Medicare volume performance standards
- Beneficiary protection
- Limiting charge
- Uniformity provision
- Adjustments
- Site-of-service limitations
- Surgical modifier circumstances
- Medicare fraud
- Fraud defined
- Specific regulations are in the IOMs
- Managed health care
- Types of plans
- References
- UNIT 2. ICD-10-CM
- 2. An overview of ICD-10-CM
- The ICD-10-CM
- ICD-10-CM format
- Index
- Tabular
- Chapters
- Bold type
- Italicized type
- Official instructional notations in the ICD-10-CM
- Conventions
- Includes
- Excludes
- Code first/use additional code
- Code also
- Default codes
- Code assignment and clinical criteria
- 7th characters and placeholder X
- Cross-references
- 3. ICD-10-CM outpatient coding and reporting guidelines
- The guidelines
- First-listed diagnosis
- Unconfirmed diagnosis
- Outpatient surgery
- Additional diagnoses
- Z codes
- Status code
- Index location
- Circumstances to assign Z codes
- History of
- External causes
- Observation stay
- First-listed diagnosis and coexisting conditions
- Uncertain diagnoses
- Chronic diseases
- Documented conditions
- Diagnostic services
- Therapeutic services
- Preoperative evaluation
- Preoperative evaluations only
- Prenatal visits
- 4. Using ICD-10-CM
- Organization of the guidelines
- Accurate coding
- Alphabetic index and tabular list
- Level of specificity
- Integral conditions
- Multiple coding
- Acute and chronic
- Combination codes
- Late effects (sequela)
- Reporting same diagnosis code more than once
- Laterality
- 5. Chapter-specific guidelines (ICD-10-CM Chapters 1-10)
- Certain infectious and parasitic diseases
- Resistant infections
- A codes (A00-A99)
- Sepsis, severe sepsis, and septic shock
- B codes (B00-B99)
- Viral hepatitis
- Human immunodeficiency
- Neoplasms
- Neoplasm classifications and staging
- Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
- Anemia
- Coagulation defects, purpura, and other hemorrhagic conditions
- Other disorders of blood and blood-forming organs (D70-D77)
- Endocrine, nutritional, and metabolic diseases
- Mental, behavioral and neurodevelopmental disorders
- Dementia
- Substance use
- Psychological disorders
- Psychological pain
- Diseases of the nervous system
- Pain (nonpsychological)
- Dominant and nondominant sides
- Diseases of the eye and adnexa
- Hordeolum and chalazion
- Entropion and ectropion
- Lacrimal system
- Diseases of the ear and mastoid process
- Ear
- Diseases of the circulatory system
- Hypertension
- Kidney disease and hypertension
- Myocardial infarction
- Diseases of the respiratory system
- 6. Chapter-specific guidelines (ICD-10-CM Chapters 11-14)
- Diseases of the digestive system
- Hemorrhage
- Diseases of the skin and subcutaneous tissue
- Ulcers
- Diseases of the musculoskeletal system and connective tissue
- Infectious arthropathies
- Pathological fractures
- Diseases of the genitourinary system
- 7. Chapter-specific guidelines (ICD-10-CM Chapters 15-22)
- Pregnancy, childbirth, and the puerperium
- General rules of obstetric diagnosis reporting
- First-listed diagnosis in normal pregnancy
- First-listed diagnosis in high-risk patients
- First-listed diagnosis for delivery
- Trimesters
- Peripartum and postpartum periods
- Normal delivery
- Ectopic pregnancy
- Hydatidiform mole
- Hypertension in pregnancy
- Fetal conditions
- Diabetes mellitus in pregnancy
- Certain conditions originating in the perinatal period
- First-listed diagnosis
- Congenital malformations, deformations, and chromosomal abnormalities
- Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified
- Injury, poisoning, and certain other consequences of external causes
- Code extensions
- Coding injuries
- Coding fractures
- Coding burns and corrosions
- Coding adverse effects, poisoning, underdosing, and toxic effects
- Abuse, neglect, and other maltreatment
- Open wounds, lacerations, and punctures
- Complications
- External causes, Z codes, and codes for special purposes
- External causes
- Z codes
- Codes for special purposes
