ICL-Coding Operative Report

Ingenix Coding Lab:

Coding from the Operative Report

©2003 Ingenix, Inc.

iii

CPT ©2003 American Medical Association. All Rights Reserved.

Contents

Chapter 1: History ...................................................................................................................................................1

Early Record Keeping ................................................................................................................................................ 1Hospital Records ....................................................................................................................................................... 1Record Keeping in America ....................................................................................................................................... 2Standardized Record Keeping .................................................................................................................................... 2Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ............................................................. 2Summary ................................................................................................................................................................... 4Discussion Questions ................................................................................................................................................ 4

Chapter 2: Documentation ..................................................................................................................................5

Content ..................................................................................................................................................................... 5Timeliness ................................................................................................................................................................. 6Operative Reports ...................................................................................................................................................... 6Summary ................................................................................................................................................................... 9Discussion Questions ................................................................................................................................................ 9

Chapter 3: Coding ................................................................................................................................................ 11

Applying Diagnosis Coding ..................................................................................................................................... 11Diagnosis Coding Guidelines .................................................................................................................................. 13Applying Procedure Coding Guidelines ................................................................................................................... 16HCPCS System ....................................................................................................................................................... 18Anesthesiology ......................................................................................................................................................... 18Future Coding ......................................................................................................................................................... 18Summary ................................................................................................................................................................. 20Discussion Questions .............................................................................................................................................. 20

Chapter 4: Reimbursement .............................................................................................................................. 21

Medicare ................................................................................................................................................................ 21Payment Systems ..................................................................................................................................................... 22Medicare Claims ...................................................................................................................................................... 24Summary ................................................................................................................................................................. 24Discussion Questions .............................................................................................................................................. 24

Chapter 5: Fraud and Abuse ............................................................................................................................ 25

Fraud ....................................................................................................................................................................... 25Abuse ...................................................................................................................................................................... 25Sanctions ................................................................................................................................................................. 26Compliance ............................................................................................................................................................. 26Summary ................................................................................................................................................................. 28Discussion Questions .............................................................................................................................................. 28

Chapter 6: Operative Report Coding ............................................................................................................ 29

Names and Terms That Describe Operative Reports ............................................................................................... 29

Ingenix Coding Lab: Coding From The Operative Report

iv

©2003 Ingenix, Inc.CPT ©2003 American Medical Association. All Rights Reserved.

Operative Report Coding Guidelines .......................................................................................................................31The Operative or Procedure Progress Note ..............................................................................................................33Retrieving Information from Documentation in the Operative Report ....................................................................36Underdocumented or Incorrect Information ...........................................................................................................37Code Selection .........................................................................................................................................................37When to Seek Clarification or Additional Information from the Physician ..............................................................38

Chapter 7: Integumentary System (10021–19499) ................................................................................39

Introduction ............................................................................................................................................................39Incision and Drainage of Abscess .............................................................................................................................40Incision and Removal of Foreign Body ....................................................................................................................43Incision/Aspiration of Hematoma ............................................................................................................................46Complex Incision and Drainage ...............................................................................................................................48Debridement with Removal of Foreign Material ......................................................................................................50Debridement ...........................................................................................................................................................52Biopsy of Skin .........................................................................................................................................................54Removal of Skin Tags ..............................................................................................................................................56Shaving/Excision of Lesions (11300–11646) ...........................................................................................................58Excision of Pilondial Cyst ........................................................................................................................................61Insertion/Removal of Contraceptive Capsules ..........................................................................................................62Repair (12001–13160) ............................................................................................................................................63Adjacent Tissue Transfer (14000–14350) ................................................................................................................66Skin Grafts (15000–15776) .....................................................................................................................................68Blepharoplasty (15820–15823) ................................................................................................................................70Burns, Local Treatment (16000–16036) ..................................................................................................................72Destruction of Benign or Premalignant Lesions (17000–17286) .............................................................................73Breast (19000–19499) .............................................................................................................................................75

Chapter 8: Musculoskeletal System (20000–29999) ..............................................................................81

Introduction ............................................................................................................................................................81Anatomy ..................................................................................................................................................................81General Information ................................................................................................................................................84Wound Exploration .................................................................................................................................................87Biopsy (20200–20521) ............................................................................................................................................89Foreign Body ...........................................................................................................................................................92Arthrotomy, Arthroscopy, and Arthroplasty .............................................................................................................94Hip Arthroplasty ......................................................................................................................................................97Excision of Cysts, Lesions, and Tumors ...................................................................................................................99Knee Arthroplasty ..................................................................................................................................................101Excision Bone Cyst/Tumor ....................................................................................................................................102Fascia .....................................................................................................................................................................104Fractures and Dislocations .....................................................................................................................................106Repair, Revision and/or Reconstruction .................................................................................................................110Muscles and Tendons ............................................................................................................................................114Spine .....................................................................................................................................................................116

Chapter 9: Respiratory and Cardiovascular Systems (30000–39599) ...........................................119

Introduction ..........................................................................................................................................................119Respiratory System ................................................................................................................................................119Turbinates .............................................................................................................................................................120


1


Chapter 1: History

The history of operative reports in medical record keeping runs parallel to the practice of medicine and surgery. As far back as 25,000 BC there are records of the method used to amputate fingers as depicted in drawings on caverns in Spain. Centuries later, in Egypt, Imhotep is credited with six papyri describing 48 cases of clinical surgery. According to a history of medical records in the book

Medical Record Management

, each case followed a definite form. There is evidence of the surgeon’s operation, including the type of injury (e.g., penetrating wound to the head), exam, diagnosis (e.g., whether the wound is treatable), and treatment. Another early medical record attributed to Egyptian scribes, dated 500 years later in 1550 BC, is methodical in describing disease and the methods of treating individual cases.

E

ARLY

R

ECORD

K

EEPING

While many of the early records of operations may be a far cry from present documentation, they do show the early interest in charting patient care and the methodology of record keeping. Evidence of early “hospital” record keeping is found in the names of patients, summaries of their cases, and treatment outcomes inscribed in columns in the ruins of temples in Egypt dedicated to the care of the sick, according to the book

Medical Record Management

. Hippocrates, the “Father of Medicine” born in 460 BC, supposedly drew upon the information from the columns to enhance his medical knowledge. The Hippocratic Oath physicians pledge to this day contains language acknowledging the privacy that must exist between physician and patient. Hippocrates’ detailed method of record keeping provides evidence of his clinical expertise and lends support to his medical theories.

H

OSPITAL

R

ECORDS

The origin of the word “hospital,” from the Latin hospitalis, is found in writings about a hospital established in Rome some 700 years after the time of Hippocrates. During the Middle Ages, there is evidence of the first clinical notes derived from the work of Hippocrates. The preserved case histories of patients at St. Bartholomew’s Hospital, built in Medieval times, indicate that records were kept on all patients from the start in 1137.

The reign of King Henry VIII during the Renaissance brought rules and regulations to hospitals, including those governing record keeping and privacy. The Belgian Monk Andreas Vesalius kept secret his anatomical sketches made from the bodies of criminals due to the Roman Catholic ban on human dissection, similar to the silencing of Leonardo DaVinci’s portfolio of anatomical drawings in the Middle Ages. Soon after the death of King Henry VIII, a Papal decree in 1556 lead to legalized dissection that ultimately advanced the study of surgery. In 16th and 17th century Europe, the term medical record was beginning to mean more than a single case history. Physicians were required to write orders for inpatients that were maintained as part of the entire patient record.

In this chapter, you will learn:• About standards of medical records• The history of AHIMA• The role of JCAHO and medical records

� OBJECTIVE

The caduceus used as the symbol of the medical profession is the staff of Aesclapius, son of Apollo, the Greek god of healing. Aesclapius is credited with curing terminally ill patients as well as resurrecting the dead.

� QUICK TIP

Ingenix Coding Lab: Coding from the Operative Report

4


2. If the operative report is not placed in the medical record immediately after sur-gery due to transcription or filing delay, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. This operative progress note should contain at a minimum comparable operative report information. These elements include; name of primary surgeon and assistants, findings, tech-nical procedures used, specimens removed, and postoperative diagnosis as well as estimated blood loss.

3. Immediately after surgery is defined as “upon completion of surgery, before the patient is transferred to the next level of care, for example the post anesthesia care unit.” This is to ensure that pertinent information is available to the next caregiver.

JCAHO Accreditation

JCAHO surveys most hospitals every three years and its accredited hospitals are not subject to the Medicare survey and certification process, though eligible for Medicare funding. Any hospital that meets the following requirements may apply for a JCAHO accreditation survey under current hospital standards:

• The hospital operates in the United States or its territories, or is run by the U. S. government or under a charter of Congress if outside the United States.

• The hospital assesses and improves the quality of its services, including a review of care by clinicians.

• The hospital identifies the services it offers, indicating which it provides directly, under contract, or through some other arrangement.

• The hospital provides services covered by Joint Commission’s standards.

JCAHO publishes the

Comprehensive Accreditation Manual for Hospitals: The Official Handbook

(CAMH), which explains the accreditation process, identifies and describes the standards, and explains the scoring of compliance with the standards.

S

UMMARY

The process of keeping records of a patient encounter regardless of the location of service has evolved from the days of earliest recorded medical care to the present. Current guidelines affect what is required and when it should be recorded. These guidelines affect care in a hospital, clinic, and even private practice across all medical specialties.

D

ISCUSSION

Q

UESTIONS

• Why would it be important to have standardization in keeping medical records?• What is the current name of the medical record group and why does the name

reflect the current practice of record retention?• Why would JCAHO require standards in record keeping?

