The document discusses guidelines for coding inpatient procedures using ICD-9-CM Volume 3. It describes the format of Volume 3 and notes that ICD-9-CM procedures codes are only used to code inpatient hospital procedures. It provides information on various coding conventions like principal vs significant procedures, bilateral procedures, operative approaches and closures, and cancelled/planned procedures.
http://cpc.certifiedcodertraining.com/index.php/what-is-medical-coding | Curious about the field of Medical Coding? Certified Coder presents a brief overview of Medical Coding and why it is important.
Medical coding textbook for beginners that is easy to read and understand. Covers diagnosis coding with ICD-9-CM and ICD-10-CM and procedure coding with CPT-4, HCPCS, and ICD-10-PCS. This presentation showcases all of this textbook's features.
Presentation of proper coding and usage of modifiers (Level I and Level II)
Have trouble knowing what modifier to use and how use will impact your claim? Take a look at the presentation "The In's and Out's of Coding with Modifiers", which explain modifiers for you! Hope you enjoy!
http://cpc.certifiedcodertraining.com/index.php/what-is-medical-coding | Curious about the field of Medical Coding? Certified Coder presents a brief overview of Medical Coding and why it is important.
Medical coding textbook for beginners that is easy to read and understand. Covers diagnosis coding with ICD-9-CM and ICD-10-CM and procedure coding with CPT-4, HCPCS, and ICD-10-PCS. This presentation showcases all of this textbook's features.
Presentation of proper coding and usage of modifiers (Level I and Level II)
Have trouble knowing what modifier to use and how use will impact your claim? Take a look at the presentation "The In's and Out's of Coding with Modifiers", which explain modifiers for you! Hope you enjoy!
Comprehensive Medical Coding and Billing Training for the AAPC CPC Exam. Online Training with videos and Skype sessions. HIPAA Training included along with Medical Billing. Trainer is Dr Guptha, world record holder.
The presentation speaks about the history and the purpose of why Medical Coding was brought into practice. It also speaks about how it came into picture and what are the recent advancements in this field.
This presentation was shared with an audience at the AHLA Fundamentals of Health Law program in November 2008.
It contains some basic coding and compliance information to introduce health lawyers to the coding world including recent hot topics under scrutiny.
Hospital Management System (HMS) is a ‘best-in-class’ software solution which is designed to make hospitals and healthcare facilities absolutely ‘paperless’ and reduce human intervention in the tasks conducted on a daily basis. It is available in two languages – English and Marathi.
Understanding ASC Coding and Billing
Medical Billers and Coders (MBC) offer complete transparency and control of the ASC revenue cycle along with key analytics, actionable insights, recommendations, and proven strategies. Such offerings will maximize the ASC’s efficiency, profitability, and physician disbursements. To know more about Ambulatory Surgical Center (ASC) medical billing and coding services contact us at 888-357-3226/info@medicalbillersandcoders.com
Click Here: https://www.medicalbillersandcoders.com/blog/understanding-asc-coding-and-billing/
#ASC #ambulatorysurgicalcentermedicalbilling #ascrevenuecycle #medicalbillingandcodingservice #ascbilling #medicalbillersandcoders #MBC #medicalbillingservices
Comprehensive Medical Coding and Billing Training for the AAPC CPC Exam. Online Training with videos and Skype sessions. HIPAA Training included along with Medical Billing. Trainer is Dr Guptha, world record holder.
The presentation speaks about the history and the purpose of why Medical Coding was brought into practice. It also speaks about how it came into picture and what are the recent advancements in this field.
This presentation was shared with an audience at the AHLA Fundamentals of Health Law program in November 2008.
It contains some basic coding and compliance information to introduce health lawyers to the coding world including recent hot topics under scrutiny.
Hospital Management System (HMS) is a ‘best-in-class’ software solution which is designed to make hospitals and healthcare facilities absolutely ‘paperless’ and reduce human intervention in the tasks conducted on a daily basis. It is available in two languages – English and Marathi.