- UNIT 3. CPT and HCPCS
- 8. Introduction to CPT
- The purpose of the CPT manual
- Updating the CPT manual
- CPT manual format
- Important symbols and appendices
- CPT sections
- CPT guidelines
- Code format
- Modifiers
- Unlisted procedures
- Category II codes
- Category III codes
- Special reports
- Starting with the index
- Locating the terms
- Single code
- Multiple codes
- Range of codes
- See
- General rules
- 9. Introduction to the Level II National Codes (HCPCS)
- History of national level codes
- Two levels of codes
- Code groupings
- Updating the HCPCS manual
- HCPCS format
- Index
- Alphanumeric listing
- Modifiers
- Table of drugs
- Durable medical equipment
- National physician fee schedule
- 10. Modifiers
- CPT modifiers
- Modifiers -22 through -26
- -22, Increased procedural services
- -23, Unusual anesthesia
- -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period
- -25, Significant separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service
- -26, Professional component
- Modifiers -32 through -52
- -32, Mandated services
- -33, Preventive service
- -47, Anesthesia by surgeon
- -50, Bilateral procedures
- -51, Multiple procedures
- -52, Reduced services
- Modifiers -53 through -59
- -53, Discontinued procedure
- Modifiers -54, -55, and -56
- -57, Decision for surgery
- -58, Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period
- -59, Distinct procedural service
- Modifiers -62 through -82
- -62, Two surgeons
- -63, Procedure performed on infants less than 4 kg
- -66, Surgical team
- -76, Repeat procedure or service by same physician or other qualified health care professional
- -77, Repeat procedure by another physician or other qualified health care professional
- -78, Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period
- -79, Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period
- -80, Assistant surgeon
- -81, Minimum assistant surgeon
- -82, Assistant surgeon (when qualified resident surgeon not available)
- Modifiers -90 through -99
- -90, Reference (outside) laboratory
- -91, Repeat clinical diagnostic laboratory test
- -92, Alternative laboratory platform testing
- -93, Synchronous telemedicine service, audio-only
- -95, Synchronous telemedicine service, audio and video
- -96, Habilitative services
- -97, Rehabilitative services
- -99, Multiple modifiers
- 11. Evaluation and management (E/M) services
- Contents of the E/M section
- Three factors of E/M codes
- Place of service
- Type of service
- Patient status
- Medical records documentation
- Office or other outpatient code guidelines
- Medical decision making (mdm)
- Time
- Various levels of E/M service
- Key component
- An E/M code example
- Using the E/M codes
- Office or other outpatient services
- Telemedicine services
- Hospital observation services
- Hospital inpatient or observation care services
- Consultation services
- Emergency department services
- Critical care services
- Nursing facility services
- Home services
- Prolonged services
- Case management services
- Care plan oversight services
- Preventive medicine services
- Non-face-to-face services
- Special evaluation and management services
- Newborn care services
- Delivery/birthing room attendance and resuscitation services
- Inpatient neonatal intensive care and pediatric and neonatal critical care services (99466-99486)
- Cognitive assessment and care plan services (99483)
- Care management services (99424-99427, 99437, 99439, 99487-99491)
- Psychiatric collaborative care management services (99492-99494)
- Transitional care management services (99495-99496)
- Advance care planning (99497-99498)
- General behavioral health integration care management (99484)
- Other evaluation and management services
- Coding practice
- Documentation guidelines
- 12. Anesthesia
- Types of anesthesia
- Moderate (conscious) sedation
- Anesthesia section format
- Formula for anesthesia payment
- B is for base unit
- T is for time
- M is for modifying unit
- Summing it up!
