Study Guide: Lesson #1 Understanding AHA Coding Clinic for

Medical Coders
What is the AHA Coding Clinic?
 The AHA Coding Clinic is a guide created by the American
Hospital Association (AHA) to help medical coders use the
correct codes for:
o ICD-10-CM: Diagnoses (what's wrong with the patient).
o ICD-10-PCS: Procedures (what the doctor did).
o Some HCPCS codes used by hospitals, doctors, and other
healthcare professionals.
 It is a team effort that involves:
o AHA, AHIMA, CDC, NCHS, and CMS (all big
organizations in healthcare).
o Experts like doctors and coding specialists who
approve every update.
How Does Coding Clinic Help?
 Quarterly Updates: New coding advice comes out four
times a year (not once a year).
 Example Scenarios: It gives real-life examples to explain
tricky coding questions.
 Guidelines for Accuracy: Helps coders make sure they are
using codes correctly for the best patient care and smooth
insurance claims.

Steps to Find the Right Code (ICD-10-CM)

1. Look in the Alphabetic Index: Find the main term for the
diagnosis.
2. Check the Tabular List: Double-check the details of the code.
Look out for:
 o "Code first" or "Use additional code" instructions.
o Notes like "Excludes 1" or "Excludes 2" (they tell you
what NOT to include).
3. Follow Official Guidelines: Read the ICD-10-CM Official
Guidelines for Coding and Reporting for extra rules.
4. Use Outside References: Check Coding Clinic for specific
advice.
5. Know Payer Rules: Insurance companies might have extra
rules, but they will not conflict with official coding guidelines.

Examples from Coding Clinic

1. Obstetric Patient with Contractions (First Quarter, 2021)
o A patient is 37 weeks pregnant and has contractions.
o Question: How do we code "contractions"?
o Answer: Use code O47.1 (False labor at or after 37
completed weeks of gestation). This includes Braxton
Hicks contractions.
o Note: The doctor must document "contractions," not
vague symptoms like abdominal pain.
2. Aspiration Pneumonia and COVID-19 Pneumonia
(Updated January 1, 2021)
o A patient has pneumonia due to COVID-19 and
aspiration pneumonia (caused by food or vomit).
o Question: Can both codes be used even with an
"Excludes 1" rule?
o Answer: Yes! These are unrelated conditions with
different causes, so both codes are allowed:
 J12.82: Pneumonia due to COVID-19.
 J69.0: Pneumonitis due to inhalation of food/vomit.
 How to Use the AHA Coding Clinic
1. Access Options:
o Print or online subscriptions are available.
o Many hospitals include it in coding tools like 3M,
TruCode, or Optum.
2. Submit Questions for Free:
o Coders can ask the Coding Clinic Advisor for help (no
membership required).
o Make sure to remove patient names and details from
documents.
3. Search by Code or Topic: Coders can look up past advice by
code, keyword, or date.

What Are Coding Clinic Updates Called?

 Each update is named after the quarter it was released:
o Quarter 1: January–March.
o Quarter 2: April–June.
o Quarter 3: July–September.
o Quarter 4: October–December.

Quick Quiz (Check Your Knowledge)

1. True or False? Coding Clinic provides updates annually.
o Answer: False – Updates are quarterly.
2. True or False? The first step to finding an ICD-10-CM code is
to look in the Alphabetic Index.
o Answer: True.
3. True or False? November is part of the 4th quarter of the
year.
 o Answer: True.
Study Guide: Lesson #2 Understanding CPT Assistant
What is CPT Assistant?
 CPT Assistant is a special newsletter created by the
American Medical Association (AMA).
 It helps medical coders understand how to use CPT codes
correctly.
What are CPT Codes?
 CPT (Current Procedural Terminology) codes are used to
describe what procedures doctors and healthcare workers
perform, like surgeries or check-ups.
Why is CPT Assistant Important?
 Keeps Coders Updated: Teaches about new, updated, and
older codes.
 Helps with Denials: Explains why a procedure code might be
denied by insurance and how to fix it.
 Provides Clear Examples: Offers real-life clinical
scenarios, pictures, charts, and answers to FAQs.
How Often is it Published?
 Every Month! Coders get monthly updates with the latest
healthcare coding information.

Ways to Use CPT Assistant

1. Searchable Online Archive: Access articles dating back to
1990 with a subscription.
2. CPT QuickRef App: A free app for quick code lookup
(premium features require scanning a code from a CPT book).
3. Integrated in Encoders: Found in coding tools like 3M or
Optum for easy access while coding.
 How to Access CPT Assistant
 Subscription Plans:
o Buy as an individual or get a license for up to 10 users.
o Annual subscriptions with discounts for AMA members.
 QuickRef App: Basic features are free; premium features are
unlocked with a CPT book.

How Coders Use CPT Assistant

 Search by Code or Topic: Look up procedures or codes to
learn the right way to use them.
 Examples:
o If a coder wants to know about scar revision, they can
search by the letter "S" or by typing "scar revision."

Quick Quiz (Check Your Knowledge)

1. True or False? CPT Assistant is published by the American
Hospital Association (AHA).
o Answer: False – It’s published by the American Medical
Association (AMA).
2. True or False? You can buy a CPT Assistant subscription for
one person or up to 10 users.
o Answer: True.
3. True or False? AMA members get a discount on CPT Assistant
subscriptions.
o Answer: True.
Study Guide Lesson #3: Encoders in Medical Coding
What is an Encoder?
 An encoder is a software program that helps coders find the
right codes for medical procedures, diagnoses, and supplies.
  It acts like an electronic codebook, saving time and
improving accuracy.
Code Sets Used in Encoders
Encoders include the following official code sets:
 ICD-10-CM/PCS: For diagnoses and inpatient hospital
procedures.
 CPT: For outpatient and professional services (like surgeries
and office visits).
 HCPCS: For supplies, medications, and certain services.