American Health Information Management Association (AHIMA). Web site: http://www.ahima.org/. Huffman, Edna, RRA. Medical Record Management (6th ed.) Illinois: Physicians’ Record Company, 1972.Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Web site: http://www.jcaho.org/

� FOR MORE INFO


5


Chapter 2: Documentation

Medical documentation is performed to establish and maintain a lasting record of a patient’s encounters with health care professionals and services. It is chronological written evidence of what happened to a patient’s health during single, multiple, or a lifetime of encounters. The written record at one time can be as simple as a short written note or at another time as complicated as an operative report.

Documentation in the medical record must contain information to justify that the admission and continued hospitalization, the encounter or visit, and the services performed for a patient are medically necessary. It must describe the patient’s progress and response to therapies and surgeries while at the same time allowing continued care of the patient by other health care professionals. A chart that is comprehensive, well-organized, and accurate enables the physician and other health care professionals to quickly access needed information and is essential in providing quality patient care. To meet all of these needs, record documentation must have several characteristics present to reflect the adequacy and type of care received by the patient.

C

ONTENT

Hospitals, outpatient facilities, and providers are required to keep a medical record of every patient admitted or seen in an encounter or visit. A complete medical record generally includes the following components depending on where the service was rendered:

• Consent to treatment statement (when applicable)• Consultations and reports• Discharge summary (when applicable)• Discharge/transfer instructions (when applicable)• History and physical (when applicable)• Laboratory and pathology tests and results• Radiology procedures (results and notes)• Other services performed (e.g., pulmonary, respiratory, physical, occupational

therapy, dietary) • Medication records• Nursing assessments or services• Visits and examinations• Operative/procedural consent to treatment statement• Operative reports • Physician’s orders• Progress notes

JCAHO has developed guidelines that dictate documentation and medical records. According to the guidelines, inpatient medical records must contain the following:

• Patient’s name, address, date of birth, and next of kin

In this chapter, you will learn:• The required elements of documentation• About the contents of operative reports• The importance of accurate documentation

� OBJECTIVE

Medical coding specialists translate a physician’s documentation into ICD-9-CM and CPT codes. Codes submitted for reimbursement become part of the statistics used for quality assurance, research, grants, studies, vital statistics (births, infectious disease, morbidity, and mortality), tumor registry, utilization review, and case management.

* KEY POINT


8


— objective information such as amount of fluids taken and subjective data regarding the patient’s response to therapy

The primary surgeon is responsible for any documentation regarding the findings, the procedures used, biopsy (if any), and the postoperative diagnosis. Any assistants participating in the surgery should be listed in addition to the primary surgeon.

The operative progress note summarizing each procedure must be included in the patient record. If eponyms are used, a technical description should be documented to aid in the selection of the ICD-9-CM diagnostic or inpatient procedural codes and CPT procedural codes. In addition to the basic elements, the summary should contain the following items:

• Pre- and postoperative diagnoses• Title of procedure• Surgeon, cosurgeon, assistant surgeon• Anesthetic and anesthesiologist• Summary of procedure• Complications and unusual services• Immediate postoperative condition• Estimate of blood loss and replacement• Fluids given and invasive tubes, drains, and catheters used• Hardware or foreign bodies intentionally left in the operative site

While all elements may not be necessary, the importance of each element increases with the complexity of the procedure. For example, a biopsy does not require the same level of detail as an open laparotomy procedure.

Each clinical event should be documented as soon as possible after its occurrence. The records of discharged patients must be completed within 30 days following discharge.

Outpatient

Documentation of operations and procedures performed in outpatient hospitals, short-stay surgery facilities, physician offices, and group practices generally follow the requirements of accrediting agencies and site specific internal guidelines. Major differences may be found in the type of forms used to document the information and the type of information required by each facility.

Accuracy

The importance of the accuracy of documentation cannot be overstated. Documentation is the foundation for reimbursement and its accuracy can make and sustain decisions in cases of appeal. Inadequate documentation leads to improper reimbursement and inconsistent determinations, delays in the appeals process, and reversals at higher appellate levels. The elements of accuracy in the operative report include:

• Approved abbreviations understood by anyone authorized to make entries in the record and the coders and others required to interpret the records

• Legibility• Proper correction of errors—standard is a line through the error and the note

“wrong record” followed by the recording of the correct information• Explanations for accidental omissions and out-of-sequence data.

An operative progress note summarizing each procedure performed must be included in the patient record.A technical description should be documented to aid in code selection especially when eponyms are used.Those who are authorized to make entries in the medical record should use only those abbreviations approved by the provider/facility. This aids in consistency and allows coders and others to correctly interpret the records.

� QUICK TIP


11


Chapter 3: Coding

Translating information from an oral or written operative report for documentation and payment of claims requires a certain level of proficiency in diagnosis and procedure coding. Reimbursement also demands that coders have a working knowledge of federal health care programs (e.g., Medicare, Medicaid, state Children’s Health Insurance Program) and the regulations as they apply to surgical patients. Penalties for proven fraud and abuse are equally harsh, no matter the program or type of facility.

A

PPLYING

D

IAGNOSIS

C

ODING

International Classification of Diseases

There are two related classifications of diseases with similar titles. The International Classification of Diseases (ICD) is used to code and classify mortality data from death certificates. The International Classification of Diseases, Clinical Modification (ICD-CM) is used to code and classify morbidity data from the inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys. NCHS serves as the World Health Organization (WHO) coordinating center for the classification of diseases in North America.

The

International Classification of Diseases, Ninth Revision, Clinical Modification, Fifth Edition

, commonly referred to as ICD-9-CM, is a three-volume set.

• The alphabetic index (volume 2) is presented first in most publications since it is referenced first in selecting a diagnosis code. Volume 2 is divided into three sections: section 1, “Alphabetic Index to Diseases”; section 2, “Table of Drugs and Chemicals”; and section 3, “Index to External Causes.”

• The tabular list (volume 1) is a numerical and alphanumerical list of the same diseases and conditions found in volume 2. It is divided into three sections: classification of diseases and injuries (chapters 1–17); supplementary classifica-tions (V and E codes); and appendixes.

• Procedures (volume 3) is a numerical list first as an index to procedures then as a tabular list of operations by systems, and as miscellaneous diagnostic and ther-apeutic procedures.

Volumes 1 and 2 of ICD-9-CM contain numeric and alphanumeric codes that are used by inpatient and outpatient facilities and physicians to report diagnoses. ICD-9-CM volume 3 contains numeric codes that are used to report procedures performed in an inpatient hospital setting for determining diagnosis-related groups (DRGs) for reimbursement.

In addition, codes listed in volumes 1 and 2 provide statistical information for grants, financial analysis, and compliance with standards set by the National Committee on Quality Assurance (NCQA) and the JCAHO. Inpatient and outpatient procedural codes in volume 3 create a more precise clinical picture for medical records, medical

In this chapter, you will learn:• About inpatient diagnosis coding guidelines• About outpatient diagnosis coding guidelines• Diagnosis and procedure coding concepts• HCPCS and CPT procedure coding concepts

� OBJECTIVE

The treating physician determines the diagnosis. The diagnostic codes may be assigned by the treating physician or derived by coders from the physician’s documentation. Among the most important aspects of diagnosis coding is the conveyance of a patient’s health status. An ICD-9-CM code usually represents a patient’s condition, and in many instances is contained in the medical record for the life of the patient.

* KEY POINT

Official ICD-9-CM Guidelines for Coding and Reporting can be obtained through the AHA Coding Clinic for ICD-9-CM, at:One North FranklinChicago, Il 606061-312-422-30001-800-242-2626www.aha.org/

� FOR MORE INFO


16


J. Reporing chronic diseases:

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

K. Coexisting conditions:

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10–V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

L. Diagnostic services:

For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.

M. Therapeutic services:

For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

N. Preoperative evaluations:

For patients receiving preoperative evaluations only, sequence a code from category V72.8 Other specified examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

O. Ambulatory surgery:

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

P. Prenatal visits:

For routine outpatient prenatal visits when no complications are present codes V22.0 Supervision of normal first pregnancy, and V22.1, Supervision of other normal pregnancy, should be used as principal diagnoses. These codes should not be used in conjunction with chapter 11 codes.

A

PPLYING

P

ROCEDURE

C

ODING

G

UIDELINES

Inpatient Procedure Coding

ICD-9-CM, Volume 3

The UHDDS is used to determine which procedures are reported to the government and other payers. Hospitals may have internal requirements—beyond those listed in the UHDDS—for studies or other informational purposes. Coders should consult the hospital’s health information management administrator for the current guidelines. UHDDS defines a significant procedure as:

• Surgical in nature• Carries a procedural risk• Carries an anesthetic risk

Outpatient visits for chemotherapy, radiation therapy, or rehabilitation are reported with the appropriate V code followed by the code for the diagnosis or problem for which the treatment is being performed.

* KEY POINT

© 2003 Ingenix, Inc.

21


Chapter 4: Reimbursement

M

EDICARE

CMS administers Medicare, a federal health insurance program for people 65 years or older, people with certain disabilities, and those with permanent kidney failure treated with dialysis or a transplant. Medicare has two parts—Part A for hospital insurance, and Part B for medical insurance.

Part A

Part A payment covers all nonphysician services delivered to an inpatient of a hospital (except pneumococcal vaccine and its administration and hepatitis B vaccine and its administration). Part A is available to anyone meeting eligibility requirements who has worked at least 10 years in Medicare covered employment.

Factors considered when admitting patients include:

• Severity of the signs and symptoms exhibited by the patient• Medical predictability of something adverse happening to the patient• Need for diagnostic studies that appropriately are outpatient services (e.g., their

performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted

• Availability of diagnostic procedures at the time when and at the location where the patient presents

• Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital

Section 3101 of the

Medicare Intermediary Manual

covers payment of inpatient hospital services available online at http://www.cms.hhs.gov/manuals/cmsindex.asp.