Understanding ASC Coding and Billing
Medical Billers and Coders (MBC) offer complete transparency and control of the ASC revenue cycle along with key analytics, actionable insights, recommendations, and proven strategies. Such offerings will maximize the ASC’s efficiency, profitability, and physician disbursements. To know more about Ambulatory Surgical Center (ASC) medical billing and coding services contact us at 888-357-3226/info@medicalbillersandcoders.com
Click Here: https://www.medicalbillersandcoders.com/blog/understanding-asc-coding-and-billing/
#ASC #ambulatorysurgicalcentermedicalbilling #ascrevenuecycle #medicalbillingandcodingservice #ascbilling #medicalbillersandcoders #MBC #medicalbillingservices
There are 394 code changes in the 2020 CPT code set, including 248 new codes, 71 deletions, and 75 revisions. In making these updates, the CPT Editorial Panel considered broad input from physicians, medical specialty societies and the greater health care community.
Modifiers List in Medical Billing and CodingNick Johnson
A CPT Modifier is a two-position alpha and alpha-numeric code used to identify certain situations that require the basic value of a procedure to be either enhanced or diminished. A modifier provides the means by which a service or procedure that has been performed can be altered without changing the procedures code. Modifying circumstances include. CPT Modifiers are an important part of the managed care system or medical billing.
A service or procedure that has both a professional and technical component. (26 or TC)
A service or procedure that was performed more than once on the same day by the same physician or by a different physician. (76 or 77)
A bilateral procedure service that was performed. (50)
A distinct procedure service. (59)
Coding for Subcutaneous Cardiac Rhythm MonitorsJessica Parker
On Nov. 2, 2020, the American Medical Association (AMA) CPT® Editorial Panel announced the approval of a new Category III CPT® code to describe remote programming of subcutaneous cardiac rhythm monitors.
ASC CODING AND BILLING: KNOWING WHAT’S IMPORTANTJessica Parker
The basics of the ambulatory surgery center (ASC) coding and billing aren’t hard to master, but they do differ from physician and facility requirements. The following overview will help you know what’s most important in the ASC setting. ASCs use a combination of hospital and physician billing.
Coding Guidelines for General Surgery Billings PPT.pptxMithaliParekh
Surgery that targets the esophagus, stomach, small and large intestines, liver, pancreas, gallbladder, appendix, bile ducts, thyroid gland, and other organs is known as general surgery. Billers and coders for general surgery must be knowledgeable of the codes and terminology used in the field.
Coding Guidelines for General Surgery Billings PDF.pdfMithaliParekh
Surgery that targets the esophagus, stomach, small and large intestines, liver, pancreas, gallbladder, appendix, bile ducts, thyroid gland, and other organs is known as general surgery. Billers and coders for general surgery must be knowledgeable of the codes and terminology used in the field.
CHAPTER 16 r AnesthesiaPRACTICATWith the use of the CP.docxbartholomeocoombs
CHAPTER 16 r Anesthesia
PRACTICAT
With the use of the CPT manual, identify the following physical status modifiers:
9. Patient with a severe systemic disease that is a constant threat to life.
Modifier:
10. Normal healthy patient.
11. Patient with a severe systemic disease.
Modifier: f 3
12. Declared brain-dead patient whose organs are being removed for donor
purpo$es.
Modifier: V b
Patient with mild systemic disease.
Modifier: Pe
Moribund patient who is not expected to survive without the operation.
Modifier: P(
Loca in the CPT manual index under the entry
"A then subtermed by the anatomic site. Write the CPT index
location olp the line provided (e.g., Anesthesia, Thyroid). Then locate the code
identified ln the anesthesia section of the CPT manual. Choose the correct code
and writelthe code on the line provided.
15. Dia ic arthroscopic procedure of knee joint.
CPT Code:
16. Radical hysterectomy.
Index location:
cPTCode: '10,?t{'r;
17. Corneal transplant.
Index location:
CPT Code:
Odd-numbered answers are located in Appendix B, while the full answer key is only available in the TEACH
Instructor Resources on Evolve.
13.
14.
Copyright O 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved
19.
20.
27.