Why Coders Should Learn Code Books First

It’s important to know how to use physical code books because:
1. Certification Exams: Only code books are allowed during
tests like the CPC exam.
2. Job Expectations: Employers expect coders to understand
their books even if encoders are provided.
3. Technical Issues: If the encoder isn’t working, coders must
rely on their books.
4. Accuracy: Encoders can sometimes suggest incorrect codes,
so books are the most reliable source.

Types of Encoders
There are two main types of encoders, each with unique features:
1. Logic-Based Encoder
 How it works: Guides coders through a series of questions
based on the patient’s condition.
 Who benefits: Helpful for new coders who need extra
guidance.
  Downside: Coders might become dependent on the software
and not learn how to code on their own.
2. Knowledge-Based Encoder
 How it works: Provides the same codes found in the official
code books. Coders follow the same process as using a
physical book.
 Who benefits: Ideal for experienced coders who are confident
with their coding skills.

Examples of Encoders
1. Optum360 EncoderPro
 Provides access to multiple coding references and guides.
 Content Includes:
o ICD-10-CM/PCS, CPT, and HCPCS codes.
o Specialty guides and cross-coding tools.
o Subscription options: Standard, Professional, and Expert
levels.
2. TruCode
 A knowledge-based encoder designed for experienced
coders.
 Special Features:
o Includes built-in references like the AHA Coding Clinic and
AMA CPT Assistant.
o Offers webinars and updates to keep coders informed.
o Helps with building procedure codes by showing only
appropriate choices.
3. 3M CodeFinder
 A logic-based encoder with decision-tree logic to guide
coders to the right codes.
  Benefits:
o Integrates with hospital systems and EHRs.
o Adjusts for inpatient or outpatient coding needs.
o Focuses on improving coding quality and healthcare data.

Check Your Knowledge

1. True or False? A logic-based encoder provides codes just as
they are published in physical code books.
o Answer: False. A knowledge-based encoder provides
codes as they are published.
2. True or False? Most encoders include references like the
Coding Clinic and CPT Assistant.
o Answer: True.
3. True or False? The 3M CodeFinder can adjust settings to show
inpatient or outpatient codes based on the case.
o Answer: True.
Study Guide: Lesson #4 - Automated Coding

Artificial Intelligence (AI) in Medical Coding

What is AI?
 AI refers to systems or machines that mimic human
intelligence and improve over time based on data they collect.
It enhances human capabilities, rather than replacing humans.
AI in Medical Billing and Coding:
 The main AI application in medical coding is Computer
Assisted Coding (CAC).
 CAC uses machine learning and Natural Language
Processing (NLP) to extract data from medical documents,
like medical records, physician notes, and billing documents.
  AI recognizes keywords and phrases in various formats (printed
text, handwriting) to help identify codes automatically.

Impact of AI on Coding
Coding Analogy:
 The analogy used in AI-powered coding is planting a tree.
The initial “seed” (the condition) grows through decisions
(roots) to eventually generate the appropriate codes for the
record.
 AI helps move from a reimbursement-focused process to a
quality-focused healthcare environment by providing more
accurate coding suggestions based on a comprehensive
understanding of clinical data.

Benefits of Automated Coding

1. Fewer Expenses:
o Automation reduces errors in coding, leading to fewer
claim corrections and faster processing, which in turn
speeds up payments.
2. More Efficient:
o AI systems can analyze large amounts of data and link
historical and clinical information to propose accurate
codes.
3. Better Accuracy:
o Since AI tools use up-to-date coding guidelines, they
provide better accuracy than manual coding, reducing
human errors.
4. Smoother Workflow:
o Automation allows coders to focus more on complex tasks
while the AI handles routine coding suggestions.
 Disadvantages of Automated Coding
1. Learning Curve:
o Users need to understand technology and software to
adapt effectively to automated coding systems.
2. High Costs:
o The initial setup and ongoing maintenance of automated
systems can be expensive, especially for smaller
practices.
3. Potential for Errors:
o Automated systems can still make coding errors or lead to
fraudulent claims if not monitored carefully.
4. Technological Limitations:
o Not all medical data can be standardized into pre-defined
templates, leading to challenges in translating varied
information.
5. Lack of Industry Standards:
o AI and automated coding systems are evolving rapidly,
which makes it difficult to establish consistent standards
across the industry.

AI's Role in Evolving Healthcare

 AI, particularly through Natural Language Processing
(NLP), is evolving healthcare coding by focusing on quality
rather than just reimbursement, ensuring that the codes are
accurate and reflective of the patient’s condition.

Check Your Knowledge

1. True or False: Companies are using machine learning and
Natural Language Processing (NLP) to automatically recognize
and extract data from medical documents for proper coding
and billing.
 o Answer: True
2. True or False: There aren't any potential possibilities for
errors and fraudulent claims when using automated coding.
o Answer: False – There is potential for coding errors and
fraudulent claims with automated coding.

This concludes the overview of Automated Coding. The next

lesson will focus on physician queries and how coders ensure
compliance in querying physicians for clarification.