ICL-Coding Operative Report

Ingenix Coding Lab:
Coding from the Operative Report
Contents
Chapter 1: History ...................................................................................................................................................1
Early Record Keeping ................................................................................................................................................ 1 Hospital Records ....................................................................................................................................................... 1 Record Keeping in America ....................................................................................................................................... 2 Standardized Record Keeping .................................................................................................................................... 2 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ............................................................. 2 Summary ................................................................................................................................................................... 4 Discussion Questions ................................................................................................................................................ 4
Chapter 2: Documentation ..................................................................................................................................5

Content ..................................................................................................................................................................... 5 Timeliness ................................................................................................................................................................. 6 Operative Reports ...................................................................................................................................................... 6 Summary ................................................................................................................................................................... 9 Discussion Questions ................................................................................................................................................ 9
Chapter 3: Coding ................................................................................................................................................ 11

Applying Diagnosis Coding ..................................................................................................................................... 11 Diagnosis Coding Guidelines .................................................................................................................................. 13 Applying Procedure Coding Guidelines ................................................................................................................... 16 HCPCS System ....................................................................................................................................................... 18 Anesthesiology ......................................................................................................................................................... 18 Future Coding ......................................................................................................................................................... 18 Summary ................................................................................................................................................................. 20 Discussion Questions .............................................................................................................................................. 20
Chapter 4: Reimbursement .............................................................................................................................. 21

Medicare ................................................................................................................................................................ 21 Payment Systems ..................................................................................................................................................... 22 Medicare Claims ...................................................................................................................................................... 24 Summary ................................................................................................................................................................. 24 Discussion Questions .............................................................................................................................................. 24
Chapter 5: Fraud and Abuse ............................................................................................................................ 25

Fraud ....................................................................................................................................................................... 25 Abuse ...................................................................................................................................................................... 25 Sanctions ................................................................................................................................................................. 26 Compliance ............................................................................................................................................................. 26 Summary ................................................................................................................................................................. 28 Discussion Questions .............................................................................................................................................. 28
Chapter 6: Operative Report Coding ............................................................................................................ 29

Names and Terms That Describe Operative Reports ............................................................................................... 29
2003 Ingenix, Inc. CPT 2003 American Medical Association. All Rights Reserved.
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Ingenix Coding Lab: Coding From The Operative Report
Operative Report Coding Guidelines .......................................................................................................................31 The Operative or Procedure Progress Note ..............................................................................................................33 Retrieving Information from Documentation in the Operative Report ....................................................................36 Underdocumented or Incorrect Information ...........................................................................................................37 Code Selection .........................................................................................................................................................37 When to Seek Clarification or Additional Information from the Physician .............................................................. 38
Chapter 7: Integumentary System (1002119499) ................................................................................39

Introduction ............................................................................................................................................................39 Incision and Drainage of Abscess .............................................................................................................................40 Incision and Removal of Foreign Body ....................................................................................................................43 Incision/Aspiration of Hematoma ............................................................................................................................46 Complex Incision and Drainage ...............................................................................................................................48 Debridement with Removal of Foreign Material ......................................................................................................50 Debridement ...........................................................................................................................................................52 Biopsy of Skin .........................................................................................................................................................54 Removal of Skin Tags ..............................................................................................................................................56 Shaving/Excision of Lesions (1130011646) ...........................................................................................................58 Excision of Pilondial Cyst ........................................................................................................................................61 Insertion/Removal of Contraceptive Capsules ..........................................................................................................62 Repair (1200113160) ............................................................................................................................................63 Adjacent Tissue Transfer (1400014350) ................................................................................................................66 Skin Grafts (1500015776) .....................................................................................................................................68 Blepharoplasty (1582015823) ................................................................................................................................70 Burns, Local Treatment (1600016036) ..................................................................................................................72 Destruction of Benign or Premalignant Lesions (1700017286) .............................................................................73 Breast (1900019499) .............................................................................................................................................75
Chapter 8: Musculoskeletal System (2000029999) ..............................................................................81