18. Cesarean deliverY onIY'
Index location:
CHAIJ'IER 16 r Airesthesia
patient having mild systemic
late effect of Fen-Phen, taken as
cPr code: f"tq b I
OtoscoPY used
Index location:
in procedure for middle ear'
CPT Code:
Transurethral resection of the prostate.
Index location:
Anesthesia for a cardiac catheterization
disease.
CPT Code:
cPr code: n 01lq
Mitral valve regurgitation as a
prescribed, initial encounter.
qyr'rdc*n
22. Anesthesia for aggiqgqtomy on a healthy S-year-old patient.
CPT Code: 00 f e D
Assign the diagnosis code(s) for Questions 23-26.
23. Diverticulitis of colon with hemorrhage.
ICD-10-CM Code:
(ICD-9-CM Code:
24. Atherosclerosis of coronary artery bypass graft utilizing internal
mammary artery.
ICD-10-CM Code:
(ICD-9-CM Code:
25. Toxic diffuse goiter with thyrotoxic crisis.
ICD-10-CM Code:
(ICD-9-CM Code:
26.
ICD-L0-CM Codes:
(ICD-9-CM Codes:
Odd-numbered answers are located tn Appendtx B, while the full answer key is only available ln the TEACE
Instructor Resources on D,volve.
Copyright @ 2015 by Saunders, an imprint of Elsevier hc. AII riShts reserved.
Surgery Guidelines and
General Surgery
THEORY
Without the use of reference material, answer the following:
1. The more complex subsections referred to in the text are
Integumentary, Musculoskeletal, Respiratory, Cardiovascular, Digestive,
and
2. The information in the
is necessary to correctly
repeated elsewhere.
code in the section,
contains information that
and the information is not
3. Notes may appear before subsections, subheadings,
and subcategories within the CPT manual.
4. When a note is present, that note must be read and
if the coding is to be accurate.
5. Within the Surgery Guidelin.
What Are CPT Modifiers And Why Medical Billing Companies Use Them?Jessica Parker
CPT modifier may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be critical to a claim’s status with the insurance payer.
ASC CODING AND BILLING: KNOWING WHAT’S IMPORTANTJessica Parker
The basics of the ambulatory surgery center (ASC) coding and billing aren’t hard to master, but they do differ from physician and facility requirements. The following overview will help you know what’s most important in the ASC setting. ASCs use a combination of hospital and physician billing.
The Ultimate Guide to Orthopedic Medical Billing - Best Practices and Strateg...Cosentus
This is truly extraordinary how something as simple can have a hold in such a profound level of specialty. This can contribute to the field of medicine in a very important manner. Orthopedics is the medical level of discipline that
works on the surgery that is connected with the conditions of the musculoskeletal system like bones, tendons, joints, and ligaments. An important process for orthopedic practitioners is to work with orthopedic medical billing.
A Guide for Medical Billing and Coding Audits for Wound Care Providers.pdfSolemanOne
Utilizing evidence-based clinical practice guidelines, wound care practitioners can use this medical billing road map to enhance their clinical documentation and adhere to payer coverage policy and medical necessity requirements.
Medical coding is the process of transforming transcribed data into set of numerical codes using a system of numbers to represent various medical problems, (diagnoses), and treatments (procedures
Mastering Ambulatory Surgery Center Billing_ Essential Guidelines for Success...Cosentus
In this article, we’ll cover everything you need to know about ambulatory surgery center billing and what makes it so complex. We’ll also look at some of the issues that arise around the billing process, as well as some industry best practices and ambulatory surgery center billing guidelines you can adopt to ensure your business doesn’t face any hiccups on account of ambulatory surgery center billing.
TCI’s cardiology resources get you up to speed and moving faster than ever with how-to coding advice on the cardiology CPT®, HCPCS, and ICD-10-CM code sets—all at your fingertips.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. FORMAT OF VOLUME 3
The format of Volume 3, Alphabetic Index and
Tabular List, follows the same format and
conventions that are used in Volume 1, Tabular List
of Diseases and Injuries, and Volume 2, Alphabetic
Index of Disease and Injuries.
The procedural codes are used to code hospital
inpatient procedures.
ICD-9-CM procedures codes are not used by
hospital outpatient departments or by physician
practices.
