Medical Coding I – Week 5 Respiratory, Cardiovascular and Heme /Lymphatic Systems

1. Medical Coding I – Week 5Respiratory, Cardiovascular and Heme/Lymphatic Systems Robyn Korn, MBA, RHIA, CPHQ

2. Respiratory - Nose • Incision • Excision • Introduction – only 3 codes • Removal of foreign body • Repair – mainly cosmetic – noncosmetic procedures need operative report to support procedure • Destruction • Other procedures

3. Respiratory – Accessory Sinuses • Frontal • Ethmoid • Sphenoid • Maxillary

4. Respiratory – Accessory Sinuses • Incision- identify sinus and procedure • Excision – ethmoid and maxillary only • Endoscopy – unilateral; modifier 50 used is bilateral • Other procedures

5. Respiratory - endoscopy • Diagnostic – inspection of the entire nasal cavity • Is included with surgical endoscopy • Surgical – nasal endoscopy used to complete surgical procedure • Also includes sinusotomy if preformed

6. Respiratory - Larynx • Excision • Introduction • Endoscopy – direct and indirect; type of scope and reason • Repair – reference repair, or larynx or laryngoplasty • Destruction – only one code 31595 • Other procedures

7. Respiratory – Trachea and Bronchi • Incision – planned, or emergency or fenestration • Endoscopy – no difference between rigid or flexible scopes; fluoroscopic guidance is included • Introduction – catheterization and contrast material • Repair – site, type, reason, revision of tracheostomy scar • Excision • Other procedures

8. Respiratory - Bronchoscopy • Codes are differentiated by • With or without cell washing • Brushing or protected brushings • Bronchial alveolar lavage • With biopsy • Dilation • Placement of stents • Excision or destruction of tumors • Placement of catheters • Therapeutic aspiration • Injection of contrast material

9. Respiratory – Lungs and Pleura • Incision • Excision • Endoscopy • Repair – 4 codes • Lung transplantation • Surgical collapse therapy; thoracoplasty • Other procedures

10. Respiratory - Endoscopy • Diagnostic differentiated by • Site • Biopsy or no biopsy • Surgical differentiated by • Type of procedure performed via the scope • Reference – thoracoscopy, surgical, then type of procedure

11. Respiratory - Transplant • Three distinct components • Removal of lung or lungs from cadaver • Backbench work • Transplant of lung into the recipient

12. Case 1 - Respiratory Preoperative Diagnosis: Mass on larynx Postoperative Diagnosis: Pending pathology report Procedure: Laryngoscopy The patient was prepped and draped in the usual fashion and placed in the supine position. The operating table was turned to 90 degrees, and a donut headrest was used for stabilization. Mirrors were placed for indirect visualization. A laryngoscope was inserted and suspended for visualization. The larynx and the surrounding area were inspected, and a biopsy of the larynx was taken. Hemostasis was verified, and the scope was extracted. The patient tolerated the procedure and was sent to the recovery room. CPT code(s): _____________________________

13. Respiratory Case 1 Answer • Case 1—31510 • Rationale: The laryngoscope was used to visualize the larynx. In addition, a biopsy of the larynx was taken. Reference the main term Larynx in the Index with the subterm biopsy.

14. Case 2 - Respiratory Preoperative Diagnosis: Foreign body in bronchus Postoperative Diagnosis: Foreign body in bronchus Procedure: Removal of foreign body in the bronchus of the left lung via scope The patient was consciously sedated, and a bronchoscope was introduced into the left nasal passage. There were no abnormal structures noted as the scope was placed into the left bronchial tree. In the left bronchial tree, there was a foreign body, and the bronchial tree appeared slightly inflamed. The foreign body was removed and sent to pathology for inspection. The scope was removed, and the patient tolerated the procedure and was sent to recovery in stable condition. CPT code(s): _________________________________

15. Respiratory Case 2 Answer • Case 2—31635 • Rationale: Reference the main term Bronchi with the subterm endoscopy. Foreign body removal is located under Endoscopy.