Part B

Medicare Part B helps pay for physician services, outpatient hospital care, blood, medical equipment and some home health services. Part B also pays for other medical services such as lab tests and physical and occupational therapy. Some preventive services such as mammograms and flu shots are also covered.

Medicare Part B covers hospital inpatient services, but only if payment cannot be made under Part A (e.g., the patient has exhausted Part A coverage) and the patient is entitled to Part B benefits. The services covered under Part B are:

• Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests• X-ray, radium, and radioactive isotope therapy, including materials and services

of technicians• Surgical dressings, and splints, casts, and other devices used for reduction of

fractures and dislocations• Prosthetic devices (other than dental) which replace all or part of an internal

body organ (including contiguous tissue), or all or part of the function of a per-manently inoperative or malfunctioning internal body organ, including replace-ment or repairs of such devices

In this chapter, you will learn:• Medicare Part A and Part B guidelines• About payment systems for inpatient and out-

patient services• The claims submission process

� OBJECTIVE

Medical necessity: Medicare and other government and private health care plans pay only for services that are "reasonable and necessary." Upon request, a facility or provider office should be able to furnish medical record documentation, such as diagnostic information and operative reports or notes that support a service as being medically necessary.

� DEFINITIONS

Part B covers the following hospital inpatient services, regardless of the beneficiary’s eligibility for Part A coverage:• Physicians' services • Pneumococcal vaccine and its administration• Hepatitis B vaccine and its administrationHowever, Medicare (Part A or Part B) requires that any nonphysician service for a hospital inpatient must be provided directly or arranged for by the hospital.

* KEY POINT


24

© 2003 Ingenix, Inc.CPT ©2003 American Medical Association. All Rights Reserved.

M

EDICARE

C

LAIMS

All claims submitted to Medicare require diagnostic (ICD-9-CM) codes. Code selection is important since claims for certain services, especially when local policy has been established, may be denied due to the diagnosis.

The Administrative Simplification provision of the Health Insurance Portability and Accountability Act (HIPAA) requires that payers have the capability of receiving claims electronically to reduce costs and administrative functions of health care tracking and reimbursement. The provision applies to all payers and providers and affects all health claims and equivalent encounter information (professional, institutional, and dental). Health care providers, physicians, and suppliers of medical equipment must complete an Electronic Data Interchange (EDI) Enrollment Form prior to submitting claims electronically. Completed and signed EDI forms may be submitted to local carriers or fiscal intermediaries.

Hospital Claims

Inpatient and outpatient hospital claims are grouped into one or more of the DRGs or APCs and submitted for reimbursement using a Form CMS-1450 (UB-92 claim form). Institutions and other selected providers use the UB-92 to complete a Medicare, paper claim submitted to Medicare Fiscal Intermediaries. The paper UB-92 is neither a government printed form nor distributed by CMS. The National Uniform Billing Committee is responsible for the form’s design.

Other Outpatient Claims

Providers (non-institutional) and medical suppliers bill Medicare Part B covered services using the CMS-1500 form. It is used for billing several Medicaid covered services. Outpatient physician procedures are coded using HCPCS Level I (CPT) codes and Level II national codes. Follow CPT rules and append Medicare and CPT modifiers as appropriate.

S

UMMARY

It is important for the coder and biller to know the rules and guidelines for government payers and private payers. Although many private payers follow both Medicare and/or Medicaid guidelines, they may alter them to meet internal guidelines. Private payers have different coverage guidelines and may pay for items not covered by government payers. It is also important to know which payers require electronic submission of claims and which request paper claims.

D

ISCUSSION

Q

UESTIONS

• Inpatient claims are reimbursed based upon DRGs. What are the six compo-nents for determining DRGs, and how can they impact the final DRG selected?

• Outpatient facility claims are reimbursed according to APC guidelines based upon CPT codes. Why is the CPT based method better than diagnosis based for outpatient services?

• What are the three main areas of the Medicare fee schedule?

The CMS-1500 and the UB-92 are available online at: www.cms.gov/forms/The Web site includes the forms and step-by-step instructions.

Medicare carriersContact the U.S. Government Printing Office at (202) 512-1800 or your local Medicare carrier. For a list of local Medicare carriers, including their telephone number, go to http://cms.hhs.gov/providers/enrollment/A copy of place of service (POS) codes is available at: http://cms.hhs.gov/states/poshome.aspAn electronic data interchange (EDI) Enrollment Form that must be completed and signed prior to submitting a Medicare form is available at: http://cms.hhs.gov/providers/edi/edi5.asp

✍ FOR MORE INFO


25


Chapter 5: Fraud and Abuse

The federal government and several of the states have laws governing health care claims. Physicians found in violation of the laws can be denied payment, banned from federal programs, or sued. In extreme cases, a physician may be charged with mail and wire fraud for mailing or filing the fraudulent claims.

F

RAUD

Fraud is defined as an intentional false statement or representation of material facts made by a person to obtain some benefit or payment when none exists. Fraud may be committed either for the person’s own benefit or for the benefit of some other party. It is necessary to prove that fraudulent acts were performed knowingly and willfully.

Examples of fraud found in documentation and reimbursement include:

• Billing for services that were not furnished or supplies not provided• Altering claims forms or receipts in order to receive a higher payment amount• Submitting duplicate billings to both the Medicare program and the benefi-

ciary, Medicaid, or some other insurer in an effort to receive payment greater than allowed

• Repeatedly violating the participation agreement, assignment agreement, or charge limitation amount

• Conspiring to submit or manipulate bills by a provider and a beneficiary, two or more providers and suppliers, or a provider and a carrier employee that result in higher costs or charges to the program

• Billing procedures over a period of days when all treatment occurred during one visit (e.g., split billing schemes)

Four elements must be in place to prosecute for fraud. These elements are as follows:

• Intentionally misrepresents the truth about an important event or fact• The misrepresentation is believed by the victim (the organization or person to

whom the misrepresentation was made)• The victim relies upon and acts upon misrepresentation• The victim suffers loss of money and/or property as a result of relying upon and

acting upon the misrepresentation

A

BUSE

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program. Abuse is similar to fraud except that in fraud cases it must be proven that acts were committed knowingly and willfully.

CMS uses the following three standards to judge abusive billing practices:

• Were the services medically necessary?

In this chapter, you will learn:• The definition of fraud and abuse• About sanctions• Compliance issues and the role of the OIG• Compliance components

� OBJECTIVE

Fraud: an intentional false statement or representation of material facts made by a person to obtain some benefit or payment when none exists.Abuse: practices that, either directly or indirectly, result in unnecessary costs to the Medicare program.

� DEFINITIONS

It is a crime to defraud the United States government. Those found guilty may be sent to prison, fined, or both. Criminal convictions usually include restitution and significant penalties. Civil Monetary Penalties (CMPs) can be as high as $10,000 per claim, and the government can collect three times the amount of actual damages caused by the defendant. A criminal conviction could result in exclusion from Medicare for a period of five years or more. A provider can be excluded for any of the actions listed as fraud.

* KEY POINT

Chapter 5: Fraud and Abuse


27


• Written standards of conduct and written policies and procedures that promote the physician and/or practice to compliance

• Designation of a chief compliance officer and/or a corporate compliance com-mittee

• Development and implementation of educational and training programs for all employees involved in health care delivery and the reimbursement process

• Maintenance of a process to receive complaints (hotline), including the adop-tion of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation

• Investigation and correction of identified systemic problems and the develop-ment of policies addressing the non-employment or retention of sanctioned employees

• Development of a system to reply to allegations of improper or illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies or governmental health care program regulations

• Monitoring of compliance by auditing and/or other examination methods to regulate compliance and reduce problems or potential problems

Office of Inspector General (OIG)

Compliance Program for Hospitals

In February 1998, the OIG issued its “Compliance Program Guidance for Hospitals.” According to the guidelines, with respect to reimbursement claims, a hospital’s written policies and procedures must follow federal and state statutes and regulations regarding claims submission and Medicare cost reports. Policies and procedures should:

• Provide for proper and timely documentation of all physician and other profes-sional services prior to billing to ensure that only accurate and properly docu-mented services are billed

• Emphasize that claims must be submitted with documentation that supports the claims. Documentation, which may include patient records, must record the length of time spent in conducting the activity leading to the record entry, and the identity of the individual providing the service. The hospital should consult with its medical staff to establish other appropriate documentation guidelines

• State that, consistent with appropriate guidance from medical staff, physician and hospital records and medical notes used as a basis for a claim submission must be organized in a legible form so they can be audited and reviewed

• Indicate that the diagnosis and procedures reported on the reimbursement claim are based on the medical record and other documentation, and that the documentation necessary for accurate code assignment is available to coding staff

• Show that compensation for coders and billing consultants does not give finan-cial incentive to improperly upcoded claims

In addition, the guidelines recommend paying particular attention to issues of medical necessity, appropriate diagnosis codes, DRG coding, individual Medicare Part B claims (including evaluation and management coding) and the use of patient discharge status codes.

Following is an excerpt from the OIG letter published to announce the development of government compliance programs:“...While compliance programs are not a novel idea, they are becoming increasingly popular as affirmative steps toward promoting a high level of ethical and lawful corporate conduct. Numerous providers have expressed interest in better protecting their operations from fraud through the adoption of compliance programs. Many companies already have a program or are in the process of developing one either in-house or with the assistance of outside consultants. When fraud is discovered, both the Department of Justice and my office look at the entity to see if reasonable efforts have been made by management to avoid and detect any misbehavior that occurs within their operations. We use this analysis to determine the level of sanctions, penalties and exclusions that will be imposed upon the provider. To my knowledge, this is the first time the government is revealing the elements upon which we base those judgments...”

* KEY POINT


29


Chapter 6:Operative Report Coding

As part of the medical record, the operative report plays many roles in the overall scheme of health care. The chief role of the operative report is for the current and continuing care of inpatient services. The operative report may also be used for the billing and reporting of services to the government and other payers and track information for studies and statistics.

