Buck's The Next Step: Advanced Medical Coding and Auditing, 2025/2026 Edition
- 1st Edition - December 4, 2024
- Imprint: Elsevier
- Authors: Elsevier Inc, Jackie Koesterman
- Language: English
- Paperback ISBN:9 7 8 - 0 - 4 4 3 - 2 4 8 8 0 - 1
- eBook ISBN:9 7 8 - 0 - 4 4 3 - 2 6 1 4 3 - 5
- eBook ISBN:9 7 8 - 0 - 4 4 3 - 2 6 1 4 2 - 8
Master advanced coding skills! Buck’s The Next Step: Advanced Medical Coding and Auditing shows how to code for services such as medical visits, diagnostic testing and interpr… Read more
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Request a sales quoteMaster advanced coding skills! Buck’s The Next Step: Advanced Medical Coding and Auditing shows how to code for services such as medical visits, diagnostic testing and interpretation, treatments, surgeries, and anesthesia. Real-world cases (cleared of any patient identifiers) takes your coding proficiency a step further by providing hands-on practice with physician documentation. With this guide, you’ll learn to pull the right information from medical documents, select the right codes, determine the correct sequencing of those codes, and properly audit cases.
- NEW! Coding updates include the latest information available, including 2026 code updates when released
- Real-world patient cases (cleared of any patient identifiers) simulate the first year of coding on the job by using actual medical records, allowing you to practice coding with advanced material
- UNIQUE! Evaluation and Management (E/M) audit forms include clear coding instructions to help reduce errors in determining the correct level of service
- More than 150 full-color illustrations depict and clarify advanced coding concepts
- Coverage of CPT E/M guidelines changes for office and other outpatient codes
- From the Trenches boxes highlight the real-life experiences of professional medical coders and include photographs, quotes, practical tips, and advice
Medical Assisting (Administrative) Students; Medical Secretarial Students; Insurance/Coding Students; Health Information Management Students
- Buck’s The Next Step : Advanced Medical Coding and Auditing, 2025/2026 Edition
- Cover image
- Title page
- Table of Contents
- Copyright
- Dedication
- About the author
- Acknowledgments
- Preface
- Development of this edition
- Introduction
- List of physicians
- List of Illustrations
- List of Tables
- 1. Evaluation and management services
- E/M review—the basics
- Three factors of E/M code
- Office or other outpatient code guidelines
- Key component
- Hospital inpatient and observation care services
- Initial hospital inpatient or observation care
- Subsequent hospital inpatient or observation care
- Hospital inpatient or observation care services (including admission and discharge services)
- Hospital inpatient or observation discharge services
- Diagnosis coding
- Inpatient and outpatient coders
- Time to code!
- Diabetic ketoacidosis
- Asthma
- Medical decision making complexity (MDM)
- Level of diagnoses
- Level of data to review
- Level of risk
- Time
- Hospital inpatient or observation discharge services
- Consultations, prolonged services, standby, and critical care services
- Consultation services
- Critical care services
- Prolonged services
- Standby services
- Cerebral hemorrhage
- Office and other outpatient services
- Hospital observation services
- Observation care services
- Initial and subsequent observation care
- Observation care discharge services
- Neonatal care services
- Neonatal critical care (NCC)
- Newborn care (NC)
- Newborn diagnosis coding
- Reporting the liveborn infant
- Disorders relating to short gestation and low birth weight
- Preventive medicine services
- Z codes
- 2. Medicine
- Immune globulins/immunizations/vaccines/toxoids (90281-91322)
- Diagnosis coding for vaccinations and immune globulins
- Hydration, (96360, 96361); and therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy and other highly complex drug or highly complex biologic agent administration) (96365-96379)
- Hydration
- Therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy and other highly complex drug or highly complex biologic agent administration) (96365-96379)
- Psychiatry
- Dialysis
- Peritoneal dialysis
- Complications
- Noninvasive vascular diagnostic studies
- Late effects
- Cardioversion
- Ultrasound
- Codes reviewed elsewhere
- Central nervous system assessments/tests (e.g., neurocognitive, mental status, speech testing)
- Dementia
- Health behavior assessment and intervention
- Chemotherapy administration (96401-96549)
- Diagnosis coding for chemotherapy
- Photodynamic therapy
- Physical medicine and rehabilitation (97010-97799)
- Medical nutrition therapy
- Osteopathic and chiropractic manipulative treatment
- Special services, procedures, and reports
- HCPCS level II modifiers
- 3. Radiology
- Positions and placement
- Component coding
- Interventional radiology
- Contrast
- Facility specifics
- Diagnostic radiology
- Hemodialysis catheter placement
- Types of catheters
- Nasogastric tube
- Cine-pharyngoesophagram