16. Case 3 - Respiratory This 32-year-old female was brought to the emergency department by her sister with right side chest pain. Patient states pain is between 9 and 10 on the pain scale. She is having shortness of breath for the last four hours. She was fine yesterday except for a little fatigue. The pain started when she woke up this morning. A chest x-ray showed some pleural effusion at the left base. At this time it was determined that a pneumocentesis is necessary to aspirate the fluid and make the patient more comfortable. This procedure was performed, and the patient is resting and much more comfortable. The patient states that the pain is now at a 4 out of 10. CPT code(s): ____________________________

17. Respiratory Case 3 Answer • Case 3—32420 • Rationale: Reference Pneumocentesis in the Index.

18. Case 4 - Respiratory This 24-year-old patient was brought to the emergency room with difficulty breathing after being stung by a bee. The patient is experiencing a severe reaction to the bee sting. She was able to administer the EpiPen but she is still in need of breathing assistance. An emergency tracheostomy was performed, after which the patient was resting comfortably. CPT code(s): _________________________

19. Respiratory Case 4 Answer • Case 4—31603 • Rationale: Reference Tracheostomy in the Index, then the subterm emergency, which gives you a code range to reference.

20. Case 5 - Respiratory Preoperative Diagnosis: Small unidentified mass in the right lung Postoperative Diagnosis: Same Procedure: Bronchoscopy with biopsy with washings Conscious sedation of Fentanyl, 20 mcg, and 2 mg of Versed was administered to this patient. Bronchoscope was introduced through the left nostril and moved down past normal vocal cord structure and into the bronchial tree on the right side. There were no ulcerations of the mucosa. Fluoroscopic guidance allowed for the bronchoscope to move into the upper lobe of the right lung. Endobronchial biopsy of a small mass was noted, and washings and brushings were taken. The sample was sent for histology. The patient tolerated the procedure well. CPT code(s): ________________________________

21. Respiratory Case 5 Answer • Case 5—31625, 31623 • Rationale: In the Index, reference Bronchoscopy, then biopsy. Code 31625 is used for biopsy of single or multiple sites with or without cell washing. Also add code 31623 for brushing.

22. Cardiovascular Procedures • Notation at beginning of section – important to read • Special rules for assigning pacemaker procedures • Note procedures completed with or without bypass

23. Cardiovascular – Coronary Artery Bypass Grafts (CABG) • Venous grafting only – number of grafts • Combined arterial-venous – correct number and who harvested the graft (modifier 80) and who performs the bypass (+add-on codes) • Arterial grafting • Anomaly repair – aorta, pulmonary artery, and or septal and ventricular defects • Reference – name of procedure and then anomaly

24. Cardiovascular – Heart/Lung Transplant • Cadaver donor cardiectomy with or without pneumonectomy • Backbench work • Transplantation of heart with or without lung allotransplantation

25. Cardiovascular – Arteries and Veins • Embolectomy/Thrombectomy – select code by vessel and approach/method • Venous reconstruction – type of reconstruction dictates codes • Transposition • Grafts • Anastomosis • Sutures

26. Cardiovascular - Aneurysm • READ notations – detailed information is in code book regarding code assignments • Site of surgery is essential • Codes are differentiated by • Aneurysm and associated occlusive disease • Ruptured aneurysm • An aneurysm, pseudoaneurysm and associated occlusive disease

27. Cardiovascular • Fistula – differentiated by site • Direct repair of blood vessel – site • Repair of vessel with vein graft – site • Repair of vessel with graft other than vein – site • Thromboendarterectomy – artery on which procedure is completed • Angioscopy – add on code with therapeutic intervention • Transluminal angioplasty – location and approach • Transluminal artherectomy – location and approach • Bypass graft – differentiated by vein used

28. Cardiovascular – Vascular Injections • Selective – catheter moves into one of the great vessels off the aorta • Movement from one vascular family is reported separately • Radiology services performed in conjunction with catheter movement is coded separately • Nonselective – catheter is functioning and does not go into another vessel

29. Cardiovascular – Arterial and Arteriovenous • Arterial – punctures and catheterization • Hemodialysis – access, cannulation, shunt insertion • Numerous notations read carefully • Many are separate procedures and coded if no other procedure is completed • Transcatheter - Read notations • Endoscopy – 2 codes • Ligation – type of procedure and type

30. Case 1 Cardiovascular Procedure: Replacement of pacemaker generator The patient was brought to the operating room and was prepped and draped in the usual fashion. The patient was consciously sedated. The previous subcutaneous right infraclavicular skin pocket was identified, and an incision was made in this area to remove the previously inserted generator. The atrial and ventricular leads were checked. Since the pocket was clean, it was determined that the same pocket could be used for the reinsertion of a new generator. A pulse generator was placed and tested. Noting no complications, the physician sutured the site. The patient was found to be in stable condition and was returned to the recovery room in satisfactory condition. CPT code(s): _____________________________

31. Cardiovascular Case 1 Answer • Case 1—33213, 33233 • Rationale: Replacement of the pulse generator. The atrial and ventricular leads identify this as a dual chamber. Both the removal and replacement are coded.