For documented services to be readily available for various health care, financial, and other needs, it is necessary to change the written word into a more user-friendly system. The change is accomplished by a coder using various coding systems such as ICD-9-CM and CPT. The coder changes the written word into numeric and alphanumeric codes that can be entered and later retrieved from computers and their associated databases.

It is in this modifying of data that the medical records coder has become an integral part of today’s health care environment. Information incorporated into codes must be accurate if it is to be used by health care entities. Because codes are also used for reimbursement accuracy, coding is indispensable to the operation and continued fiscal health of a hospital, surgery center, or physician’s practice.

In all coding and coding systems, there are many different facets that come into play. Accurate coding is of premier importance. However, to accurately code for operative and procedural services it is necessary to understand other issues, such as how the reports are organized, the forms that are used, and the documentation required (see the Documentation chapter). A coder must also know how to code from the operative report by extracting the information necessary to code a service. Skills to learn include the following:

• Names and terms that describe operative reports• Retrieving information from documentation in the operative report• Underdocumented or incorrect information (and where to find the correct

information)• Code selection (simplifying the search)• When to seek clarification or additional information from the physician

N

AMES

AND

T

ERMS

T

HAT

D

ESCRIBE

O

PERATIVE

R

EPORTS

The first step in coding from an operative report is understanding the various names that are used to define the documentation recorded for a surgical or treatment session. The operative report and the operative progress, procedure, and treatment note contain both diagnostic and procedural information. Generally, the terms fall into the following categories:

• Operative report• Operative or procedure progress note

In this chapter, you will learn:• About operative report content• How to identify key terms

� OBJECTIVE

The coding system used to code operative reports depends on what services were performed and who provided them.

* KEY POINT


32


the pathology department and a pathology report is not in the chart. The coder can send an inquiry to the physician to determine if lesions were biopsied, destroyed, or not found. The physician can amend the documentation according to the facility guidelines or write or dictate an addendum.

Reading the complete operative or procedure report and not relying on the heading information may also affect diagnosis coding. The findings section of the report may identify conditions not listed in the pre- or post-procedure or operative report diagnosis. Comorbidities or complications may be identified; additional or different diagnosis codes would then be assigned.

OP Report #1

Preoperative Diagnosis:

<¥>

Degenerative joint disease, bilateral hip

1

Postoperative Diagnosis:

<¥>

Degenerative joint disease, bilateral hip

1

Operation:

<¥>

Bilateral total hip arthroplasty

1

Graft Information:

Wright hip system was used. A bone graft was used

Anesthesia:

Spinal

Complications:

None

Blood Loss:

1000 cc

Drains:

Right and left wounds

Indications:

<¥

>

The patient is a 53-year-old female with a long history of bilateral degenerative joint disease of the

>

hips.

2

The patient has had an increase in pain and difficulty in ambulation. The patient was evaluated in the office, and it was felt that she would benefit from bilateral total hip replacement.

Informed Consent:

The risks and benefits of the procedure were explained to the patient. She accepted this and elected to proceed with the procedures.

Component Information:

Size of femoral stem: RT: Number four.Type: Resolution, porous.

Size of femoral stem: LT: Number four.Type: Resolution, porous.

Size of femoral ball head: RT: 28 mm.Type: Ceramic.

Size of femoral ball head: LT: 28 mm.Type: Ceramic.

Size of acetabulum: RT: 54 mm.Type: Quadrant, porous.

Size of plastic insert: RT: 54 mm.Number of screws: RT: Two screws were used.Number of screws: LT: NoneScrew sizes (mm): RT: 3.0 mm, 3.5 mm

Approach & Surgical Procedure(s):

<

<¥>

The patient was moved to the operating suite and, under satisfactory anesthetic, was positioned in

>

the

<¥>

right lateral decubitus position on the operating room table.

4

><¥>

The approach to the hip was a modified Gibson posterolateral approach extending sharply through

>

the

<¥>

skin and subcutaneous tissue to the deep fascia.

5

The deep fascia was entered in line with the skin incision. The proximal femur was exposed, and the dissection plane was carried along the posterior proximal femur. The short external rotators were taken down from their insertion into the femur to expose the hip capsule.

report continued on following page

* CODING POINTS

1 Diagnostic information

2 History or indication for surgery

3 Body of the operative report

4 Operation(s) or procedure(s) performed

5 Procedures performed


39


Chapter 7: IntegumentarySystem (10021–19499)

I

NTRODUCTION

CPT surgery section codes 10021–19499 are listed under the subsection heading of the Integumentary System. The integumentary system includes the skin, subcutaneous tissue, and accessory structures, such as hair and nails. Codes in this subsection describe procedures performed predominately on the integumentary system. However, deeper structures also are included because of the commonly accepted way the procedure is performed (e.g., mastectomy with removal of the underlying muscle and allied lymph nodes). There are also other subcategories in the CPT surgery section that are used to report services for procedures performed on subcutaneous tissue, for example 23330 Removal of foreign body, shoulder; subcutaneous.

The integumentary codes are some of the most frequently performed procedures and most are used across all specialties. Providers report services from this CPT subsection, either alone or in combination with other services; therefore, this chapter of


lists more procedures than other chapters. When assigning codes from this section it is important to understand the anatomy of the skin and other issues involved.

Some code ranges are discussed in their entirety in this text. For other code ranges a representative selection of the codes has been chosen to correlate with the included operative reports. It is important to refer to the current CPT codes for the full range of codes.

The CPT code selection is briefly identified in the “Coding Points” adjacent to the operative report. The codes are not necessarily reported in the correct sequence for physician coding. The correct sequence for physician coding is contained under the “Codes for Op Report” heading. The ICD-9-CM diagnosis and procedure codes might be abbreviated within the “Codes for Op Report,” section, and the full description can be found in the current ICD-9-CM book.

Anatomy—The Skin

The skin is composed of two principal layers: the epidermis and dermis. The epidermal portion of the skin is avascular (without blood) and contains four to five layers depending on its body location: stratum corneum, lucidum (e.g., soles of feet, palms of hand), granulosum, spinosum, and basale. The deepest layer of the epidermis, the stratum basale (also known as the stratum germinativum) has some cells that grow into the dermis from which sudoriferous (sweat) and sebaceous (oil) glands, along with hair follicles are derived. Nerve endings called tactile (Merkel’s) discs also are found in the stratum basale. Our nails and other specialized glands, such as those that excrete cerumen (earwax) also originate in the epidermal portion of the skin.


44


• When exploration and enlargement of a wound, extension of dissection (to determine penetration), with removal of an FB of the soft tissues, report by site a code from the series 20100–20103. Debridement and other services are included in these codes. Read the notes carefully.

• When an FB is located in the subcutaneous tissue (especially when in the deep subcutaneous tissue next to the muscle or muscle fascia) and the service requires more than superficial or easy removal, report a specific code related to a site (e.g., 24200 Removal of foreign body, upper arm or elbow area; subcutaneous).

• When an FB is located in the soft tissue (muscle, tendon, deep subfascial) and does not require exploration, and an extended dissection, code to the body site when possible (e.g., 27087 Removal of foreign body, pelvis or hip; deep subfas-cial or intramuscular), or when the site is not listed separately code to the ana-tomical site (e.g., 20520 Removal of foreign body in muscle or tendon sheath; simple).

CCI Edits (Version 9.3)

10120 01995, 11055, 11056, 11057, 11719, 11720, 11721, 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 90780, G0127

10121 01995, 10120, 11720, 11721, 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 90780

OP Report #1–2


1. Multiple gunshot wounds to the left upper extremity2. Splinter fragments in the right axilla3. Through and through bullet wound to the left neck, with macerated skin

and subcutaneous tissue


1.

<

Multiple gunshot wounds to the left upper extremity:A. Left upper extremity:

a. Left shoulder 1.5 cm

<¥>

b.

>

Left forearm proximal lateral posterior 6 cm laceration with

<¥>

<>

exposed muscle and tendon, 8 cm laceration with exposed

<¥>

>

muscle and tendon and 10 cm laceration with exposed

<¥>

>

muscle and tendon and 4 cm laceration with exposed

<¥

>

>

muscle

2

c. Distal one third of the forearm 5 cm laceration with exposed muscle

2. Splinter laceration to the right axilla, 0.5 c3. Through and through bullet wound to the left neck, with macerated skin

and subcutaneous tissue at the exit site

Operation:

1. Repair of multiple lacerations and removal of multiple foreign bodies (bullet fragments) from left upper extremity including:

<¥

>

A. Repair of left shoulder 1.5 cm full-thickness laceration and

<¥

>

removal of bullet fragments

1

B. Repair of 4 cm laceration at the left elbow region, anterolateral, with removal of bullet fragments

C. Repair of 8 cm, 6 cm and 10 cm lacerations on left elbow, proximal, anterolaterally with removal of multiple bullet fragments and debridement of exposed flexor group muscles with repair and drainage with Penrose drain

D. Repair of 5 cm laceration of distal left forearmE. Explore and remove bullet fragments from right axilla 0.5 cmF. Debride, and irrigate tunnel and exit wound of the left neck

continued on the following page

Soft tissue: Soft tissue generally includes the deep fascia, muscles, tendons, and ligaments.• Deep fascia: Lies beneath the second layer of

subcutaneous tissue (hypodermis) of the Integumentary System. Its purpose in the musculoskeletal system is to line extremities and to hold groups of muscles together.

• Muscle tissues: There are three types of muscle tissue: skeletal, cardiac and visceral. Muscle tissue consists of specialized cells that allow contraction that produces voluntary or involuntary movement of body parts. The term musculoskeletal in this CPT surgery subcate-gory refers to skeletal muscle.