Physicians and hospital outpatient services are
coded using Current Procedural Terminolgy(CPT)
for procedural coding.
3. FORMAT OF VOLUME 3
The use of ICD-9-CM procedure codes is restricted
to the reporting of inpatient procedures by
hospitals. (Ref : CC 2008 1Q P.15)
A hospital may still collect ICD-9-CM procedural
data but only for internal or non-claim-related
purposes.
Volume 3 consists of 17 chapters. Most of these
chapters are classified by body system.
It should be noted that Chapter 0 contains
procedures and interventions that represent new
technology.
4. VOLUME 3 TABLE OF CONTENTS
0. Procedures and Interventions, Not Elsewhere classifiable(00)
1. Operations on the Nervous System (01-05)
2. Operations on the Endocrine System (06-07)
3. Operations on the Eye (08-16)
4. Operations on the Ear (18-20)
5. Operations on the Nose, Mouth, and Pharynx (21-29)
6. Operations on the Respiratory System (30-34)
7. Operations on the Cardiovascular System (35-39)
8. Operations on the Hemic and Lymphatic System (40-41)
9. Operations on the Digestive System (42-54)
10.Operations on the Urinary System (55-59)
11.Operations on the Male Genital Organs (60-64)
12.Operations on the Female Genital Organs (65-71)
13.Obstetrical Procedures (72-75)
14.Operations on the Musculoskeletal System (76-84)
15.Operations on the Integumentary System (85-86)
16. Miscellaneous Diagnostic and Therapeutic Procedures (87-99)
5. ALPHABETIC INDEX
The location of procedures in the Alphabetic Index
can be found under the common name of a
procedure (e.g., appendectomy, hysterectomy).
However, procedures may be listed under the
general type of procedure with terminology such as
the following :
Insertion Incision Excision Clipping
Repair Implantation Examination Removal
6. OMIT CODE
Omit code is an instructional note that is found only
in the Alphabetic Index and Tabular List of Volume3.
This instruction denotes that no code is to be
assigned.
The omit code instruction is generally found under
codes that are used for approaches and closures
and therefore may be integral to the operative
procedure.
7. CODE ALSO
“Code also” is an instructional note found in Volume
3 that directs the coder to code an additional
procedure if it was performed.
8. ADJUNCT CODES
Adjunct Codes are assigned as add-on codes to a
primary procedure to provide additional information
about the primary procedure performed. These
codes cannot be used alone and are assigned as
secondary procedure code.
Codes 00.45 and 00.40 are adjunct vascular
system procedure codes. These codes cannot be
used alone and are used only to provide more
information about the procedure that was
performed.
9. UHDDS DEFINITION
Uniform Hospital Discharge Data Set (UHDDS)
definitions are used by acute care, short-term hospitals
to report inpatient data elements in standardized
manner. Definitions that pertain to the assignment of
procedure codes are presented in the following
sections.
PRINCIPAL PROCEDURE
A principal procedure is one that was performed for
definitive treatment rather than for diagnostic or
exploratory purposes or for treatment of a complication.
If two procedures appear to be principal, the one most
related to the principal diagnosis should be selected as
principal procedure.
10. SIGNIFICANT PROCEDURE
A significant procedure is considered significant if it
Is surgical in nature
Carries a procedural risk
Carries an anesthetic risk
Requires specialized training
It should be noted that a significant procedure does not
have to be performed in an Operative Room.
Procedures can be done in the emergency room (ER)
before admission, at the patient’s bedside, in a
treatment room, or in an interventional radiology
department.
These procedures can be easily missed because an
operative report describing the procedure may not have
been completed.
11. SIGNIFICANT PROCEDURE
These procedures are documented with a brief, handwritten
note on the ER record or in a progress note or in a consultation
note.
Consent for treatment may assist the coder in attempting to
verify a procedure, but not all procedures require consent
forms.
A signed consent form doesn’t confirm that the procedure was
actually performed.
A complete review of the entire health record is necessary to
ensure that all completed procedures have been coded.