- CAT/CT scans
- Reconstruction
- Congestive heart failure
- Hypoxemia
- CT guidance
- Ultrasound
- Modes and scans
- Ultrasound guidance
- Radiation oncology
- Clinical treatment planning
- Simulation
- Radiation treatment management
- Proton beam treatment delivery
- Hyperthermia
- Clinical brachytherapy
- Treatment delivery
- Nuclear medicine
- Interventional radiology
- Central venous access procedures
- 4. Pathology and laboratory
- Types of services
- Superbill/requisition form
- Organ- or disease-oriented panels
- Therapeutic drug assays
- Urinalysis, molecular pathology, and chemistry
- Urine/stool
- Timed urine
- Molecular pathology
- Chemistry
- Calculations
- Chromatography
- Hematology and coagulation
- Laboratory use only
- Coagulation
- Immunohematology
- Immunology
- Body fluid
- Office testing
- Other laboratory and pathology services
- Presumptive drug class screening
- Diagnoses coding in drug test and drug abuse
- Evocative/suppression testing
- Transfusion medicine
- Microbiology
- Anatomic pathology
- Pathology clinical consultations
- Cytopathology and cytogenetic studies
- Surgical pathology
- Specimens
- Other procedures
- 5. Integumentary system
- Debridement
- Skin biopsy and skin tags
- Lesion excision
- Keratosis
- Nails
- Repair (closure)
- Modifier -59
- Adjacent tissue transfers or rearrangements
- Skin grafts
- Other procedures
- Pressure ulcers
- Breast procedures
- 6. Cardiovascular system
- Evaluation and management services
- Arteriosclerosis
- Coronary artery bypass grafts
- Pacemaker
- Sick sinus syndrome
- Echocardiography
- Valve insufficiencies
- Holter
- Preimplantation, implantation, and postimplantation
- Stress tests
- Myocardial perfusion scan
- Review of previous history
- Cardiac catheterization
- Miscellaneous reports
- Cardioversion
- 7. Digestive system, hemic/lymphatic system, and mediastinum/diaphragm
- Digestive system
- E/M services
- Intestinal obstruction
- External procedures
- Hemorrhoids
- Catheters
- Endoscopy procedures
- Gastritis and duodenitis
- Ulcer
- Hernia
- Rectal procedures
- Polyps
- Abnormal findings
- Abdominal pain
- Cytomegalovirus
- Laparoscopic procedures
- Closed procedures converted to open procedures
- Cholecystectomy
- Incisional (open) surgical procedures
- Crohn’s disease
- Crohn’s disease diagnosis
- Hernia
- Hemic/lymphatic system
- Diagnosis coding of hematopoietic and lymphatic neoplasms
- 8. Musculoskeletal system
- Arthrocentesis
- Fractures
- Fixation
- Excision
- Repair, revision, and reconstruction
- Sprains and strains
- Grafts (or implants)
- Late effects
- Fractures
- Amputation
- Arthroscopy
- 9. Respiratory system
- E/M services
- Enzyme immunoassay
- Residents
- Medicine services
- Spirometry
- Sleep studies
- Symptoms, signs, and ill-defined conditions
- Symptoms as diagnoses
- Nonspecific abnormal findings
- Pulmonary stress test
- Septoplasty and turbinates
- Thoracentesis
- Tracheostomy
- Endoscopic procedures
- 10. Urinary, male genital, and endocrine systems
- Urinary system
- Chronic renal failure
- Diagnosis coding
- Nephrostomy tube
- Nephrectomy
- Urinary system subcategories
- Urinary system cysts
- Renal calculus
- Urodynamics
- Stress incontinence
- Bladder rupture
- Hydronephrosis
- Bladder stones
- Urethral and ureteral strictures
- Male genital system
- Hemangioma
- Diagnosis coding of hemangioma
- Balanitis and circumcision
- Vasectomy
- Hydrocele
- Prostate-specific antigen
- Prostate cancer
- Staging
- Cryoablation
- Endocrine system
- 11. Female genital system and maternity care/delivery
- Female genital system
- Evaluation and management
- Surgical procedures
- Colposcopy
- Pelvic pain
- Endometriosis
- Dysfunctional uterine bleeding
- Maternity care/delivery
- Routine obstetric care
- Echography
- Cesarean section
- 12. Nervous system
- Twist drill or burr holes
- Craniotomy
- Subdural hematoma
- Stealth surgery
- Cranioplasty
- Shunts
- Lumbar puncture
- Pump implantation
- Laminotomy and foraminotomies
- Spinal fusion
- Neurology and neuromuscular procedures
- 13. Eye and auditory systems
- Eye
- Eye examinations
- Cataracts
- Photocoagulation
- Ectropion and entropion
- Epiphora
- Ear
- Office services
- Myringotomy and tympanostomy
- 14. Anesthesia
- Introduction
- Anesthesia
- Types of anesthesia
- Base units
- Physical status modifiers
- Concurrent care modifiers
- Positioning
- Qualifying circumstances
- Anesthesia time
- Calculation of charge/payment
- Summary
- Pain management
- Obstetrics
- Labor
- Delivery
- Hysterectomy
- Critical care
- Moderate (conscious) sedation
- Patient-controlled analgesia
- Anesthesia services in the hospital setting
- Figure credits
- Appendix A. CMS AB 01 144
- Appendix B. Online resources
- Appendix C. Abbreviations
- Appendix D. Answers to every other case
- Glossary
- Index
- Edition: 1
- Published: December 4, 2024
- Imprint: Elsevier
- No. of pages: 576
- Language: English
- Paperback ISBN: 9780443248801
- eBook ISBN: 9780443261435
- eBook ISBN: 9780443261428
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