• Tendons: Fibrous cords that vary in length. They are found at the ends of muscles and serve the purpose of connecting muscles to bones.

• Ligaments: Bands of fibrous tissue their pur-pose is to connect two or more bones, or carti-lage.

� DEFINITIONS

1 Documentation does not support the 3 for-eign bodies at separate sites of the shoul-der that are listed in operations performed. CPT code 20103 x 1

2 Five areas were explored and foreign bod-ies removed from the forearm and elbow area; all were in the soft tissue. CPT codes 20103-51 X 5

3 Exporation, and debridement of the wound of the axilla was not necessary—the for-eign body was removed simply. CPTcode 10120-51

4 CPT code 11042-51

* CODING POINTS


81


Chapter 8:Musculoskeletal System

(20000–29999)

I

NTRODUCTION

The musculoskeletal system (20000–29999) surgery subsection has the greatest number of codes. The musculoskeletal system includes the soft tissue, joints, bursa, cartilage, and bones. These codes report services performed in many different settings, including inpatient and outpatient hospitals, other surgery centers or facilities, and physicians’ offices.

Some code ranges are discussed in their entirety in this text. For other code ranges a representative selection of the codes have been chosen to correlate with the included operative reports. It is important to refer to the current CPT codes for the full range of codes.

The CPT code selection is briefly identified in the “Coding Points” adjacent to the operative report. The codes are not necessarily reported in the correct sequence for physician coding. The correct sequence for physician coding is contained under the “Codes for Op Report” heading. The ICD-9-CM diagnosis and procedure codes may be abbreviated within the “Codes for Op Report” section, and the full description can be found in the current ICD-9-CM book.

A

NATOMY

Soft Tissue

The term soft tissue generally includes the deep fascia, muscles, tendons, and ligaments.

• Deep fascia lies beneath the second layer of subcutaneous tissue (hypodermis) of the Integumentary System. Deep fascia in the musculoskeletal system lines extremities and holds together groups of muscles.

• There are three types of muscle tissue: skeletal, cardiac, and visceral. Muscles tis-sue consists of specialized cells that allow contraction to produce voluntary or involuntary movement of body parts. The term musculoskeletal in this CPT surgery subcategory refers to skeletal muscle.

• Tendons are fibrous cords that vary in length. They are found at the ends of muscles and connect muscles to bones.

• Ligaments are bands of fibrous tissue that connect two or more bones or carti-lage.


90


OP Report #2–3

Codes

20220 Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous pro-cess, ribs)

20225 deep (vertebral body, femur)20240 Biopsy, bone, open; superficial (eg, ilium, sternum, spinous process, ribs,

trochanter of femur)20245 deep (eg, humerus, ischium, femur)

Codes for biopsy of a bone are determined by site (e.g., trochanter of femur, vertebral body-thoracic, lumbar or cervical) and whether a needle or trocar is used to obtain the specimen through an excision or through the skin. An exception occurs when a vertebral body biopsy by needle or trocar is performed. Vertebral body biopsy by needle or trocar are listed with the other bone biopsy codes. However, open biopsy of the vertebral body has separate codes listed by site. Following are the depths probed by the instruments and excisions to consider:

Trocar or Needle

• Superficial• Deep

Excision

• Superficial• Deep• Site


Neuromuscular disorder


Same

Operation:

Right thigh muscle biopsy

Anesthesia:

General by laryngeal mask

Complications:

None

Blood Loss:

Minimal

Drains:

None

Indications:

Patient presents with history of proximal muscle weakness and unknown neuromuscular disorder. This biopsy is to be used for diagnostic purposes.

Informed Consent:

The risks and benefits of the procedure were explained to the patient. The patient elected to proceed with the procedure(s).


The patient was brought to the operating room and placed in the supine position on the operating table. After adequate administration of general anesthesia by laryngeal mask the right thigh was prepped and draped in the usual sterile fashion.

<

¥

>

Skin was incised with a 15 blade to the level of vastus lateralis fascia.

<¥>

The fascia was then sharply incised. Blunt hemostasis were used to separate a small portion of the

<¥>

vastus lateralis muscle fibers from surrounding muscle tissue. The separated bundle of muscle was cut

<¥>

at its proximal and distal ends with tenotomy scissors. Care was taken to handle the specimen only by

<¥

>

the peripheral tissue. The proximal end was tagged with a stitch for orientation for pathology.

1

Hemostasis was achieved by electrocautery. The vastus lateralis fascia was closed with 4-0 Dexon, skin was closed with a combination of 3-0 and 4-0 Dexon in interrupted and running subcuticular stitch. The wound was Steri-Stripped and then injected with 7 cc of 0.25% Marcaine prior to dressing with Steri-Strips, gauze and Hypafix tape. The patient tolerated the procedure well.

1 CPT code 20205

* CODING POINTS

ICD-9-CM DIAGNOSIS CODES358.9 Myoneural disorders, unspecified ICD-9-CM OPERATIONS/PROCEDURES83.21 Biopsy of soft tissue CPT PROCEDURES20205 Biopsy, muscle; deep

CODES FOR OP REPORT

Biopsy: Tissue or fluid removed for diagnosis. A pathologist confirms a diagnosis through analysis of the cells in the biopsy specimen.Muscle tissue: There are three types of muscle tissue: skeletal, cardiac, and visceral. Muscle tissue consists of specialized cells that contract to produce voluntary or involuntary movement of body parts. The term musculoskeletal in this CPT surgery subsection refers to skeletal muscle.

� DEFINITIONS

Ask the physician in your office to compile a list you can use to determine which bones are superficial or deep by using the examples in CPT as a guide. Store the information for easy retrieval by anyone needing the information.

* KEY POINT


119

CPT only ©2003 American Medical Association. All Rights Reserved.

Chapter 9: Respiratory andCardiovascular Systems

(30000–39599)

I

NTRODUCTION

The CPT surgery section codes 30000–39599 include two subsection headings:

• 30000–32999 Respiratory System• 33010–39599 Cardiovascular System

Selective areas of these subsections will be discussed.



R

ESPIRATORY

S

YSTEM

Nose and Accessory Sinuses

The nose consists of an external and internal portion called the nasal cavity. The nasal cavity is divided into two sides (right and left) by the nasal septum.

External Nose

The external nose is made up of bone and cartilage covered with skin on the outside and mucous membrane on the inside.

• The nose root is the area of the nose that is attached to the forehead. Its is located in the surface area that exists between the eyes in the upper portion of that space

• The bridge of the nose is also located between the eyes in the mid to lower por-tion of the surface area of that space

• The tip of the nose is called the Apex• The dorsum (dorsum nasi) of the nose is the outside area between the root (top)

and the apex (bottom) of the nose

Nasal bones

Lateralnasal

cartilage

Greaterand lesser

alar cartilage

Septalcartilage

Maxillarysinus

Frontal sinus

Mid frontalcutaway view

Ethmoid aircells (sinus)

Inferiorturbinate

Middleturbinate

Superiorturbinate

Eyesocket


122

©2003 Ingenix, Inc.CPT only ©2003 American Medical Association. All Rights Reserved.

OP Report #3–1


<>

Chronic Sinusitis. Deviated nasal septum. Turbinate hypertrophy.


Same

Operation:

Endoscopic sinus surgery with bilateral total ethmoidectomies, nasal polypectomy bilateral nasoantral windows, and partial excision of the middle turbinates.

Anesthesia:

General endotracheal.

Complications:

None

Blood Loss:

None

Drains:

One Doyle nasal splint on each side of the septum.

Informed Consent:



The patient was identified, taken to the operating room, and placed in a neutral position. Smooth endotracheal anesthesia was induced. The patient was prepped and draped in the standard fashion. 1% Lidocaine with 1:100,000 epinephrine was injected into the septum, uncinate process nasal polyps, and middle turbinates. Visualization with the sinus endoscope revealed a marked spur along the left septum impinging on the left inferior and the middle turbinate and a marked deviation of the superior septum to the right side precluding adequate visualization of the right middle turbinate.

<¥>

Therefore, a left

<¥>

hemitransfixation incision was performed, mucoperichondrial flaps elevated, 1.0 cm caudal and dorsal

<¥>

struts outlined, incised, and a portion of the perpendicular plate of the ethmoid, vomer, and quadrangular

<¥>

cartilage as well as a large maxillary crest spur were resected. The septum was shortened by

<

¥

>

approximately one mm to allow it to return to the midline and the incision was closed with a 4-0 chromic

<¥>

interrupted simple sutures.

1

<¥>

Next, the left middle turbinate and middle meatus was identified and a

<¥>

large polyp was seen to completely obstruct the middle meatus. The polyp was removed with power

<¥>

instrumentation and the insertion of the middle turbinate incised and the anterior two-thirds of the

<¥>

middle turbinate resected.

2

<¥>

The polyp was then further removed entering the into the ethmoid sinus.

<¥

>

The uncinate process was then infractured and sharply resected gaining entrance to the maxillary

<¥>

sinus.

3

>

<¥>

A large polyp was then noted to almost completely fill the maxillary sinus on the left side and

<¥>

this was

>

removed with curved power instrumentation.

4

The ethmoid sinus was then entered again and a marked polypoid and thickened mucosa was noted throughout. The fovea ethmoidalis and laminal papyracea were identified and used as landmarks for the procedure. The basal lamella was entered and the posterior cells also opened wider. Thicken mucosa was noted in the sinuses as well. The sinoethmoidal recess was evaluated and was seen to be free of polypoid tissue. The posterior insertion of the turbinate was cauterized with bipolar cautery as was the anterior insertion. The same procedure was performed on the opposite side with similiar findings, except only a small polyp was noted in the right maxillary sinus. Splints coated in ointment were sutured to the nasal septum with 3-0 Prolene. The throat pack that was placed at the beginning of the case was removed and the patient was extubtated and transported to the recovery room in good and stable condition.