Other UHDDS data elements that must be coded include the
date of the procedure and the NPI (National Provider Identifier)
of the person who performed the procedure. It may be the
coder’s responsibility to abstract these data elements.
12. PROCEDURE CODES THAT SHOULD BE REPORTED
Any procedures that affect payment or reimbursement must be
reported.
Other procedures may be reported at a hospital’s discretion or in
accordance with hospital policy.
Encoders(ICD9CM Coding Software) may also have special
popup notices that alert the coder about non-covered or limited
coverage OR procedures.
After assigning procedure codes, the coder should review the
diagnosis codes to ensure the assignment of diagnosis codes
that support the performance of a procedure.
Example : If It was determined that lysis of peritoneal adhesion was sufficient to
warrant a procedure code in this male patient. It would make sense that a
diagnosis code should be assigned to identify the peritoneal adhesions.
Procedure : Lysis of Peritoneal Adhesions 54.59
Diagnosis : Peritoneal Adhesions 568.0
13. PROCEDURE CODES THAT SHOULD BE REPORTED
The Centers for Medicare and Medicaid Services (CMS) has
categorized procedures into different classifications through the
Medicare Code Editor (MCE).
The Medicare Code Editor is software that detects errors in coding on
Medicare Claims. For example, it would identify a male-only procedure
performed on a female patient.
During a patient’s hospitalization, it may be necessary for a procedure to
be performed at an outside facility. This could be for reasons such as
the service may not be offered at the admitting hospital or equipment
may malfunction. The patient may be transported by ambulance to this
outside facility and after the procedure, returns for continued care at the
admitting hospital. In these cases, the admitting hospital may assign
procedure codes for services performed at the outside facility. The
admitting hospital also would include these charges on the hospital
bill, and the admitting hospital would reimburse the outside facility for
the procedure.
14. VALID OR PROCEDURE
A Valid OR Procedure is a procedure that may
affect MS-DRG assignment.
Designation of a procedure as a valid OR
procedure doesn’t mean that it must be performed
in the inpatient setting.
Many surgical procedures can be safely performed
on an outpatient basis, and many third party payers
and/or insurance companies require that certain
surgical procedures be performed in an outpatient
setting. Repair of direct inguinal hernia is
designated as a valid OR procedure, but this
procedure is usually performed and billed as an
outpatient procedure.
15. NON-OR PROCEDURE AFFECTING MS-DRG ASSIGNMENT
A procedure designated as “non-OR procedure affecting
MS-DRG assignment” is a procedure that may affect MS-
DRG assignment, even though the procedure is not
routinely performed in the OR.
In some case, the procedure code 86.07, will make a
difference in MS-DRG assignment; in other cases, it will not.
The patient was admitted with progressive CKD V. A VAD was implanted for
future hemodialysis. (585.5, 86.07)
In this case, the codes group to surgical MS-DRG:675, Kidney & Urinary
Tract Procedures without CC/MCC
The Patient was admitted with primary liver cancer. It was decided to
implant a VAD for future chemotherapy (155.0, 86.07)
In this case, the codes group to medical MS-DRG 437, Malignancy of
Hepatobiliary System or Pancreas without CC/MCC.
16. NON-COVERED OR PROCEDURE
Non-covered OR procedure codes are identified by
the Medicare Code Editor as procedures for which
Medicare does not provide reimbursement.
Sterilization procedures are identified by the
Medicare. It is possible to assign an MS-DRG but
that does not guarantee payment.
17. LIMITED COVERAGE
Limited Coverage procedures are identified by the
Medicare Code Editor as procedures covered under
limited circumstances.
For transplant facility to obtain Medicare coverage
for organ transplantation, it must meet preapproved
guidelines. Criteria are set forth and updated in
Federal Register Notices.
18. SURGICAL HIERARCHY
The MS-DRG grouper software (computer program
that assigns an MS-DRG), using diagnosis and
procedure codes, identifies whether a particular
patient falls into a medical MS-DRG or a surgical
MS-DRG.
The MS-DRG grouper is able to determine which
procedure is most resource intensive and assigns
the procedure to that particular surgical MS-DRG.
