She is taking out a small piece of a mass to confirm the diagnosis. If any complex procedure is not completed, such as exploratory surgery followed by intervention if warranted, code selection should reflect the maximum level actually done. For the example shown here, 127 operational codes are defined in the 2009 published code set. Can you give me some guidance? Outside of a focused on ease of use, little practical knowledge exists concerning the ease or efficacy of coding procedures in the code set. For example, the volume 3 code 06.
Parathyroid procedures have many codes because six anatomical locations are assigned. For example, a repair of inguinal hernia is anatomically located in the Inguinal Region found in the Medical and Surgical Section Y Anatomical Regions, Lower Extremities , which for some may not be intuitive. The actual set of codes for each succeeding character is fixed by the preceding one. The cardiac mapping must also be coded and review of the Alphabetic Index main term, Mapping; subterm cardiac directs the coder to 37. Review of both tables reveals very few choices when coding map procedures. The approach is currently always open and involves no devices or qualifiers.
Centers for Medicare and Medicaid Services. Table 2 offers a similar table from the Imaging section showing the changes in axis definitions. Common procedures now in use involving interventional radiology or robotics are not readily accommodated. Axis 3 of the two examples defines the procedure type. If the physician is removing fluids or gases, use root operation drainage. These codes are 021209W and 02100Z9.
The other six characters vary according to the preceding character. Regardless, most coders will need to refer to reference material for coding, and many computerized coding aids will be available. Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately. . There are only two body system choices for Map: Central Nervous System 00K and Heart and Great Vessels 02K.
Note that in this case the anatomical code is for the entire pancreas, and the excision operative code is the sole indication that only the head of the pancreas usually is involved. Centers for Medicare and Medicaid Services. Table 4 shows the standard anatomical parts that correspond to the femoral artery grouping. With the implementation date quickly approaching, it is time to master the 31 Medical and Surgical root operations and review documentation to ensure readiness. Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of the classification as Two Coronary Artery Sites and the qualifier specifies the Aorta as the body part bypassed from. That is one way that the new code set does not differ from the old one.
The varied assignments for each axis make code such matching difficult. Thank you for the article it is very helpful. The range of bypass procedures includes normal routes such as those made in coronary artery bypass procedures, and abnormal routes such as those made in colostomy formation procedures. These three groups all bring important pieces of knowledge to the table and working collaboratively will benefit the quality of patient health record documentation which in turn enhances patient care and provides accurate reimbursement to both the facility and the clinician. If part of the left lobe was also removed, the best code selection would be a resection of the right and excision of the left lobe. The second option represents the specific organs excised. A similar thyroid tissue biopsy would differ only in that it is an excision and other approaches Open or Percutaneous are possible.
To achieve this, it takes collaboration between coders, clinical documentation professionals, and clinicians. Because the removal of the stone was unsuccessful no additional codes are necessary for complete coding. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from. Journal of the American Medical Informatics Association 17, no. The definitions of each code are quite precise, and application can be somewhat problematic. The code set divides the upper and lower body at the diaphragm.
Coding the Whipple Pancreaticoduodenectomy, commonly called a Whipple procedure, is a complex surgical procedure involving multiple abdominal organs. Take advantage of this time to cultivate trust and respect between clinical documentation professionals, clinicians, and coders. The coding index shows that the accepted code for the insertion of a cardiac stent is a Dilation operation involving a Percutaneous Endoscopic approach but gives no indication of radiographic involvement. The first code identifies the use of the saphenous vein as the autologous graft. Since both the stomach and duodendum are body parts in the Gastrointestinal body system, what am I missing here? With the table provided the coder goes directly to table 4A0.
The seven-character alphanumeric code starts with a fixed character designating the section. References Centers for Medicare and Medicaid Services. For this procedure, the index main term is Excision; subterm Vein, which is further subdivided by Greater Saphenous, and directs the user to Table 06B. Similarly, new robotic devices are handled crudely in the Other Procedure 8 section only. Both would benefit by the introduction of new approaches or qualifiers. References Centers for Medicare and Medicaid Services. The bypass root operation includes one or more anastomosis, with or without the use of a device.
Facilities should be taking this last year to do a deep dive into their current documentation and identify areas that need improvement. Another subterm entry identifies internal mammary-coronary which identifies code 36. For coding guidelines related to the Bypass root operation, see the sidebar on page 75. Starting with Bypass, the index main term is Bypass; subterm artery and further subdivided by coronary. All of the drainage operations involve different anatomical parts of the thyroid and correspond to 06.