1 CPT code 305202 CPT code 30130-51, -503 CPT code 31255-51, -504 CPT code 31267-51

* CODING POINTS

ICD-9-CM DIAGNOSIS CODESPostoperative473.9 Unspecified sinusitis, chronic 471.8 Other polyp sinus470 Deviated nasal septum478.0 Other diseases of upper respira-

tory tract ICD-9-CM OPERATIONS/PROCEDURES22.63 Ethmoidectomy21.31 Local excision or destruction of

intranasal lesion22.62 Excision of lesion of maxillary

sinus with other approach22.2 Intranasal antrotomy21.5 Submucous resection of the nasal

septum21.69 Other turbinectomyCPT PROCEDURES30520 Septoplasty or submucous resec-

tion, with or without cartilage scoring, contouring or replace-ment with graft

31255-51, 50Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (ante-rior and posterior)

31267-51 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinusPerformed only on the left maxil-lary sinus.

30130-51, 50Excision turbinate, partial or com-plete, any methodThe turbinates were removed due to polyp development and not as access only and are reported. Some payers may require the use of modifier 59 to identify that the removal was not incidental to obtaining access into the sinus(es).

CODES FOR OP REPORT

• Use caution when coding multiple procedures performed through the same scope, as some are considered to be included in others.

• Local anesthesia is included in the procedure and should not be reported separately.

• Surgical endoscopies always include diagnos-tic endoscopies. The diagnostic endoscopy should not be reported separately.

* KEY POINT


143

CPT® 2003 American Medical Association. All Rights Reservd.

Chapter 10: Digestive System(40490–49999)

I

NTRODUCTION

The digestive system, codes 40490–49999, includes the lips, mouth (vestibule, tongue, floor), dentoalveolar structures, palate and uvula, salivary glands and ducts, pharynx, adenoids, and tonsils, esophagus, stomach, intestines, Meckel’s diverticulum and the mesentery, appendix, rectum, anus, liver, biliary tract, pancreas, and the abdomen, peritoneum, and omentum. Selective areas of this subsection will be discussed.



Endoscopy

Diagnostic procedures may include the following:

• Diagnostic endoscopy• Biopsy same lesion, same area• Collection of specimen by brushing or washing

Minor therapeutic procedures may include the following:

• Dilation• Biopsy different lesion, different area• Removal of a foreign body• Removal of a stent

Major therapeutic procedures may include the following:

• Control of bleeding• Removal of tumor, polyp, or other lesions by hot biopsy forceps or bipolar cau-

tery• Removal of tumor, polyp, or other lesions by snare technique• Ablation of tumor, polyp, or other lesions not amenable to removal by hot

biopsy forceps, bipolar cautery, or snare technique

A significant portion of CPT digestive system codes involve endoscopies. When reporting endoscopy procedures keep in mind that the codes are based on the type of endoscope used and the anatomy involved. They may also be distinguished as diagnostic or therapeutic, as defined by the following:• A procedure is diagnostic when the endoscope

is placed only to determine the abnormality or the extent of a disease and therapeutic when the endoscope is placed for treatment of abnormality or disease process.

• Diagnostic endoscopy is always included in a surgical (therapeutic) endoscopy of the same code family. It is reported when it is performed independently, is not immediately related to other services, and is the only procedure per-formed on the date of service.

* KEY POINT


154


OP Report #4–5


Severe gastroesophageal reflux disease and symptomatic cholelithiasis


Same

Operation:

Laparoscopic Nissen fundoplication and laparoscopic cholecystectomy

Anesthesia:

General with endotracheal intubation

Blood Loss:

Minimal

Drains:

No drains placed

Indications:

This is a 40-year-old female with severe right upper quadrant and epigastric pain with workup consistent with severe gastroesophageal reflux disease and symptomatic cholelithiasis.

Informed Consent:



The patient was taken to the Operating Room and received a dose of IV antibiotics and underwent general anesthesia with endotracheal intubation. The abdomen was shaved and then prepped and draped with DuraPrep and sterily draped in the usual fashion. SCD boots were placed. An upper midline incision was made. This was carried down to the midline fascia, which was opened approximately 1 cm and freed of any adhesions below. A purse-string suture with 2-0 Prolene was placed and a blunt Hasson trocar was placed under direct vision into the abdomen. Pneumoperitoneum was developed with C02 insufflation and the abdomen explored. Due to adhesions a 5 mm trocar was placed in the right upper abdomen. Using endo shears, adhesions in the area were taken down; adhesiolysis was continued in the upper abdomen until it was free of adhesions and we could continue with the planned surgery. Using laparoscopic vision, two other 10 mm trocars and a single 5 mm trocar were placed in the left upper quadrant. Adhesions were taken down from the gallbladder.

<¥>

The gallbladder was grasped and

<¥>

retracted anteriorly and laterally. The cystic duct was well-identified and the cystic duct clipped and

<¥>

transected, as was the cystic artery. It was elected not to perform cholangiogram as the patient had no

<¥>

evidence of extra gallbladder biliary obstruction.

>

The gallbladder was then removed from the

<¥>

infrahepatic fossa using electrodissection and then removed from the abdomen. The right upper

<¥

>

quadrant was irrigated, hemostasis was secured and clips appeared in good condition.

2

Attention was

>

then turned to the left upper quadrant. The left lobe of the liver was retracted anteriorly. This did not allow quite enough space to expose the gastroesophageal junction; therefore, the triangular ligament of the left lobe of the liver was taken down. This gave better exposure. The stomach was then mobilized along the lesser curve and then peritoneum taken down over the right crura across the crus and down the left crura to completely free the gastroesophageal junction.

<¥>

The fundus was quite mobile and with

<¥>

the hiatus well-cleared, the crura was reapproximated using separate Ethibond. The fundus was then

<¥>

grasped and passed posteriorly and with a 15 nasogastric tube in place, a 48 inch French bougie was

<¥>

also placed through the gastroesophageal junction and, with these in place, the 360 degree

<¥>

laparoscopic Nissen fundoplication was completed fundus-to-fundus, a bite of gastroesophageal

<¥>

junction was performed to give a loose wrap. One suture was placed in the right crura to prevent

<¥>

slippage into the chest.

1

When the procedure was completed, the bougie and nasogastric tube were removed. The liver was returned to its normal position and each of the trocar sites was closed with an 0 Vicryl using an endoclose device. The Hasson was then removed and the previously placed Prolene suture was tied. The wounds were infiltrated with Marcaine and closed with subcuticular 4-0 Vicryls, Mastisol, and Steri-Strips. Sterile dressings were applied and the patient was awakened, extubated and taken to the Recovery Room in stable condition.

1 CPT code 432802 CPT code 47562-51

* CODING POINTS

ICD-9-CM DIAGNOSIS CODESPreoperative530.81 Esophageal reflux574.20 Calculus of gallbladder without

mention of cholecystitisPostoperative530.81 Esophageal reflux574.20 Calculus of gallbladder without

mention of cholecystitisICD-9-CM OPERATIONS/PROCEDURES44.66 Other procedures for creation of

esophagogastric sphincteric com-petence

51.23 Laparoscopic cholecystectomyCPT PROCEDURES43280 Laparoscopy, surgical, esophago-

gastric fundoplasty (eg, Nissen, Toupet procedures)

47562-51 Laparoscopy, surgical; cholecys-tectomy

CODES FOR OP REPORT

Modifier 51 is not applicable in hospital ASC or hospital outpatient facilities in accordance with CPT modifiers approved for ambulatory surgery center (ASC) outpatient hospital use.

� CODING AXIOM


167


Chapter 11:Urinary, Male Genital and

Female Genital Systems, andMaternity Care and Delivery

(50010–59899)

I

NTRODUCTION

The CPT surgery section codes 50010–59899 include four subsection headings:

• Urinary System 50010–53899• Male Genital System 54000–55899• Female Genital System 56405–58999• Maternity Care and Delivery 59000–59899

Selected areas of these subsections will be discussed.

U

RINARY

S

YSTEM

The Urinary System consists of the two kidneys, two ureters, the bladder, and the urethra.

Kidneys

The kidneys are paired organs between the parietal peritoneum and the posterior abdominal wall (retroperitoneal). They are located in the area of the last thoracic vertebrae to the third lumbar vertebrae.

Think of the kidneys as the body’s blood filter. Items no longer needed are removed from the blood by the filter (kidneys) and eliminated in the form of urine. Elements the body needs are put back into the blood to be used by the cells and tissues of the body. Some of the blood the heart outputs with each cardiac cycle is sent to the kidneys to be filtered via two renal arteries (one to each kidney). In the kidneys the renal arteries drain into other small arteries, then into even smaller arterioles and capillary networks called glomerulus where filtration takes place. Once the blood has been filtered and cleaned in the kidneys, it goes through venous capillaries that change into small veins called venules. Venules drain into larger veins that finally drain into the renal veins. The renal veins return the blood that has been filtered to the heart via the inferior vena cava.


170


Codes

50590 Lithotripsy, extracorporeal shock wave

Lithotripsy may be performed alone or with other procedures. When assigning codes for lithotripsy consider the site, approach, and codes available for selection, as follows:

Site

• Kidney• Ureter

Approach and codes available for selection:

Percutaneous

50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm

50081 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm

Lithotripsy (ESWL)

50590 Lithotripsy, extracorporeal shock wave

Cystourethroscopy

52353 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)


50590 36000, 36410, 37202, 52000, 52005, 52320, 52325, 52330, 52351, 52352, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 76000, 76001, 90780

OP Report #5–2


Left renal calculus

Operation:

Extracorporeal Shock Wave Lithotripsy

Anesthesia:

IV sedation

Indications:

Pre-Op Findings: There was a stone measuring 4 mm located in the left upper calyx. A stent was not placed.