19. SURGICAL HIERARCHY
In the above case, the patient was admitted and after
study was determined to have breast cancer of the right
upper outer quadrant (174.4). She also has a
comorbidities of congestive heart failure (428.0). The
principal procedure is one that is performed for definitive
treatment; in this case, that would be the modified radical
mastecotmy (85.43). The mastectomy is more resource
intensive than a breast biopsy. It is appropriate to code
the diagnostic breast biopsy (85.12) as an additional
procedure code.
20. SURGICAL HIERARCHY
In the above case, all codes are same, but the breast
biopsy is incorrectly sequenced as the principal
procedure instead of the mastectomy. Because of the
surgical hierarchy within the grouper, it groups to the
mastectomy MS-DRG, so the reimbursement and MS-
DRG assignment would be correct. Even if the grouper
will automatically arrange the codes to fit the surgical
hierarchy, the code should be sequenced as the principal
procedure on the basis of the UHDDS definition.
21. SURGICAL HIERARCHY
In the above case, a data entry error was made and
congestive heart failure was incorrectly sequenced as
the principal diagnosis, resulting in a 983 MS-DRG
assignment. Although MS-DRG 983 may be the correct
assignment in some cases, it is not appropriate in this
case, and the coder should review the entered codes.
In this case, the principal diagnosis combined with the
procedure codes resulted in the MS-DRG assignment.
If the data entry error had not been corrected before
billing, the facility would have been incorrectly
reimbursed.
22. BILATERAL PROCEDURES
A bilateral procedure occurs when the same procedure
is performed on paired anatomic organs or tissues
(i.e., eyes, ears, joints such as shoulder or knee).
According to CC 1988 1Q P.9, “when the same
procedures are performed bilaterally and ICD-9-CM
provides a single code that identifies the procedures as
bilateral, assign that code. When the same procedure is
performed bilaterally and ICD-9-CM does not provide a
code to identify that procedure as being performed
bilaterally, record the procedure code twice. When there
is difference in the procedure performed on one side as
opposed to the other side involving different code
assignments, report both codes.”
23. BILATERAL PROCEDURES
The coding of bilateral procedures should be
addressed by facility policy.
For major procedures such as joint
replacements, the coder must assign two codes.
24. OPERATIVE APPROACHES & CLOSURES
An important convention in Volume 3 is the “Omit
code.”
Main terms in the Alphabetic Index may be used to
identify incisions. If an incision is made only for the
purpose of performing further surgery, the
instruction “omit code” is given.
25. OPERATIVE APPROACHES & CLOSURES
It is Coder’s responsibility to review the entire
operative report to determine the extent of the
procedure and to decide what should be coded.
Closure of the operative wound is a routine part of
most surgical procedures, so it is not necessary to
code this separately. In some instances, a surgical
wound is not closed at the time of surgical
operation but is allowed to heal and will be closed
at a later date. In this case, a closure would be
added since it is like a “delayed type closure.”
26. CLOSED SURGICAL PROCEDURES
As technology has advanced, procedures are
increasingly being performed through scopes
which are less invasive than open procedures.
This has resulted in quicker recoveries, shorter
hospital stays, a fewer complications.
Common closed surgical approaches include
laparoscopic, thoracoscopic and arthroscopic
procedures.
Closed procedures may be diagnostic and/or
therapeutic in nature.
27. CONVERSION TO OPEN PROCEDURE
A surgical procedure may start with a closed
approach that may need to be converted to an open
procedure. V codes describe the conversion from a
closed surgical procedure to an open procedure.
These codes are found in the index under the main
term “Conversion.”
In the case of conversion from closed to open, only
assign the open procedure code. Some reasons
for conversion to an open procedure include
adhesions, bleeding, technical difficulties due to
anatomic body structure and/or inflammatory
changes, and injury to an organ.
28. CONVERSION TO OPEN PROCEDURE
“Until specific codes for laparoscopic and
thoracoscopic approaches can be created, the
codes for open approaches must be applied. Do
not assign a separate code for the laparoscopy or
thoracoscopy.” (CC 1992 3Q P.12)
It may be the policy of some facilities to assign an
additional procedure code for the laparoscopy
(54.21) so that data can be collected on the number
of laparoscopic procedures performed.