- Multiple procedures
- Concurrent modifiers
- Unlisted anesthesia code
- Other reporting
- Return to operating room
- Preanesthetic examination
- 13. Surgery guidelines and general surgery
- Introduction to the surgery section
- Notes and guidelines
- Unlisted procedures
- Special reports
- Separate procedure
- Surgical package
- General subsection
- 14. Integumentary system
- Integumentary system
- Format
- Skin, subcutaneous, and accessory structures
- Introduction and removal (10030-10036)
- Incision and drainage
- Debridement
- Excision—debridement
- Introduction to lesions
- Paring or cutting
- Biopsy
- Skin tags
- Shaving of epidermal or dermal lesions
- Excision—benign lesions
- Excision—malignant lesions
- Nails, pilonidal cyst and introduction
- Pilonidal cyst
- Introduction
- Repair (closure)
- Repair factors
- Repair component
- Tissue transfers, grafts, and flaps
- Other procedures
- Pressure ulcers
- Burns
- Destruction
- Mohs micrographic surgery
- Breast procedures
- 15. Musculoskeletal system
- Format
- Fractures and dislocations
- Fractures
- Dislocations
- General
- Wound exploration
- Excision
- General introduction or removal
- Grafts (or implants)
- Other procedures
- Spinal instrumentation and fixation
- Foot and toe repairs
- Application of casts and strapping
- Endoscopy/arthroscopy
- 16. Respiratory system
- Format
- Endoscopy
- Nose
- Incision
- Excision
- Introduction
- Removal of a foreign body
- Repair
- Destruction
- Other procedures
- Accessory sinuses
- Incision
- Larynx
- Excision
- Introduction
- Repair
- Trachea/bronchi
- Incision
- Introduction
- Excision/repair
- Lungs and pleura
- Incision
- Excision
- Removal
- Surgical collapse therapy; thoracoplasty
- 17. Cardiovascular system
- Coding highlights
- Coding from three sections
- Invasive
- Noninvasive
- Electrophysiology
- Nuclear cardiology
- Cardiovascular coding in the surgery section
- Heart and pericardium
- Arteries and veins
- Cardiovascular coding in the medicine section
- Other therapeutic services and procedures
- Cardiography and cardiovascular monitoring services
- Implantable, insertable, and wearable cardiac device evaluations
- Echocardiography
- Cardiac catheterization
- Intracoronary brachytherapy
- Intracardiac electrophysiologic procedures/studies
- Peripheral arterial disease rehabilitation
- Noninvasive physiologic studies and procedures
- Other procedures
- Cardiovascular coding in the radiology section
- Heart
- Aorta and arteries
- 18. Hemic, lymphatic, mediastinum, and diaphragm
- Hemic and lymphatic systems
- Format
- Coding highlights
- Lymph nodes and lymphatic channels
- Mediastinum and diaphragm
- Mediastinum
- Diaphragm
- 19. Digestive system
- Format
- Lips
- Vestibule of mouth
- Tongue and floor of mouth
- Dentoalveolar structures
- Palate and uvula
- Salivary gland and ducts
- Pharynx, adenoids, and tonsils
- Esophagus
- Stomach
- Intestines (except rectum)
- Meckel’s diverticulum and the mesentery
- Appendix
- Colon and rectum
- Endoscopy (proctosigmoidoscopy, sigmoidoscopy, and colonoscopy)
- Anus
- Liver
- Biliary tract
- Pancreas
- Abdomen, peritoneum, and omentum
- 20. Urinary and male genital systems
- Urinary system
- Kidney
- Ureter
- Bladder
- Urethra
- Male genital system
- Format
- Penis
- Testis
- Epididymis
- Tunica vaginalis
- Scrotum
- Vas deferens
- Spermatic cord
- Seminal vesicles
- Prostate
- 21. Reproductive, intersex surgery, female genital system, and maternity care and delivery
- Reproductive system procedures
- Intersex surgery
- Female genital system
- Format
- Vulva, perineum, and introitus
- Vagina
- Cervix uteri
- Corpus uteri
- Oviduct/ovary
- Ovary
- In vitro fertilization
- Maternity care and delivery
- Format
- Maternity and delivery
- Routine obstetric care
- Antepartum services
- 22. Endocrine and nervous systems
- Endocrine system
- Format
- Coding highlights
- Nervous system
- Structure and function of the nervous system
- Code assignment
- Skull, meninges, and brain
- Spine and spinal cord
- 23. Eye, ocular adnexa, auditory, and operating microscope
- Eye and ocular adnexa