Informed Consent:



A scout film was taken in the AP projection and the approximate position of the stone was marked on the patient's abdomen. The patient was then positioned over the plenum and coupled with mineral oil and water bag. X-ray exposures were then made in the oblique projection.

<

¥

>

Stone position was determined

<¥>

and marked on exposed film. IV contrast was used for stone localization. The targeted stone was then

<¥>

brought into the F2 focus using table coordinates generated by the computer digitizing process.

<¥>

Following position confirmation, treatment was begun. A total of 2000 shocks was administered at a

<¥>

power setting of 24 KV using EKG override. A total of 12 IRIS images and film was taken during the

<¥>

procedure to confirm stone targeting and to assess stone disintegration.

1

Post-treatment films showed indeterminate results.The patient tolerated the procedure well and left the lithotripsy room in good condition. Antibiotics were not administered. Foley catheter was not used.

Water cushion

Kidney Lithotripsyunit

Patient in position for lithotripsy

Radiographicmonitors

Pelvis

Calculus

Ureter

Cutaway schematic of kidney stone

Kidney

1 CPT code 50590

* CODING POINTS

ICD-9-CM DIAGNOSIS CODESPreoperative592.0 Calculus of kidneyPostoperative592.0 Calculus of kidneyICD-9-CM OPERATIONS/PROCEDURES98.51 Extracorporeal shockwave lithot-

ripsy [ESWL]CPT PROCEDURES50590 Lithotripsy, extracorporeal shock

wave

CODES FOR OP REPORT


185


Chapter 12: Endocrine andNervous Systems, Eye and

Ocular Adnexa, and AuditorySystem (60000–69990)

I

NTRODUCTION

The CPT surgery section codes 60000–69990 include four subsection headings:

• Endocrine System 60000–60699• Nervous System 61000–64999• Eye and Ocular Adnexa 65091–68899• Auditory System 69000–69979

Selected areas of these subsections will be discussed.



Endocrine System

The endocrine glands excrete hormones close to capillaries where the hormones are picked up by the blood. The many endocrine glands include the following:

• Pituitary gland (hypophysis): One, located in the sella turcica of the sphenoid bone

• Thyroid glands (right and left lateral lobes): Two, located just below the larynx• Parathyroid glands (superior and inferior): Two pairs, embedded in the back

(posterior) portion of the thyroid glands• Adrenal glands: Two, located above (superior) each kidney• Thymus: One, located in the superior mediastinum to the back (posterior) to

the sternum, between the lungs

Operations and procedures performed on the pancreas are located in the digestive system subsection (40000s).


190


OP Report #6–3


Left temporal glioma


Left temporal glioma

Operation:

Placement of stereotactic head ring. Stereotactic radiosurgery with a single isocenter of 45 mm in diameter with 1,000 cGy normal 80% isodose contour

Anesthesia:

0.50% Marcaine with 1:100,000 Epinephrine with intravenous sedation

Blood Loss:

Less than 10 cc

Indications:

The patient had undergone resection of a left temporal parietal GBM and has undergone external fractionated radiation therapy, and now comes in for delivery of stereotactic radiosurgery to the area of the tumor.

Informed Consent:



After placement of a peripheral intravenous line, the patient received the usual preoperative antibiotics, steroids, and H2 blockers. Once the patient was adequately sedated with intravenous sedation, the scalp was prepped with alcohol.All four cranial fixation pin sites were infiltrated with a total of approximately 30 cc of 0.50% Marcaine with 1:100,000 Epinephrine. Care was taken to make sure that all of the pins were placed away from the patient's craniotomy site. Because of the temporal lobe involvement, the frame was put in a particularly low lying position. The procedure was well tolerated.At the appointed time, the patient was brought to the CT scanning suite. After leveling and placement of the patient in the CT scanning head-holder, the fiducial plates were attached and appropriately localized to the right side of the patient.

<¥>

Contrast was administered. Iohexol was used so as to avoid any inadvertent nausea or vomiting or

<¥>

possible airway compromise in a patient where the stereotactic head ring was firmly affixed to the skull

<¥>

over the mouth region. The Iohexol was allowed to circulate for a full 8 minutes to permit maximal

<¥>

enhancement of the tumor. In the meantime, the CT scans were checked for adequate magnification

<¥>

and centering. 4 mm cuts were chosen. The tumor was well visualized. Each cut was reviewed as it

<¥>

appeared on the CT scanning console.

1

After the imaging was completed, the patient was taken to back to their hospital room. The images were transferred by tape-to-tape transfer from the work station. Once the images were on the work station, we rechecked the fiducial markers as well as the skin contours. I digitized the tumor outline, the left motor strip, and the brain stem. I also digitized the radial eloquent structures such as the optic nerve, optic globes, and optic chiasm.At this point, I turned the 3-dimensional reconstruction from the CT scan over to another doctor, reviewing potential radiosensitive targets such as the adjacent motor strip immediately next to the tumor margins.For details of the quality assurance, calibration of the linear accelerator, and final dosimetric decisions such as size of the collimator and radiation delivered, please refer to the medical record.At the end of the procedure, the stereotactic head ring was removed. All four cranial fixation pin sites were cleansed with hydrogen peroxide. Bacitracin was applied to them and Band-Aid dressings placed over them.Discharge plans, precautions, and follow-up medications were reviewed with the patient in detail. In addition, a printed standard discharge precaution sheet for stereotactic patients was given to the patient.EBL for the procedure was less than 10 cc. No blood products were given. All stereotactic equipment and pins were accounted for x two.At the appointed time, the patient will be brought to the CT scanning suite for imaging.I was present and performed this surgery personally.

1 CPT code 61793

* CODING POINTS

ICD-9-CM DIAGNOSESPreoperative191.2 Malignant neoplasm of temporal

lobe of brainICD-9-CM OPERATIONS/PROCEDURES92.31 Single source photon radiosur-

geryCPT PROCEDURES61793 Stereotactic radiosurgery (particle

beam, gamma ray or linear accel-erator), one or more sessionsThe description states that this is one or more sessions and is inclu-sive of the multiple procedures provided.

CODES FOR OP REPORT


201


Chapter 13: Radiology(70010–79999)

I

NTRODUCTION

The CPT radiology section codes 70010–79999 include four subsection headings:

• Diagnostic Radiology – CT (computerized tomography)– MRI (magnetic resonance imaging)– Interventional radiology procedures

• Diagnostic Ultrasound• Radiation Oncology • Nuclear Medicine

The radiology section is organized by anatomic site and body system within each section and subsection. These services are performed in a variety of health care settings, such as practitioner offices, freestanding facilities, and hospitals.

Procedures are either diagnostic or therapeutic and generally described by type of service (modality) and specific body site, followed by additional information, such as contrast material, number or type of views, and the complexity of the procedure. Radiation oncology is organized according to treatment planning, medical radiation physics, treatment delivery, treatment management, treatment delivery, hyperthermia, and clinical brachytherapy.

Selected areas of the radiology subsections will be discussed later in this chapter.



Technical and Professional Components

The majority of radiology procedures are comprised of two components: technical and professional.

The technical component includes the provision of the equipment, supplies, technical personnel, and costs attendant to the performance of the procedure other than the professional services.


206


H

EAD

AND

N

ECK

C

ODES

Codes

70450 Computerized tomography, head or brain; without contrast material70553 Magnetic resonance (eg, proton) imaging, brain (including brain stem);

without contrast material, followed by contrast material(s) and further sequences

Computerized tomography (CT or CAT scan) involves imaging that employs basic tomographic technique enhanced by computer imaging. Computer enhancement synthesizes the images obtained from different directions in a given plane, effectively reconstructing a cross-sectional plane of the body.

Magnetic resonance imaging (MRI) involves the application of an external magnetic field that forces a uniform alignment of hydrogen atom nuclei in the soft tissue. The nuclei emit radiofrequency signals that are converted into sets of tomographic images and displayed on a computer screen for three-dimensional visualization of the soft tissue structures.

Issues

• Magnetic resonance angiography (MRA) with or without contrast is assigned to code 70544–70546, 70547–70549.

• For magnetic spectroscopy, see 76390.


70450 01922, 70480*, 70481*, 70482*70553 01922, 36000, 36011, 36406, 36410, 70551, 70552, 76000, 76003, 76942,

76986, 90780, 90782, 90783, 90784*Mutually exclusive

Informed Consent:


Procedure(s):

Clinical History - Patient with the history of right arm numbness.

¥

CT of the brain without contrast enhancement - On 2/26/00.

1

Findings - The brain is unremarkable. There is no sign of intraparenchymal or subarachnoid hemorrhage. The sinuses are negative.Conclusion - Negative head CT.

Informed Consent:


Procedure(s):

¥

MRI Head: Utilizing T1, T2 and FLAIR sequences, sagittal, axial and coronal sections were obtained

¥

through the head pre and post intravenous administration of gadolinium. Additional diffusion images were

¥

also obtained and reviewed in this patient with lung cancer. This was compared to previous exam dated

¥

February 23, 2000.

1

The ventricles are normal in size, shape and position. The previously described multiple focal areas of contrast enhancement no longer enhance and the metastases have decreased in size, the largest of which measures no more than 10 mm. The brainstem and craniocervical junction are normal.Impression - Improved but incomplete resolution of multiple cerebral metastases

1 CPT code 70450-26. This is a report of the radiologist’s findings. It should be assigned to CT scan of the brain w/o contrast, super-vision and interpretation only. Although there were no findings on the x-ray, the diagnosis of right arm numbness is assigned.

* CODING POINTS

1 CPT code 70553-26 MRI. Gadolinium is the contrast that was used to accomplish the procedure. The diagnosis of brain metastases can be reported with code 198.3.