29. ENDOSCOPIC APPROACHES
Endoscopic examinations and procedures are
performed with an instrument that allows
examination of any cavity of the body through a
rigid or flexible scope. The scope usually inserted
into the body through an orifice or stoma. When a
colonoscopy is performed, the anus is the body
orifice that allows entry of the scope.
As the scope is inserted and various parts of the
body are examined, the coder would not code every
body part that is viewed. The coder would code the
farthest site that was reached. If a procedure such
as a biopsy is performed, only the biopsy code is
assigned.
30. PLANNED & CANCELLED PROCEDURES
If a patient’s procedure is cancelled prior to the time
that he or she presents to the hospital, no code will
be required because no services were provided, no
bill was generated, and there is no health record.
If a patient presents to have a procedure
performed, but for some reasons the procedure has
cancelled, the principal diagnosis in this case is the
reason for why the patient was going to have the
procedure performed. If a complication arose that
resulted in the cancellation, a diagnosis code for
that condition would be assigned as a secondary
diagnosis. Also V codes describe the reason for
the cancellation.
31. PLANNED & CANCELLED PROCEDURES
If a surgical procedure will be started that for
whatever reason cannot be completed. The
surgical procedure should be coded to the extend
that it was performed. These circumstances are
different from those surrounding a procedure that is
cancelled, in that the patient received anesthesia
and surgery was begun. No V codes are available
for these situations.
32. BIOPSY
Biopsy is a very common diagnostic procedure that
is often performed before more definitive treatment
is provided.
Biopsy is defined as “the removal of tissue followed
by pathologic examination to establish a precise
diagnosis.”
Biopsies may be performed in a number of different
ways such as by
aspiration, brush, core, endoscopic, excisional, inci
sional, percutaneous, punch, shave, stereotactic, a
nd washing methods.
Different codes may be assigned depending on the
biopsy method used.
33. BIOPSY
Biopsies that are performed by endoscopy or
percutaneous aspiration are coded as “closed”
biopsies. (CC 1984 J-A P.3-4)
An incisional approach for removal of tissue is
coded as an “open biopsy.” (CC 1984 J-A P.3-4)
A patient may be undergoing an open abdominal
procedure while a percutaneous biopsy of the liver
is also performed. Biopsy of the liver would be
coded to percutaneous and not to open
biopsy, even though the abdominal cavity was open
at the time per (CC 1988 4Q P.12)
34. ROBOTIC ASSISTED SURGERY
Robotic-assisted surgery is the most recent development in minimally
invasive surgery. This new technology is designed to enhance surgical
capabilities by facilitating the performance of complex surgery through
small incisions. Robotics requires the use of a surgical robot
(computerized system with a motorized construction, usually an
arm, capable of interacting with the environment).
Note that although a computer console with 3-D imaging is used with
robotic assisted surgery, it is not the same as computer assisted
surgery (00.31-00.35, 00.39). Computer assisted surgery does not use
robotic arms, devices, or other systems to perform surgical tasks
(e.g., excision or resection.) A key difference of robotic-assisted
surgery over computer-assisted surgery is its ability to repeat identical
motions. Although robotic-assisted surgeries may use computer
assistance, computer-assisted surgeries do not use robots. Computer-
assisted surgery (CAS) is any computer-based procedure that uses
technologies such as 3D imaging and real-time sensing in the
planning, execution and follow-up of surgical procedures. CAS allows
for better visualization and targeting of sites as well as improved
diagnostic abilities.
35. ROBOTIC ASSISTED SURGERY
Robotic assistance is classified on the basis of the
approach used, such as open (17.41), laparoscopic
(17.42), percutaneous (17.43), endoscopic
(17.44), thoracoscopic (17.45), and other and unspecified
(17.49). Examples of procedures performed with robotic
assistance include prostatectomies, hysterectomies, and
cholecystectomies.
36. Prakash.A. – CPC
Senior Inpatient Medical Coder
RevenueMed India Pvt Ltd
E-mail : prakasha25@gmail.com
THIS PRESENTATION DEDICATED TO
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