Introduction ............................................................................................................................................................81 Anatomy ..................................................................................................................................................................81 General Information ................................................................................................................................................84 Wound Exploration .................................................................................................................................................87 Biopsy (2020020521) ............................................................................................................................................89 Foreign Body ...........................................................................................................................................................92 Arthrotomy, Arthroscopy, and Arthroplasty .............................................................................................................94 Hip Arthroplasty ......................................................................................................................................................97 Excision of Cysts, Lesions, and Tumors ...................................................................................................................99 Knee Arthroplasty ..................................................................................................................................................101 Excision Bone Cyst/Tumor ....................................................................................................................................102 Fascia .....................................................................................................................................................................104 Fractures and Dislocations .....................................................................................................................................106 Repair, Revision and/or Reconstruction .................................................................................................................110 Muscles and Tendons ............................................................................................................................................114 Spine .....................................................................................................................................................................116
Chapter 9: Respiratory and Cardiovascular Systems (3000039599) ...........................................119

Introduction ..........................................................................................................................................................119 Respiratory System ................................................................................................................................................119 Turbinates .............................................................................................................................................................120
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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 ngers 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 denite form. There is evidence of the surgeons 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.
OBJECTIVE
In this chapter, you will learn: About standards of medical records The history of AHIMA The role of JCAHO and medical records
EARLY RECORD KEEPING

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.
QUICK TIP
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.
HOSPITAL RECORDS
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 rst clinical notes derived from the work of Hippocrates. The preserved case histories of patients at St. Bartholomews 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 DaVincis 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.
Ingenix Coding Lab: Coding from the Operative Report
2. If the operative report is not placed in the medical record immediately after surgery due to transcription or ling 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, ndings, technical procedures used, specimens removed, and postoperative diagnosis as well as estimated blood loss. 3. Immediately after surgery is dened 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 certication process, though eligible for Medicare funding. Any hospital that meets the following requirements may apply for a JCAHO accreditation survey under current hospital standards:
FOR MORE INFO

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/
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 identies the services it offers, indicating which it provides directly, under contract, or through some other arrangement. The hospital provides services covered by Joint Commissions standards. JCAHO publishes the Comprehensive Accreditation Manual for Hospitals: The Ofcial Handbook (CAMH), which explains the accreditation process, identies and describes the standards, and explains the scoring of compliance with the standards.
SUMMARY
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.
DISCUSSION QUESTIONS
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 reect the current practice of record retention? Why would JCAHO require standards in record keeping?
Chapter 2: Documentation
Medical documentation is performed to establish and maintain a lasting record of a patients encounters with health care professionals and services. It is chronological written evidence of what happened to a patients 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 patients 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 reect the adequacy and type of care received by the patient.
OBJECTIVE
In this chapter, you will learn: The required elements of documentation About the contents of operative reports The importance of accurate documentation
CONTENT 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 Physicians orders Progress notes
KEY POINT
Medical coding specialists translate a physicians 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.
JCAHO has developed guidelines that dictate documentation and medical records. According to the guidelines, inpatient medical records must contain the following: Patients name, address, date of birth, and next of kin
QUICK TIP
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.
objective information such as amount of uids taken and subjective data regarding the patients response to therapy The primary surgeon is responsible for any documentation regarding the ndings, 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 ofces, and group practices generally follow the requirements of accrediting agencies and site specic 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 errorsstandard 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.
Chapter 3: Coding
Translating information from an oral or written operative report for documentation and payment of claims requires a certain level of prociency in diagnosis and procedure coding. Reimbursement also demands that coders have a working knowledge of federal health care programs (e.g., Medicare, Medicaid, state Childrens 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.
OBJECTIVE
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
APPLYING DIAGNOSIS CODING

International Classication of Diseases
There are two related classications of diseases with similar titles. The International Classication of Diseases (ICD) is used to code and classify mortality data from death certicates. The International Classication of Diseases, Clinical Modication (ICDCM) is used to code and classify morbidity data from the inpatient and outpatient records, physician ofces, and most National Center for Health Statistics (NCHS) surveys. NCHS serves as the World Health Organization (WHO) coordinating center for the classication of diseases in North America. The International Classication of Diseases, Ninth Revision, Clinical Modication, Fifth Edition, commonly referred to as ICD-9-CM, is a three-volume set. The alphabetic index (volume 2) is presented rst in most publications since it is referenced rst 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: classication of diseases and injuries (chapters 117); supplementary classications (V and E codes); and appendixes. Procedures (volume 3) is a numerical list rst as an index to procedures then as a tabular list of operations by systems, and as miscellaneous diagnostic and therapeutic 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-9CM 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, nancial 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
KEY POINT
The treating physician determines the diagnosis. The diagnostic codes may be assigned by the treating physician or derived by coders from the physicians documentation. Among the most important aspects of diagnosis coding is the conveyance of a patients health status. An ICD9-CM code usually represents a patients condition, and in many instances is contained in the medical record for the life of the patient.
FOR MORE INFO