* CODING POINTS


213


Chapter 14: Medicine(90281–99569)

I

NTRODUCTION

The CPT medicine codes include many diagnostic, therapeutic, and testing services. Listed among the codes are services frequently performed in an outpatient setting, such as those provided in a physician’s office and in special labs (e.g., cardiac catheter-ization, pulmonary services). Some of the codes report services that are performed to determine the necessity for further work-up, surgery, or other procedures and services; they are often performed to diagnose or confirm the nature of a symptom, disease or condition, or treat an established condition, and to prevent disease.

Although evaluation and management (E/M) services are part of the 90000 series of codes, they will not be discussed in


. E/M services represent visits and encounters for health care services, but by themselves are not used to report surgeries (operations), procedures, or tests. Rather, initial and subsequent E/M encounters help determine the need for further work-up or treatment.

Certain procedures are a combination of a physician component and a technical component per CPT definition. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. When the service is purely a technical or facility component, modifier TC for technical component should be reported. For purposes of this manual the Medicine section has been coded from the physician, professional component, perspective only.



O

TORHINOLARYNGOLOGY

Special otorhinolaryngologic services are reported separately from the E/M service, using 92502–92599. These services include medical diagnostic evaluation and technical procedures (which may or may not be performed personally by the physician).

Chapter 14: Medicine (90281–99569)


217


C

ARDIOVASCULAR

T

HERAPEUTIC

S

ERVICES

Code series 92950-92998 is used to report services that are therapeutic rather than diagnostic in nature.

See the 30000 series of codes for additional information about the heart and pericardium.

Transcatheter Placement of Stents

Codes

92980 Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel

92981 each additional vessel (List separately in addition to code for primary procedure)

A stent is used to hold open a coronary artery that is closed, partially collapsed, or may close following a procedure, such as coronary angioplasty. A stent may be placed alone or in combination with other therapeutic interventions.

This operative report is a review of a stent placement when it is performed alone. The operative report following this one presents a coronary angioplasty and stent placement at the same session. See also code 92982.

Issues

• As you read the description of 92980, note the statement “with or without other therapeutic intervention” (92980 Transcatheter placement of an intracor-onary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel). Citing the inclusion of the terms “with or without other therapeutic intervention” in this code description, Medicare, other payers, specialty associations, and other operative report review services have deter-mined that PTCA is included in the placement of one or more stents. This also applies to stent placement when an atherectomy is performed. Their logic is that if a patient has narrowing in a coronary artery, the narrowing must be opened (by the use of a balloon) before there will be enough room to get a stent to the site; therefore, the balloon inflations are part of the approach necessary to perform the stenting procedure. The approach to a surgery or therapeutic inter-vention is not coded unless guidelines indicate an approach code is also war-ranted.

• Code 92980 is reported when the surgeon inserts one or more stents in a single vessel. Stent placement codes are assigned based on the number of vessels stented, not the number or stents placed. However, if three or more stents are placed in a single vessel, or when additional stenting of a single vessel consumes significant time or is difficult or complex, consider appending modifier 22 to the appropriate stent placement code (92980-92981).

• Code 92981 is reported when placing one or more stents in a subsequent vessel after the initial placement of a stent(s) that is reported with 92980. Code 92981 is an add-on code and when performed is not subject to reduction or modifier 51.


92980 01924, 01925, 01926, 33210, 34812, 34813, 35201, 35206, 35226, 35261, 35266, 35286, 36000, 36120, 36140, 36160, 36200, 36215, 36216, 36217, 36245, 36246, 36247, 36410, 36600, 36620, 36625, 36640, 37202, 76000, 76001, 90780, 90782, 90783, 90784, 92975, 92981, 92982, 92984, 92995, 92996, 93040, 93041, 93042, 93555, 93556

Percutaneous transluminal coronary angioplasty (PTCA): The surgeon advances a catheter to dilate an obstructed coronary artery. A deflated balloon attached close to the tip of the catheter is inflated inside the artery to flatten the plaque causing the obstruction.Atherectomy: The use of a special catheter with a cutting mechanism that is used to remove plaque from an artery and either store the fragments in a chamber to be emptied outside the body or removed at the time of the procedure with a vacuum mechanism.

� DEFINITIONS

See the 30000 series of codes for additional information about the heart and pericardium.

* KEY POINT


231


Abbreviations

a.c.

before eating

a.d.

right ear/to, up to

a fib

atrial fibrillation

a flutter

atrial flutter

a.m.

morning

a.s.

left ear

a.u.

each ear, both ears

A&P

auscultation and percussion

A-P

anterior posterior

A-V

arteriovenous

AAL

anterior axillary line

ab

abortion

AB

blood type

abd

abdomen

ABE

acute bacterial endocarditis

ABO

referring to ABO incompatibility

abs. fev.

without fever

ACD

absolute cardiac dullness

ACL

anterior cruciate ligament

ACLS

advanced cardiac life support

ACVD

acute cardiovascular disease

ad. hib.

to be administered

ad lib

as desired, at pleasure

ad part. dolent.

to the aching parts

ad. us. ext.

for external use

adst. feb.

when fever is present

AE

above the elbow

AF

atrial fibrillation

ag. feb.

when the fever increases

AGA

appropriate (average) for gestational age

AI

aortic insufficiancy

AIDS

acquired immunodeficiency syndrome

AIH

artificial insemination by husband

AK

above the knee

AKA

above knee amputation

alb. (albus)

white

ALL

acute lymphocytic leukemia

alt. dieb.

every other day

alt. hor.

every other hour

alt. noc.

every other night

ama

against medical advice

amb

ambulate

AMI

acute myocardial infarction

AML

acute myelogenous leukemia

AMML

acute myelomonocytic leukemia

ant

anterior

AOD

arterial occlusive disease

AODM

adult onset diabetes mellitus

AP

antepartum/anterior-posterior

Ap

apical

APM

arterial pressure monitoring

approx

approximately

aq.

water (aqua)

ARC

AIDS-related complex

ARD

Acute respiratory disease

ARDS

adult respiratory distress syndrome

ARF

acute respiratory/renal failure

AROM

active range of motion/artificial rupture of membranes

AS

aortic stenosis/ arteriosclerosis

ASAP

as soon as possible

ASCVD

arteriosclerotic cardiovascular disease

ASHD

arteriosclerotic heart disease

AV

atrioventricular

AVF

arteriovenous fistula

ax

axillary

b.i.d.

two times a day

b.i.n.

twice a night

b.i.s.

twice

B&B

bowel and bladder

Ba

barium

bal.

bath

BCC

basal cell carcinoma

BE

barium enema/below the elbow

BI

biopsy

bib.

drink

BICROS

bilateral routing of signals

BK

below the knee

BKA

below knee amputation

BM

bowel movement

BMR

basal metabolic rate

BP

blood pressure

BPD

bronchopulmonary displasia


236


NaCl

sodium chloride (salt)

NAD

no appreciable disease

NAT

nonaccidental trauma

NCA

neurocirculatory asthenia

NCPR

no cardiopulmonary resuscitation

NCR

no cardiac resuscitation

NEC

necrotizing enterocolitis/not elsewhere classified

NG

nasogastric

NIDDM

non-insulin dependent diabetes mellitus

NJ

nasojejunal

NKA

no known allergies

NKMA

no known medical allergies

NNR

new and nonofficial remedies

noc.

night

novem.

nine

NP-CPAP

nasopharyngeal continuous positive airway pressure

npt

normal pressure and temperature

NS

normal saline/not significant

NSAID

nonsteroidal anti-inflammatory drug

NSD

nominal standard dose

NSR

normal sinus rhythm

NST

nonstress test

NSVB

normal spontaneous vaginal bleeding

NT

nasotracheal/nontender

NTE

neutral thermal environment

NTP

normal temperature and pressure

nyd

not yet diagnosed

O

blood type/oxygen

o

no information

o.d.

right eye

o.m.

every morning/otitis media

o.n.

every night

o.s.

left eye

o.u.

each eye, both eyes

O2

oxygen

OA

osteoarthritis

OAG

open angle glaucoma

OB

obstetrics

OB-GYN

obstetrics and gynecology

octo.

eight

OFC

occipitofrontal circumference

omn. hor.

every hour

ONH

optic nerve head

ophth

ophthalmology

OR

operating room

ORIF

open reduction internal fixation

os, oris

mouth

OTD

organ tolerance dose

OTH

other routes of administration

ov.

ovum/office visit

oz.

ounce

P

plan/after/pulse

P& A

percussion and auscultation

p.c.

after eating

p.m.

after noon

P+PD

percussion & postural drainage

p.r.

far point of visual accommodation/through the rectum

p.r.n.

as needed for

p/o

by mouth

P2

pulmonic 2nd sound

PAC

premature atrial contraction

PAD

pulmonary artery diastolic

PAP

Papanicolaou test or smear/pulmonary artery pressure

PAR

post anesthesia recovery/parenteral

para

along side of/number of pregnancies, as para 1, 2, 3, etc

part. vic.

in divided doses

PAT

paroxysmal atrial tachycardia

path

pathology

PBI

protein-bound iodine

PC

packed cells

PCD

polycystic disease

PCG

phonocardiogram

PCN

penicillin

PCTA

percutaneous transluminal angioplasty

PCV

packed cell volume

PD

postural drainage/Parkinson’s disease

PDA

patent ductus arteriosus

PE

physical examination/pulmonary embolism/pulmonary edema

Peds

pediatrics

PEN

parenteral and enteral nutrition

PENS

percutaneous electrical nerve stimulation

PERRLA

pupils equal, regular, reactive to light and accommodation

PET

positron emission tomography

PH

past history

PI

present illness

PID

pelvic inflammatory disease

PKU

phenylketonuria

PMHx

past medical history

PMI

point of maximum intensity

PNC

premature nodal contraction

Date post:	30-Oct-2014
Category:	Documents
Upload:	himofficial
View:	222 times
Download:	3 times

ICL-Coding Operative Report

Documents