Chapter 6 — Further Reading

This chapter's further reading is unusual: most of it is a list of things to bookmark rather than things to read. Do the bookmarking. It is the chapter's actual assignment.

Tier 1 — Bookmark these today

The ICD-10-CM files and the Official Guidelines for Coding and Reporting, free from CMS and the National Center for Health Statistics, reissued every October 1. Download the current Guidelines now, before Chapter 7. They are the authority for Part II and they cost nothing.

The Medicare Coverage Database, CMS. Searchable by CPT/HCPCS code, keyword, contractor, or state. Contains every NCD, LCD, and billing and coding article. Learn to search it by code.

The Medicare Physician Fee Schedule Look-Up Tool, CMS. By code and locality. Chapter 23.

The National Correct Coding Initiative files and Policy Manual, CMS. Procedure-to-procedure edits and the Medically Unlikely Edit tables, updated quarterly; the Policy Manual annually. The Policy Manual is the document that explains why, and it is what you cite in an appeal. Chapter 21.

HCPCS Level II quarterly update files, CMS.

Medicare Claims Processing Manual, Publication 100-04. How claims are completed and processed.

Medicare Program Integrity Manual, Publication 100-08. What a reviewer applies. Chapter 37.

The NUCC 1500 Health Insurance Claim Form Reference Instruction Manual, free from the National Uniform Claim Committee. The authoritative answer to "what goes in item 17b?" Chapter 25.

Your Medicare Administrative Contractor's website. Identify yours and bookmark its LCD index, bulletins, and education pages. Chapter 3 §3.3.

Your state Medicaid agency's provider manual and fee schedule. No national substitute exists.

The OIG Work Plan, updated monthly.

ICD-10-PCS files and the ICD-10-PCS Official Guidelines, free from CMS. Relevant only if you code inpatient facility records; Chapter 33 covers the structure.

General Equivalence Mappings (GEMs) documentation from CMS — including, importantly, CMS's own explanation of what a GEM is and is not. Case Study 1's misuse warning is in that documentation.

Tier 2 — Attributed, specifics unverified

Code book publishers' annual "summary of changes" or "what's new" documents. Published by the major publishers and, for ICD-10-CM, by CMS itself in the addenda files. Reading a summary of changes is the highest-return twenty minutes in the update cycle, and §6.7 says so.

AAPC and AHIMA guidance on code books permitted in examinations. These are the rules §6.2 warns about, they differ between organizations, and they change. Verify directly with the organization administering your exam rather than relying on any secondary description, including this one. Chapter 39 §39.8.

Encoder and practice management system vendor documentation, particularly on logic pathways, edit configuration, and update scheduling. If your organization runs configurable edits, the vendor's documentation will tell you where the configuration lives and how to export it — which is step 1 of Case Study 2's inventory.

Coding productivity and quality benchmark publications from professional associations and consultancies. Useful for orientation, dangerous as targets. §6.9's warning applies: ask what is being measured — accuracy per chart and accuracy per code produce very different numbers from identical work.

Professional coding forums and communities. Genuinely useful for orientation, for discovering that a problem is common, and for finding out which primary source answers a question. Not authority. Follow every useful answer to its source before relying on it.

Published analyses of the ICD-10 transition, including CMS's own post-transition metrics and health services research on coder productivity and unspecified-code use. The basis for Case Study 1's qualitative claims; get the numbers from the sources.

Tier 3 — Illustrative and constructed

Case Study 2 in its entirety — the nine-provider practice, its seven scrubber rules, the eleven-year oldest rule, and the \$61,400 self-reported overpayment. Constructed. The mechanism is entirely ordinary and the three questions in §6.5 are real ones worth asking of any billing office.

The routing table in the Encounter checkpoint — the thirteen rows mapping Account 10-4471's questions to sources and chapters. Constructed as a teaching device; the source assignments are real.

The day-in-a-queue sketches in §6.8 and in Chapter 1 §1.6–1.7.

The actual assignment

Not reading — doing. Before you start Chapter 7:

1. Download the current ICD-10-CM Official Guidelines. You will use them for six chapters.
2. Find out which Medicare Administrative Contractor covers your location, and bookmark its LCD index.
3. Search the Medicare Coverage Database for one CPT code — any code, but a real one. See what comes back: the policy, the article, the effective dates. Ten minutes, and §3.5 and §6.6 both stop being abstract.
4. Start the question file. One line, today. Whatever you had to look up while reading this chapter.