32. Case 2 - Cardiovascular Preoperative Diagnosis: Leukemia, in remission Postoperative Diagnosis: Same Procedure: Tunneled venous access port removal Reason for Procedure: This eight-year-old male completed chemotherapy. The patient was prepped and draped in the normal sterile fashion. His right side was anesthetized, and an incision was made above the port area. The port was a tunneled device with a subcutaneous port that was peripherally inserted. The incision was taken down to the device, which was freed. The retention sutures were identified and cut. After confirmation that the device was free, it was removed. Hemostasis was obtained, and the wound was closed in layers using 3-0 nylon. A sterile dressing was applied to the area. Patient vitals were taken, and the patient was noted to be stable. He was sent to the recovery room in stable condition. CPT code(s): __________________________________

33. Cardiovascular Case 2 Answer • Case 2—36590 • Rationale: In this case, the use of the venous access device is the starting point for finding this code. The coder should reference Removal and subterm infusion pump, intravenous in the Index

34. Case 3 Cardiovascular Pre- and postperative diagnosis: Excessive fluid in pericardial sac Procedure: Initial removal of fluid from pericardial sac . After the patient was prepped and draped in the usual fashion, general anesthesia was administered. Using the sternum as an anatomical landmark, a long needle was placed below the sternum. The needle was advanced into the pericardial sac. Five cc of fluid were removed and sent to pathology for review. The patient was stable, and the wound was dressed. Patient was sent to the recovery area in satisfactory condition. CPT code(s):

35. Case 3 Cardiovascular Answer • Case 3—33010 • Rationale: In the Index, reference the main term Pericardiocentesis. Code range 33010–33011 is listed. Reference the code range in the main section of the CPT manual.

36. Case 4 Cardiovascular Preoperative diagnosis: Malignant carcinoma of breast Postoperative diagnosis: Same This 39-year-old female presents today for insertion of catheter for central venous access for chemotherapy. The patient was placed in the supine position and sterile prep occurred. Lidocaine was injected into the right clavicular area. A needle was inserted into the right subclavain vein, and a J-wire was then passed into place. A tunnel was created from the area over the clavicle to the venotomy site, and a dilator was placed over the wire and then dilated. The catheter was then placed into the subclavian vein and secured. The area was flushed, and incisions were sutured. There was minimal blood loss, and the patient was stable and sent to the recovery area. CPT code(s):

37. Case 4 Cardiovascular Answer • Case 4—36558 • Rationale: In the Index, reference the main term Insertion, then catheter, then venous. Review the range listed in the main section of the CPT manual.

38. Case 5 Cardiovascular Preoperative diagnosis: Possible hemorrhage Postoperative diagnosis: Abdominal hemorrhage of previous operative area This patient underwent abdominal surgery 36 hours ago. An exploration of the abdominal incision site is planned. After being placed under general anesthesia, the original abdominal incision site was reopened. A small bleeding site was noted, and electrocautery was used. The wound was closed. The patient tolerated the procedure and was sent to the recovery area. CPT code(s):

39. Case 5 Cardiovascular Answer • Case 5—35840 • Rationale: In the Index, reference the main term Exploration, then blood vessel, then abdomen.

40. Hemic & Lymphatic Systems The hemic and lymphatic systems often are viewed as subsystems of the circulatory system. • The repair of a ruptured spleen is also known as a splenorrhaphy. • The spleen is located in the left upper quadrant of the abdomen, behind the stomach and just below the diaphragm. • The lymphatic channels, or vessels, transport fluid away from the tissues of the body and toward the thoracic cavity.

41. Hemic & Lymphatic Systems • Lymph nodes, also known as lymph glands, are located at various areas along the lymphatic vessels. • In an autologous bone marrow transplant, cells are cultivated from the patient's own marrow. • In an allogenic bone marrow transplant, cells are taken from a donor and then transplanted. • There are four major concentrations of lymph nodes: cervical lymph nodes, submandibular lymph nodes, axillary lymph nodes, and inguinal lymph nodes.