Ofcial ICD-9-CM Guidelines for Coding and Reporting can be obtained through the AHA Coding Clinic for ICD-9-CM, at: One North Franklin Chicago, Il 60606 1-312-422-3000 1-800-242-2626 www.aha.org/
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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 (V10V19) may be used as secondary codes if the historical condition or family history has an impact on current care or inuences treatment. L. Diagnostic services: For patients receiving diagnostic services only during an encounter/visit, sequence rst the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiey responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
KEY POINT
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.
M. Therapeutic services: For patients receiving therapeutic services only during an encounter/visit, sequence rst the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiey 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 rst, 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 specied 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 ndings 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 conrmed, select the postoperative diagnosis for coding, since it is the most denitive. P. Prenatal visits: For routine outpatient prenatal visits when no complications are present codes V22.0 Supervision of normal rst 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.
APPLYING PROCEDURE CODING GUIDELINES

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 requirementsbeyond those listed in the UHDDSfor studies or other informational purposes. Coders should consult the hospitals health information management administrator for the current guidelines. UHDDS denes a signicant procedure as: Surgical in nature Carries a procedural risk Carries an anesthetic risk
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Chapter 4: Reimbursement
MEDICARE
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 partsPart A for hospital insurance, and Part B for medical insurance.
OBJECTIVE
In this chapter, you will learn: Medicare Part A and Part B guidelines About payment systems for inpatient and outpatient services The claims submission process
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.
DEFINITIONS
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 ofce 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.
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 u 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 benets. 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 permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices
KEY POINT
Part B covers the following hospital inpatient services, regardless of the beneciarys eligibility for Part A coverage: Physicians' services Pneumococcal vaccine and its administration Hepatitis B vaccine and its administration However, 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.
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MEDICARE CLAIMS
FOR MORE INFO
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 carriers Contact the U.S. Government Printing Ofce 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.asp An 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
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 Simplication 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 scal 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 UB92 is neither a government printed form nor distributed by CMS. The National Uniform Billing Committee is responsible for the forms 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 modiers as appropriate.
SUMMARY
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.
DISCUSSION QUESTIONS
Inpatient claims are reimbursed based upon DRGs. What are the six components for determining DRGs, and how can they impact the nal 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?
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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 ling the fraudulent claims.
OBJECTIVE
In this chapter, you will learn: The denition of fraud and abuse About sanctions Compliance issues and the role of the OIG Compliance components
FRAUD
Fraud is dened as an intentional false statement or representation of material facts made by a person to obtain some benet or payment when none exists. Fraud may be committed either for the persons own benet or for the benet 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 beneciary, 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 beneciary, 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
DEFINITIONS
Fraud: an intentional false statement or representation of material facts made by a person to obtain some benet or payment when none exists. Abuse: practices that, either directly or indirectly, result in unnecessary costs to the Medicare program.
KEY POINT
It is a crime to defraud the United States government. Those found guilty may be sent to prison, ned, or both. Criminal convictions usually include restitution and signicant 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 ve years or more. A provider can be excluded for any of the actions listed as fraud.
ABUSE
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?
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Chapter 5: Fraud and Abuse
Written standards of conduct and written policies and procedures that promote the physician and/or practice to compliance Designation of a chief compliance ofcer and/or a corporate compliance committee 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 adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation Investigation and correction of identied systemic problems and the development 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
KEY POINT
Ofce 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 hospitals 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 professional services prior to billing to ensure that only accurate and properly documented 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 nancial 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 afrmative 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 ofce 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 rst time the government is revealing the elements upon which we base those judgments...
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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, nancial, 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 todays 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 scal health of a hospital, surgery center, or physicians 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 nd the correct information) Code selection (simplifying the search) When to seek clarication or additional information from the physician
OBJECTIVE
In this chapter, you will learn: About operative report content How to identify key terms
KEY POINT
The coding system used to code operative reports depends on what services were performed and who provided them.
NAMES AND TERMS THAT DESCRIBE OPERATIVE REPORTS The rst step in coding from an operative report is understanding the various names that are used to dene 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
29
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 ndings section of the report may identify conditions not listed in the pre- or post-procedure or operative report diagnosis. Comorbidities or complications may be identied; additional or different diagnosis codes would then be assigned.
CODING POINTS
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 difculty in ambulation. The patient was evaluated in the ofce, and it was felt that she would benet from bilateral total hip replacement. Informed Consent: The risks and benets 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: None Screw 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 modied 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
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
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Chapter 7: Integumentary System (1002119499)

