For example, if the operative report indicates a fine-needle aspiration biopsy of the left lobe of the thyroid, a coder would consult a table similar to that of table 1 above for Medical and Surgical 0 : Endocrine System G. In most cases that has little difference except when trying to identify anatomical parts of the great arteries and veins or the spinal cord as they cross the diaphragm. The other six characters vary according to the preceding character. Richards is performing an excision. . For example, the volume 3 code 06.
Because the removal of the stone was unsuccessful no additional codes are necessary for complete coding. A bit more complex is a partial thyroidectomy. Procedures that are discontinued without any other root operation being performed are also coded to Inspection. The definitions of each code are quite precise, and application can be somewhat problematic. Coding examples that appear throughout this article are based on the 2009 code set.
The range of bypass procedures includes normal routes such as those made in coronary artery bypass procedures, and abnormal routes such as those made in colostomy formation procedures. The first option is needed because the pancreas, bile duct, and gall bladder are located in the F section of the Medical and Surgical codes, while the other gastrointestinal organs are found in G. Since both the stomach and duodendum are body parts in the Gastrointestinal body system, what am I missing here? A similar thyroid tissue biopsy would differ only in that it is an excision and other approaches Open or Percutaneous are possible. Example: Bypass from stomach to jejunum, Stomach is the body part and Jejunum is the qualifier. While the Centers for Medicare and Medicaid Services maintains , as will be explained, these tables are not intended for direct coding.
Centers for Medicare and Medicaid Services. Similarly, new robotic devices are handled crudely in the Other Procedure 8 section only. With the implementation date quickly approaching, it is time to master the 31 Medical and Surgical root operations and review documentation to ensure readiness. Suffice it to say, I am so happy that I had a terrific professor. For coding guidelines related to the Bypass root operation, see the sidebar on page 75. However, both of these codes are included in the Endocrine body system. The actual set of codes for each succeeding character is fixed by the preceding one.
If the physician is removing a portion of a body part, the root operation is excision. The codes used within Medical and Surgical may vary depending on the code of axis 2. The visual inspection may be performed with or without optical instrumentation and manual exploration may be performed directly or through intervening body layers. Axis 3 of the two examples defines the procedure type. It is assumed all locations above also were explored. Common procedures now in use involving interventional radiology or robotics are not readily accommodated.
Conduction mechanism is the only choice in this table for body part. Take advantage of this time to cultivate trust and respect between clinical documentation professionals, clinicians, and coders. Preparation Strategies The focus should be on quality clinical documentation, not huge volumes of documentation. Starting with Bypass, the index main term is Bypass; subterm artery and further subdivided by coronary. With the table provided the coder goes directly to table 4A0. By beginning this practice now, gaps in documentation should be identified and remedied prior to implementation.
This was a left heart catheterization which is coded to 37. If part of the left lobe was also removed, the best code selection would be a resection of the right and excision of the left lobe. They will then be able to look at codes and interpret the meaning position by position. The seven-character alphanumeric code starts with a fixed character designating the section. It would be much appreciated. It will be a part of my notebook of resources. Another subterm entry identifies internal mammary-coronary which identifies code 36.
Outside of a focused on ease of use, little practical knowledge exists concerning the ease or efficacy of coding procedures in the code set. Once gaps are identified, focused education can be conducted to specific groups needing the training. The number of sites treated—one, two, three, or four or more—directs the user to Table 021. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from. To achieve this, it takes collaboration between coders, clinical documentation professionals, and clinicians.
Review of both tables reveals very few choices when coding map procedures. If the partial thyroidectomy involved removal of the entire right lobe, the procedure would be coded as a resection of the right lobe. There are only two body system choices for Map: Central Nervous System 00K and Heart and Great Vessels 02K. To illustrate, the codes T, U and V refer to spinal meninges, spinal canal and spinal cord and not the breast when used to describe procedures for the central nervous system. Beginning with Catheterization in the Alphabetic Index; subterm Heart, the instructions are to see Measurement, Cardiac 4A02. Table 2 offers a similar table from the Imaging section showing the changes in axis definitions. If any complex procedure is not completed, such as exploratory surgery followed by intervention if warranted, code selection should reflect the maximum level actually done.
If the physician is removing fluids or gases, use root operation drainage. Procedures include cardiac mapping and cortical mapping. Four Vessel Coronary Artery Bypass Graft For the purposes of this example, this open four vessel coronary artery bypass was completed by grafting three coronary arteries using the left autologous greater saphenous vein, harvested endoscopically, and the fourth coronary artery was bypassed using the loosened end of the left internal mammary artery. Can you give me some guidance? The approach is currently always open and involves no devices or qualifiers. That is one way that the new code set does not differ from the old one. Facilities should be taking this last year to do a deep dive into their current documentation and identify areas that need improvement. She is taking out a small piece of a mass to confirm the diagnosis.