- Format
- Eyeball
- Anterior segment
- Posterior segment
- Ocular adnexa
- Conjunctiva
- Auditory system
- Format
- External ear
- Middle ear
- Inner ear
- Operating microscope
- 24. Radiology
- Format
- Radiology terminology
- Terms
- Planes
- Guidelines
- Supervision and interpretation, imaging guidance
- Odds and ends
- Diagnostic radiology
- Breast, mammography
- Diagnostic ultrasound
- Modes and scans
- Radiation oncology
- Clinical treatment planning
- Simulation
- Medical radiation physics, dosimetry, treatment devices, and special services
- Radiation treatment delivery
- Radiation treatment management
- Proton beam treatment delivery
- Hyperthermia
- Clinical brachytherapy
- Nuclear medicine
- 25. Pathology/laboratory
- Format
- Organ or disease-oriented panels
- Drug assay
- Therapeutic drug assays
- Evocative/suppression testing
- Pathology clinical consultations
- Urinalysis, molecular pathology, and chemistry
- Hematology and coagulation
- Immunology
- Transfusion medicine
- Microbiology
- Anatomic pathology
- Cytopathology and cytogenic studies
- Surgical pathology
- Other procedures
- 26. Medicine
- Format
- Introduction to immunizations
- Immune globulins
- Immunization administration for vaccines/toxoids
- Vaccines, toxoids
- Psychiatry
- Biofeedback
- Dialysis
- Hemodialysis
- Peritoneal dialysis
- End-stage renal disease
- Gastroenterology
- Ophthalmology
- Special otorhinolaryngologic services
- Cardiovascular
- Coronary therapeutic services and procedures
- Cardiac catheterization
- Home and outpatient international normalized ratio (INR) monitoring services
- Noninvasive vascular diagnostic studies
- Pulmonary
- Allergy and clinical immunology
- Endocrinology
- Neurology and neuromuscular procedures
- Central nervous system assessments/tests
- Health behavior assessment and intervention
- Hydration
- Therapeutic, prophylactic, and diagnostic injections and infusions
- Chemotherapy administration
- Photodynamic therapy
- Special dermatological procedures
- Physical medicine and rehabilitation
- Active wound care management
- Medical nutrition therapy
- Osteopathic manipulative treatment (OMT)
- Chiropractic manipulative treatment (CMT)
- Non-face-to-face nonphysician services
- Special services, procedures, and reports
- Other services and procedures
- Home health procedures/services
- Home infusion procedures services
- Medication therapy management services
- UNIT 4. Inpatient Coding
- 27. Inpatient coding
- Differences between inpatient and outpatient coding
- Selection of principal diagnosis
- Symptoms, signs, and ill-defined conditions
- Two or more interrelated conditions
- Two or more diagnoses
- Comparative or contrasting conditions
- Original treatment plan not carried out
- Complications
- Uncertain diagnosis
- Reporting additional diagnoses
- Present on admission (POA)
- Development of the ICD-10-PCS
- The seven characters of the ICD-10-PCS
- The index
- The tabular list completes the code
- Appendix A: Online resources
- Appendix B: Exercise, quick check, and toolbox answers
- Appendix C: Learning objective and glossary review answers
- Appendix D: EHR screens
- Glossary
- Figure credits
- Coder’s index
- Index
- Edition: 1
- Published: September 11, 2024
- Imprint: Elsevier
- Language: English
- Paperback ISBN: 9780443248788
- eBook ISBN: 9780443260650
JK
Jackie Koesterman
Jackie L Koesterman, CPC, has been a Certified Professional Coder and Medical Assistant for over 25 years. Jackie has also served as an instructor at the Minnesota Northland Technical College in the medical clerical and medical assistant programs. Jackie is employed by a large medical health system as a Senior Coder III and Reimbursement Specialist, specializing in multi-specialty coding and multi-payer denial review in both the inpatient and outpatient settings. She also serves as a trainer and mentor to the coders. Jackie performs audits for multi-specialties for private practice clinics in her area.
Affiliations and expertise
Coding and Reimbursement Specialist, JDK Medical Coding EDU, Grand Forks, North Dakota, USA