coding surgical procedures - beyond the basics - g. smith (cengage, 2011) )

[...]... using imaging guidance Another example of an NCCI edit in Table 1-3 reveals a circumstance when there is no logical rationale for these two codes to be billed together The surgeon performed either one or the other It is an important responsibility of the coder to understand the use of these edits Coding software products will query the coder to ask if a modifier should be applied The modifiers should not... stated that it took one hour to free the adhesions so the procedure could progress What is the correct coding assignment for the physician and the hospital? 5 A patient was seen in the physician’s office for severe pain in the left knee The surgeon performed an arthrocentesis to remove the excess fluid What is the correct coding assignment for the physician’s services? Coding and Reimbursement As mentioned... ultrasound probe was then inserted into the rectum, and the prostate was visualized using the ultrasound • Obtaining specimens: Two specimens were taken With the exception of the ultrasound guidance (radiology section CPT), all of the above services would be considered integral to the biopsy procedure Additional Surgical Services (Integral) In additional to the services listed above, there are many minor... for the study of surgical Current Procedural Terminology (CPT) coding Before moving ahead into the surgical sections (e .g., integumentary), the building blocks must be in place These building blocks include skill in reading an operative report, recognizing the impact of reimbursement guidelines on coding assignments, and applying official CPT guidelines This first chapter should serve as a self-assessment... were taken from the right base, two from the right mid, two from the right apex, followed by two from the left base, one from the left mid, and one from the left apex We only took one specimen on the left mid and apex because of the patient’s discomfort The patient was able to walk back to the postanesthesia care unit in stable condition We will follow up on the pathology results and call the patient PATHOLOGY... among nonsurgical breast biopsies, surgical breast biopsies, and mastectomy procedures • Apply coding guidelines for integumentary system procedures • Given a case study, correctly assign CPT codes for surgical cases Introduction The skin is the largest organ of the body Included in the integumentary system are hair, nails, sweat, and oil glands The main purpose of the skin is to protect the body from... temperature The epidermis has four separate layers of epithelial tissue As its name suggests, it is the outermost layer of the skin Beneath the epidermis is the dermis, which is composed of dense connective tissue with collagen fibers, which gives the skin elasticity In addition, the dermis includes nerves, blood vessels, and hair follicles Beneath the dermis is the subcutaneous layer (see Figure 2-1 ) The. .. require review of the documentation to determine how far the physician incised to remove the lipoma If the lipoma is located within the layers of skin, a code from the integumentary system will be selected If the lipoma is located deep in the subfascial or submuscular tissues, the appropriate code will come from the musculoskeletal system (CPT Assistant, August 200 4) Exercise 2-2 : Coding Lesions Directions:... through the skin The mass was dissected down through the deltoid muscle, down to the level of the subscapulares tendon of the shoulder joint Mass was dissected free through the muscle-slitting incision Bleeding was controlled with hemostats and Bovie cautery Estimated blood loss was 30 cc The wound was closed with 2-0 chromic gut, subcutaneous layer with 2-0 plain catgut, and skin with 2-0 Dermalon The. .. 1 Introduction to Surgical Coding 2 Patient is scheduled for a laparoscopic cholecystectomy, taken to the OR, is prepped, and anesthesia is given Hyperthermia develops, and the procedure is cancelled a What is the correct coding assignment for physician services? b What is the correct coding assignment for hospital outpatient services? 3 The surgeon performs a colonoscopy During the procedure, a biopsy . Terminology (CPT) coding. Before moving ahead into the surgical sections (e .g. , integumentary), the building blocks must be in place. These building blocks include skill in reading an operative. consider this the most challenging area of coding. Surgical coding requires knowledge and skill in all body systems from the integumentary system to auditory system. The coding professional. Report De nition of Surgical Package Coding Guidelines National Correct Coding Initiative (NCCI) Separate Procedure Review of Surgical Modi ers Coding and Reimbursement Use of Coding References 2