INTRODUCTION CPT surgery section codes 1002119499 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 Ingenix Coding Lab: Coding from the Operative Report 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 briey identied 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.
AnatomyThe 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 ve 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 (Merkels) 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.
39
DEFINITIONS
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 subcategory 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 brous tissue their purpose is to connect two or more bones, or cartilage.
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 2010020103. 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 supercial or easy removal, report a specic 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 subfascial or intramuscular), or when the site is not listed separately code to the anatomical 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 #12
CODING POINTS
1 Documentation does not support the 3 foreign bodies at separate sites of the shoulder that are listed in operations performed. CPT code 20103 x 1 2 Five areas were explored and foreign bodies 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 necessarythe foreign body was removed simply. CPT code 10120-51 4 CPT code 11042-51
1. Multiple gunshot wounds to the left upper extremity 2. Splinter fragments in the right axilla 3. Through and through bullet wound to the left neck, with macerated skin and subcutaneous tissue Postoperative Diagnosis: 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 <> >muscle2 c. Distal one third of the forearm 5 cm laceration with exposed muscle 2. Splinter laceration to the right axilla, 0.5 c 3. Through and through bullet wound to the left neck, with macerated skin and subcutaneous tissue at the exit site 1. Repair of multiple lacerations and removal of multiple foreign bodies Operation: (bullet fragments) from left upper extremity including: <>A. Repair of left shoulder 1.5 cm full-thickness laceration and <> removal of bullet fragments1 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, proxi mal, anterolaterally with removal of multiple bullet fragments and debridement of exposed exor group muscles with repair and drainage with Penrose drain D. Repair of 5 cm laceration of distal left forearm E. Explore and remove bullet fragments from right axilla 0.5 cm F. Debride, and irrigate tunnel and exit wound of the left neck Preoperative Diagnosis:
continued on the following page
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Chapter 8: Musculoskeletal System (2000029999)

INTRODUCTION The musculoskeletal system (2000029999) 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 ofces.
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 briey identied 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.
ANATOMY
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 tissue 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 brous cords that vary in length. They are found at the ends of muscles and connect muscles to bones. Ligaments are bands of brous tissue that connect two or more bones or cartilage.
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CODING POINTS
OP Report #23
Preoperative Diagnosis: Operation: Anesthesia: Neuromuscular disorder Right thigh muscle biopsy General by laryngeal mask None Minimal None Postoperative Diagnosis: Same
1 CPT code 20205
CODES FOR OP REPORT

ICD-9-CM DIAGNOSIS CODES 358.9 Myoneural disorders, unspecied ICD-9-CM OPERATIONS/PROCEDURES 83.21 Biopsy of soft tissue CPT PROCEDURES 20205 Biopsy, muscle; deep
Complications: Blood Loss: Drains:
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 benets of the procedure were explained to the patient. The patient elected to proceed with the procedure(s). Approach & Surgical 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 bers 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 SteriStrips, gauze and Hypax tape. The patient tolerated the procedure well.
DEFINITIONS
Biopsy: Tissue or uid removed for diagnosis. A pathologist conrms 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.
Codes
20220 20225 20240 20245 Biopsy, bone, trocar, or needle; supercial (eg, ilium, sternum, spinous process, ribs) deep (vertebral body, femur) Biopsy, bone, open; supercial (eg, ilium, sternum, spinous process, ribs, trochanter of femur) deep (eg, humerus, ischium, femur)
KEY POINT
Ask the physician in your ofce to compile a list you can use to determine which bones are supercial or deep by using the examples in CPT as a guide. Store the information for easy retrieval by anyone needing the information.
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
Supercial Deep
Excision
Supercial Deep Site
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Chapter 9: Respiratory and Cardiovascular Systems (3000039599)