42. Lymphatic Case 1 Preoperative diagnosis: Enlarged lymph node in left axillary area Postoperative diagnosis: Left axillary lymphadenitis Procedure: Excision of one axillary lymph node The patient was prepped and draped in the usual fashion and sedated via IV. The left axillary area was cleansed with Betadine, and 1% Xylocaine was injected. An incision was made through the skin, and the enlarged node was identified deep in the fascia. The surrounding vessels in the area were clamped, and the deep node was excised. The node, measuring 2.3 by 2.5 cm, was sent to pathology for further analysis. The subcutaneous tissue and skin were closed. There was minimal blood loss, and the patient tolerated the procedure in good condition and was sent to the recovery room. CPT code(s):

43. Lymphatic Case 1 Answer • Case 1—38525-LT • Rationale: In the Index, reference the main term Excision, then lymph nodes. Review the codes listed in the main section of the CPT manual, and select code 38525 because the documentation states that the excision occurred in “the fascia.”

44. Lymphatic Case 2 Preoperative diagnosis: Pain over spleen after falling down stairs Postoperative diagnosis: Ruptured spleen Indications for surgery: This 78-year-old male fell while completing yard work. It is felt that his spleen was ruptured due to this injury. Procedure: This 78-year-old male was prepped and draped in the usual fashion. General anesthesia was administered, and he was placed in the supine position. An incision was made in the upper midline area. Retractors were then placed. The splenic ligaments and the gastric veins were located and divided so that the left upper quadrant of the abdomen could be viewed. The spleen was ruptured. The splenic hilum was dissected, and the splenic artery and vein were identified and double ligated. They were then suture ligated and divided. Removal of the spleen occurred, and hemostasis was achieved. A drain was placed, and the area was closed in layers. There was minimal blood loss. The patient’s vitals were taken, and then he was sent to the postop recovery room in stable condition. CPT code(s):

45. Lymphatic Case 2 Answer • Case 2—38100 • Rationale: In the Index, reference the main term Spleen, then the subterm excision. Review the codes listed in the main section of the CPT manual.

46. Lymphatic Case 3 Preoperative diagnosis: Non-Hodgkin’s lymphoma Postoperative diagnosis: Non-Hodgkin’s lymphoma Procedure: Bone marrow biopsy and bone marrow aspiration Indications for surgery: Non-Hodgkin’s lymphoma Procedure: This 25-year-old male was placed in the prone position on the operating table. Posterior superior iliac spines were prepped and draped in the usual sterile fashion. 1% Lidocaine was administered to anesthetize the area. The needle was inserted into the left iliac spinal region, rotated to the right, then left, and removed. The needle was then inserted into the left iliac spinal region at a 45 degree angle, and the procedure was repeated. Bone marrow aspiration and biopsy were performed and sent for contingent flow and contingent cytogenetics. The patient tolerated the procedure well and will return for follow-up and results. CPT code(s):

47. Lymphatic Case 3 Answer • Case 3—38221 • Rationale: In this case, the aspiration is part of obtaining the biopsy, so one code is used to reflect the biopsy. As the guidelines at the start of this section state, “Each code may be reported only once per day regardless of the quantity of bone marrow/stem cells manipulated.” In the Index, reference the main term Biopsy, then bone marrow.

48. Lymphatic Case 4 This 42-year-old female presents today with an abscess in the right inguinal area. The patient is not suffering from fever or chills but is in pain in this area from the abscess. The options were explained to the patient, and she decided to proceed with an incision and drainage of the lymph node. All risks and benefits were explained, after which the patient did sign the consent form for the procedure. Procedure: After the patient was made comfortable on the procedure table, the right inguinal area was prepped and draped in the usual sterile fashion. An incision was made over the abscess and carried down through until the lymph node was visualized. The lymph node was identified, and the syringe was inserted. At this time 6 cc of fluid was removed from the node and sent to pathology. Pressure was applied to the area until the bleeding stopped, and the area was closed with Steri-Strips. The patient tolerated the procedure well and will return in 10 days for follow-up. CPT code(s):

49. Lymphatic Case 4 Answer • Case 4—38300 • Rationale: In the case fluid was removed but the node itself was not. In the Index, reference the main term Lymph Node, then abscess, then incision and drainage.

50. Lymphatic Case 5 This 54-year-old male presents with an enlarged cervical lymph node that is deep within the fat pad. The node has been enlarged for the last 6 months and has been painful. Various treatments occurred with no success. Procedure: The cervical area was anesthetized, and an incision was made to identify the node. The node was deep within the fat layer and enlarged. The node was excised with additional excision of the scalene fat pad. After bleeding was controlled, the area was sutured. The patient was sent to the recovery area in stable condition. CPT code(s):