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2006 Panel on Coding Diagnostic Coding and Documentation

2006 Panel on Coding Diagnostic Coding and Documentation. David R. Vandersteen, MD Children’s Hospitals of Minnesota Mayo Graduate School of Medicine. Coding and Documentation Tips. “Code Pairing” List appropriate diagnoses to match the procedures performed

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2006 Panel on Coding Diagnostic Coding and Documentation

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  1. 2006 Panel on CodingDiagnostic Coding and Documentation David R. Vandersteen, MD Children’s Hospitals of Minnesota Mayo Graduate School of Medicine

  2. Coding and Documentation Tips • “Code Pairing” • List appropriate diagnoses to match the procedures performed • Example: If doing a circumcision, use the redundant prepuce ICD-9 diagnostic code. • If Code Pairing not possible • Document what you do • Document why you did it! • Be specific!

  3. General coding tips • Describe details of the procedure to justify the “unpaired” codes • Example: • 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less • Dictate “Dorsal preputial rotational flaps were mobilized on a vascular pedicle, rotated ventrally, and used to resurface a 1 sq cm surface of deficient ventral penile skin.”

  4. Case #1: • 6 month old male with distal (1 cm) hypospadias with moderate chordee and tethering of the scrotum to the ventral penis.

  5. Case #1: • Diagnoses and ICD-9 codes • Hypospadias • 752.61 Hypospadias • Chordee • 752.63 Congenital chordee • Penoscrotal tethering • 752.81 Scrotal transposition  • Preputial redundancy/asymmetry • 605 Redundant prepuce and phimosis

  6. Case #1: • Diagnosis and Procedural “Code Pairing” • Hypospadias • 752.61 Hypospadias • 54324 One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap) • Chordee • 752.63 Congenital chordee • 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra

  7. Case #1: • Diagnosis and Procedural code “pairing” • Penoscrotal tethering • 752.81 Scrotal transposition • 55175 Scrotoplasty; simple • Excessive/asymmetric prepuce • 605 Redundant prepuce and phimosis • 54161 Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn

  8. Case #2: • 6 month old male with buried or concealed penis along with penoscrotal web.

  9. Case #2: • Diagnoses and ICD-9 codes • Buried penis • 752.65 Hidden penis • Penoscrotal web • 752.81 Scrotal transposition • 752.63 Congenital chordee • Preputial redundancy/asymmetry • 605 Redundant prepuce and phimosis

  10. Case #2: • Diagnosis and Procedural “code pairing” • Buried penis • 752.65 Hidden penis • ???? CPT code • Chordee • 752.63 Congenital chordee • 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra

  11. Case #2: • Diagnosis and Procedural code “pairing” • Penoscrotal tethering • 752.81 Scrotal transposition • 55175 Scrotoplasty; simple • Excessive/asymmetric prepuce • 605 Redundant prepuce and phimosis • 54161 Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn

  12. Case #3: • 6 month old male with chordee without hypospadias.

  13. Case #3: • Diagnoses and ICD-9 codes • Chordee • 752.63 Congenital chordee • Preputial redundancy/asymmetry • 605 Redundant prepuce and phimosis

  14. Case #3: • Diagnosis and Procedural “code pairing” • Chordee • 752.63 Congenital chordee • 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra • Excessive/asymmetric prepuce • 605 Redundant prepuce and phimosis • 54161 Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn

  15. Case #4: • 1 year old with high testis at level of internal ring. • Intra-op findings of large patent processus vaginalis/ hernia

  16. Case #4: • Diagnoses and ICD-9 codes • Undescended testis • (752.51) Undescended testis

  17. Case #4: • Diagnoses and ICD-9 codes • Inguinal hernia • (550.9) Inguinal hernia, without mention of obstruction or gangrene • 550.90 unilateral or unspecified (not specified as recurrent) • 550.91 unilateral or unspecified, recurrent • Congenital hydrocele • (778.6) Congenital hydrocele • Congenital hydrocele of tunica vaginalis

  18. Case #5: • 6 year old boy presents with a reducible communicating hydrocele.

  19. Case #5: • Diagnoses and ICD-9 codes • Inguinal hernia? • (550.9) Inguinal hernia, without mention of obstruction or gangrene • 550.90 unilateral or unspecified (not specified as recurrent)

  20. Case #5: • Diagnoses and ICD-9 codes • Hydrocele • (778.6) Congenital hydrocele • Congenital hydrocele of tunica vaginalis • (603) Hydrocele • Includes hydrocele of spermatic cord, testis, or tunica vaginalis • Excludes congenital hydrocele ( 778.6 ) • 603.8 Other specified types of hydrocele • 603.9 Hydrocele, unspecified

  21. General coding tips • Utilize auacodingtoday.com! • Free to all AUA members • Easily access and search of both CPT and ICD-9 codes • Bundling info/ cross check • Updated Edits • Access Medicare RVUs and Medicare fees for procedural codes • Match ICD-9 codes to CPT codes • i.e. Match diagnosis with procedure • Document!

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