INTRODUCTION
The CPT surgery section codes 3000039599 include two subsection headings: 3000032999 Respiratory System 3301039599 Cardiovascular System Selective areas of these subsections will be discussed. 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 briey identied 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.
Nasal bones
RESPIRATORY SYSTEM
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.
Lateral nasal cartilage Septal cartilage Greater and lesser alar cartilage
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 portion 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
Ethmoid air cells (sinus) Superior turbinate Middle turbinate Inferior turbinate Maxillary sinus Frontal sinus Eye socket
Mid frontal cutaway view
2003 Ingenix, Inc. CPT only 2003 American Medical Association. All Rights Reserved.
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*
1 2 3 4
OP Report #31
CODING POINTS
Preoperative Diagnosis: Operation:
<>Chronic Sinusitis. Deviated nasal septum. Turbinate hypertrophy.
CPT code 30520 CPT code 30130-51, -50 CPT code 31255-51, -50 CPT code 31267-51
Postoperative Diagnosis: Same Endoscopic sinus surgery with bilateral total ethmoidectomies, nasal polypectomy bilateral nasoantral windows, and partial excision of the middle turbinates. General endotracheal. None None One Doyle nasal splint on each side of the septum.
CODES FOR OP REPORT

ICD-9-CM DIAGNOSIS CODES Postoperative 473.9 Unspecied sinusitis, chronic 471.8 Other polyp sinus 470 Deviated nasal septum 478.0 Other diseases of upper respiratory tract ICD-9-CM OPERATIONS/PROCEDURES 22.63 Ethmoidectomy 21.31 Local excision or destruction of intranasal lesion 22.62 Excision of lesion of maxillary sinus with other approach 22.2 Intranasal antrotomy 21.5 Submucous resection of the nasal septum 21.69 Other turbinectomy CPT PROCEDURES 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 31255-51, 50 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) 31267-51 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus Performed only on the left maxillary sinus. 30130-51, 50 Excision turbinate, partial or complete, any method The turbinates were removed due to polyp development and not as access only and are reported. Some payers may require the use of modier 59 to identify that the removal was not incidental to obtaining access into the sinus(es).
Anesthesia: Complications: Blood Loss: Drains:
Informed Consent: The risks and benets of the procedure were explained to the patient. The patient elected to proceed with the procedure(s). Approach & Surgical Procedure(s): The patient was identied, 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 <>hemitransxation incision was performed, mucoperichondrial aps 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 identied 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 ll 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 identied 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 ndings, 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.
KEY POINT
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 diagnostic endoscopies. The diagnostic endoscopy should not be reported separately.
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2003 Ingenix, Inc. CPT only 2003 American Medical Association. All Rights Reserved.
Chapter 10: Digestive System (4049049999)

INTRODUCTION The digestive system, codes 4049049999, includes the lips, mouth (vestibule, tongue, oor), dentoalveolar structures, palate and uvula, salivary glands and ducts, pharynx, adenoids, and tonsils, esophagus, stomach, intestines, Meckels 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.
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 briey identied 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.
KEY POINT
A signicant 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 dened 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 performed on the date of service.
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 cautery 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
2003 Ingenix, Inc. CPT 2003 American Medical Association. All Rights Reservd.
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CODING POINTS
OP Report #45
Preoperative Diagnosis: Operation: Anesthesia: Blood Loss: Drains: Severe gastroesophageal reux disease and symptomatic cholelithiasis Laparoscopic Nissen fundoplication and laparoscopic cholecystectomy General with endotracheal intubation Minimal No drains placed Postoperative Diagnosis: Same
1 CPT code 43280 2 CPT code 47562-51
CODES FOR OP REPORT

ICD-9-CM DIAGNOSIS CODES Preoperative 530.81 Esophageal reux 574.20 Calculus of gallbladder without mention of cholecystitis Postoperative 530.81 Esophageal reux 574.20 Calculus of gallbladder without mention of cholecystitis ICD-9-CM OPERATIONS/PROCEDURES 44.66 Other procedures for creation of esophagogastric sphincteric competence 51.23 Laparoscopic cholecystectomy CPT PROCEDURES 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) 47562-51 Laparoscopy, surgical; cholecystectomy
Indications: This is a 40-year-old female with severe right upper quadrant and epigastric pain with workup consistent with severe gastroesophageal reux disease and symptomatic cholelithiasis. Informed Consent: The risks and benets of the procedure were explained to the patient. The patient elected to proceed with the procedure(s). Approach & Surgical Procedure(s): 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 insufation 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-identied 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 inltrated with Marcaine and closed with subcuticular 4-0 Vicryls, Mastisol, and SteriStrips. Sterile dressings were applied and the patient was awakened, extubated and taken to the Recovery Room in stable condition.
CODING AXIOM
Modier 51 is not applicable in hospital ASC or hospital outpatient facilities in accordance with CPT modiers approved for ambulatory surgery center (ASC) outpatient hospital use.
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Chapter 11: Urinary, Male Genital and Female Genital Systems, and Maternity Care and Delivery (5001059899)
INTRODUCTION
The CPT surgery section codes 5001059899 include four subsection headings: Urinary System 5001053899 Male Genital System 5400055899 Female Genital System 5640558999 Maternity Care and Delivery 5900059899
Selected areas of these subsections will be discussed.
URINARY SYSTEM
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 bodys blood lter. Items no longer needed are removed from the blood by the lter (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 ltered 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 ltration takes place. Once the blood has been ltered and cleaned in the kidneys, it goes through venous capillaries that change into small veins called venules. Venules drain into larger veins that nally drain into the renal veins. The renal veins return the blood that has been ltered to the heart via the inferior vena cava.
167
Radiographic monitors
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:
Water Kidney cushion
Lithotripsy unit
Site
Kidney Ureter Approach and codes available for selection:
Patient in position for lithotripsy
Pelvis Calculus Kidney Ureter Cutaway schematic of kidney stone
Percutaneous
50080 50081 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm Lithotripsy, extracorporeal shock wave Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)
Lithotripsy (ESWL)
50590 52353
Cystourethroscopy

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 #52
CODING POINTS
Preoperative Diagnosis: Operation: Anesthesia:
Left renal calculus Extracorporeal Shock Wave Lithotripsy IV sedation
1 CPT code 50590
CODES FOR OP REPORT

ICD-9-CM DIAGNOSIS CODES Preoperative 592.0 Calculus of kidney Postoperative 592.0 Calculus of kidney ICD-9-CM OPERATIONS/PROCEDURES 98.51 Extracorporeal shockwave lithotripsy [ESWL] CPT PROCEDURES 50590 Lithotripsy, extracorporeal shock wave
Indications: Pre-Op Findings: There was a stone measuring 4 mm located in the left upper calyx. A stent was not placed. Informed Consent: The risks and benets of the procedure were explained to the patient. The patient elected to proceed with the procedure(s). Approach & Surgical Procedure(s): A scout lm 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 lm. 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 conrmation, 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 lm was taken during the <>procedure to conrm stone targeting and to assess stone disintegration.1 Post-treatment lms 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.
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Chapter 12: Endocrine and Nervous Systems, Eye and Ocular Adnexa, and Auditory System (6000069990)
INTRODUCTION
The CPT surgery section codes 6000069990 include four subsection headings: Endocrine System 6000060699 Nervous System 6100064999 Eye and Ocular Adnexa 6509168899 Auditory System 6900069979
Selected areas of these subsections will be discussed. 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 briey identied 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.
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).
185
OP Report #63
CODING POINTS
1 CPT code 61793
CODES FOR OP REPORT

ICD-9-CM DIAGNOSES Preoperative 191.2 Malignant neoplasm of temporal lobe of brain ICD-9-CM OPERATIONS/PROCEDURES 92.31 Single source photon radiosurgery CPT PROCEDURES 61793 Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator), one or more sessions The description states that this is one or more sessions and is inclusive of the multiple procedures provided.
Preoperative Diagnosis: Left temporal glioma Postoperative Diagnosis: 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: The risks and benets of the procedure were explained to the patient. The patient elected to proceed with the procedure(s). Approach & Surgical Procedure(s): 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 xation pin sites were inltrated 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 ducial 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 rmly afxed 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 magnication <>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 ducial 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 nal 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 xation 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.
190
Chapter 13: Radiology (7001079999)

INTRODUCTION The CPT radiology section codes 7001079999 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 ofces, freestanding facilities, and hospitals. Procedures are either diagnostic or therapeutic and generally described by type of service (modality) and specic 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. 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 briey identied 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.
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.
201
HEAD AND NECK CODES

Codes
70450 70553 Computerized tomography, head or brain; without contrast material 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 eld 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 7054470546, 7054770549. 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
CODING POINTS
1 CPT code 70450-26. This is a report of the radiologists ndings. It should be assigned to CT scan of the brain w/o contrast, supervision and interpretation only. Although there were no ndings on the x-ray, the diagnosis of right arm numbness is assigned.
Informed Consent: The risks and benets of the procedure were explained to the patient. The patient elected to proceed with the procedure(s). 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: The risks and benets of the procedure were explained to the patient. The patient elected to proceed with the procedure(s). 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
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.
206
Chapter 14: Medicine (9028199569)

INTRODUCTION 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 physicians ofce and in special labs (e.g., cardiac catheterization, 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 conrm 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 Ingenix Coding Lab: Coding from the Operative Report. 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 denition. When the physician component is reported separately, the service may be identied by adding the modier 26 to the usual procedure number. When the service is purely a technical or facility component, modier 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. 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 briey identied 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.
OTORHINOLARYNGOLOGY
Special otorhinolaryngologic services are reported separately from the E/M service, using 9250292599. These services include medical diagnostic evaluation and technical procedures (which may or may not be performed personally by the physician).
213
Chapter 14: Medicine (9028199569)
CARDIOVASCULAR THERAPEUTIC SERVICES

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.
DEFINITIONS
Percutaneous transluminal coronary angioplasty (PTCA): The surgeon advances a catheter to dilate an obstructed coronary artery. A deated balloon attached close to the tip of the catheter is inated inside the artery to atten 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.
Transcatheter Placement of Stents Codes

92980 92981 Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel 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.
KEY POINT
See the 30000 series of codes for additional information about the heart and pericardium.
Issues
As you read the description of 92980, note the statement with or without other therapeutic intervention (92980 Transcatheter placement of an intracoronary 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 determined 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 inations are part of the approach necessary to perform the stenting procedure. The approach to a surgery or therapeutic intervention is not coded unless guidelines indicate an approach code is also warranted. 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 signicant time or is difcult or complex, consider appending modier 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 modier 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
217
Abbreviations
a.c. a.d. a b a utter a.m. a.s. a.u. A&P A-P A-V AAL ab AB abd ABE ABO abs. fev. ACD ACL ACLS ACVD ad. hib. ad lib ad part. dolent. ad. us. ext. adst. feb. AE AF ag. feb. AGA AI AIDS AIH AK AKA alb. (albus) ALL alt. dieb. alt. hor. alt. noc. ama before eating right ear/to, up to atrial brillation atrial utter morning left ear each ear, both ears auscultation and percussion anterior posterior arteriovenous anterior axillary line abortion blood type abdomen acute bacterial endocarditis referring to ABO incompatibility without fever absolute cardiac dullness anterior cruciate ligament advanced cardiac life support acute cardiovascular disease to be administered as desired, at pleasure to the aching parts for external use when fever is present above the elbow atrial brillation when the fever increases appropriate (average) for gestational age aortic insufciancy acquired immunodeciency syndrome articial insemination by husband above the knee above knee amputation white acute lymphocytic leukemia every other day every other hour every other night against medical advice amb AMI AML AMML ant AOD AODM AP Ap APM approx aq. ARC ARD ARDS ARF AROM AS ASAP ASCVD ASHD AV AVF ax b.i.d. b.i.n. b.i.s. B&B Ba bal. BCC BE BI bib. BICROS BK BKA BM BMR BP BPD ambulate acute myocardial infarction acute myelogenous leukemia acute myelomonocytic leukemia anterior arterial occlusive disease adult onset diabetes mellitus antepartum/anterior-posterior apical arterial pressure monitoring approximately water (aqua) AIDS-related complex Acute respiratory disease adult respiratory distress syndrome acute respiratory/renal failure active range of motion/articial rupture of membranes aortic stenosis/ arteriosclerosis as soon as possible arteriosclerotic cardiovascular disease arteriosclerotic heart disease atrioventricular arteriovenous stula axillary two times a day twice a night twice bowel and bladder barium bath basal cell carcinoma barium enema/below the elbow biopsy drink bilateral routing of signals below the knee below knee amputation bowel movement basal metabolic rate blood pressure bronchopulmonary displasia
231
NaCl NAD NAT NCA NCPR NCR NEC NG NIDDM NJ NKA NKMA NNR noc. novem. NP-CPAP npt NS NSAID NSD NSR NST NSVB NT NTE NTP nyd O o o.d. o.m. o.n. o.s. o.u. O2 OA OAG OB OB-GYN octo. OFC omn. hor. ONH ophth OR ORIF os, oris
236
sodium chloride (salt) no appreciable disease nonaccidental trauma neurocirculatory asthenia no cardiopulmonary resuscitation no cardiac resuscitation necrotizing enterocolitis/not elsewhere classied nasogastric non-insulin dependent diabetes mellitus nasojejunal no known allergies no known medical allergies new and nonofcial remedies night nine nasopharyngeal continuous positive airway pressure normal pressure and temperature normal saline/not signicant nonsteroidal anti-inammatory drug nominal standard dose normal sinus rhythm nonstress test normal spontaneous vaginal bleeding nasotracheal/nontender neutral thermal environment normal temperature and pressure not yet diagnosed blood type/oxygen no information right eye every morning/otitis media every night left eye each eye, both eyes oxygen osteoarthritis open angle glaucoma obstetrics obstetrics and gynecology eight occipitofrontal circumference every hour optic nerve head ophthalmology operating room open reduction internal xation mouth
OTD OTH ov. oz. P P& A p.c. p.m. P+PD p.r. p.r.n. p/o P2 PAC PAD PAP PAR para part. vic. PAT path PBI PC PCD PCG PCN PCTA PCV PD PDA PE Peds PEN PENS PERRLA PET PH PI PID PKU PMHx PMI PNC
organ tolerance dose other routes of administration ovum/ofce visit ounce plan/after/pulse percussion and auscultation after eating after noon percussion & postural drainage far point of visual accommodation/ through the rectum as needed for by mouth pulmonic 2nd sound premature atrial contraction pulmonary artery diastolic Papanicolaou test or smear/pulmonary artery pressure post anesthesia recovery/parenteral along side of/number of pregnancies, as para 1, 2, 3, etc in divided doses paroxysmal atrial tachycardia pathology protein-bound iodine packed cells polycystic disease phonocardiogram penicillin percutaneous transluminal angioplasty packed cell volume postural drainage/Parkinsons disease patent ductus arteriosus physical examination/pulmonary embolism/pulmonary edema pediatrics parenteral and enteral nutrition percutaneous electrical nerve stimulation pupils equal, regular, reactive to light and accommodation positron emission tomography past history present illness pelvic inammatory disease phenylketonuria past medical history point of maximum intensity premature nodal contraction

ICL-Coding Operative Report

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Ingenix Coding Lab:

Coding from the Operative Report

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

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

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

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

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

Ingenix Coding Lab: Coding From The Operative Report

Chapter 7: Integumentary System (1002119499) ................................................................................39

Chapter 8: Musculoskeletal System (2000029999) ..............................................................................81

Chapter 9: Respiratory and Cardiovascular Systems (3000039599) ...........................................119

EARLY RECORD KEEPING

Ingenix Coding Lab: Coding from the Operative Report

FOR MORE INFO

Ingenix Coding Lab: Coding from the Operative Report

APPLYING DIAGNOSIS CODING

FOR MORE INFO

Ingenix Coding Lab: Coding from the Operative Report

APPLYING PROCEDURE CODING GUIDELINES

Ingenix Coding Lab: Coding from the Operative Report

FOR MORE INFO

Other Outpatient Claims

Chapter 5: Fraud and Abuse

Chapter 5: Fraud and Abuse

Ofce of Inspector General (OIG)

Compliance Program for Hospitals

Chapter 6: Operative Report Coding

Ingenix Coding Lab: Coding from the Operative Report

2 History or indication for surgery

3 Body of the operative report

4 Operation(s) or procedure(s) performed 5 Procedures performed

Chapter 7: Integumentary System (1002119499)

Ingenix Coding Lab: Coding from the Operative Report

CCI Edits (Version 9.3)

Chapter 8: Musculoskeletal System (2000029999)

Ingenix Coding Lab: Coding from the Operative Report

1 CPT code 20205

CODES FOR OP REPORT

Complications: Blood Loss: Drains:

Chapter 9: Respiratory and Cardiovascular Systems (3000039599)

Mid frontal cutaway view

Ingenix Coding Lab: Coding from the Operative Report

Preoperative Diagnosis: Operation:

<>Chronic Sinusitis. Deviated nasal septum. Turbinate hypertrophy.

CODES FOR OP REPORT

Anesthesia: Complications: Blood Loss: Drains:

Chapter 10: Digestive System (4049049999)

Ingenix Coding Lab: Coding from the Operative Report

1 CPT code 43280 2 CPT code 47562-51

CODES FOR OP REPORT

Selected areas of these subsections will be discussed.

Ingenix Coding Lab: Coding from the Operative Report

Water Kidney cushion

Patient in position for lithotripsy

Pelvis Calculus Kidney Ureter Cutaway schematic of kidney stone

CCI Edits (Version 9.3)

Preoperative Diagnosis: Operation: Anesthesia:

Left renal calculus Extracorporeal Shock Wave Lithotripsy IV sedation

1 CPT code 50590

CODES FOR OP REPORT

Ingenix Coding Lab: Coding from the Operative Report

1 CPT code 61793

CODES FOR OP REPORT

Chapter 13: Radiology (7001079999)