Lecture Notes: Coding in Medical Field

Introduction

Host: Hong, the coding expert
Purpose: Learn real-world coding experience to pass CBC, COC, CCS, or CCS PSM
Key focus: Coding an operating report accurately and efficiently
Importance of staying updated with trends and new technologies in the medical field

Pre-op Diagnosis: Condition before the operation
Post-op Diagnosis: Condition after the operation, helps in finding the accurate primary co-assignment
Name of the Procedure: Understanding the treatment plan
Narrative Description of Procedure: Validates and supports the procedure codes (CPT or PCS)
Type of Anesthesia
Search Name and Signature
Pathological Findings: Crucial for diagnosis and procedure call assignment

Pre-op Diagnosis: Benign prostatic hyperplasia with urinary obstruction, bladder calculi
Post-op Diagnosis: Benign prostatic hyperplasia with urinary obstruction, bladder calculi
Procedure Performed: Aquaplasia, Cystolitholapaxy
- Aquaplasia: Uses water jet to remove prostate tissue
- Cystolitholapaxy: Crushes and extracts bladder stones
Description of Procedures: Key Details
- Cystoscopy with the 22 frame cytoscope
- Laser fragmentation of bladder stones
- Use of Aquabeam for the removal of prostate tissue

ICD-10-CM Code for Diagnosis: N40.1 (Benign prostatic hyperplasia), N21.0 (Calculus in bladder)
CPT Code for Procedures: 53218 (Cystolitholapaxy), 0421T (Aquaplasia)

Pre-op Diagnosis: Recurrent ventral hernia
Post-op Diagnosis: Recurrent ventral hernia
Procedure Performed: Laparoscopic ventral hernia repair, mesh removal
Description of Procedures: Key Details
- Peritoneal cavity accessed using a 5 mm port
- Closure with V-lock sutures and removal of old mesh

ICD-10-CM Code for Diagnosis: K43.2 (Incisional hernia without obstruction or gangrene)
CPT Code for Procedures: 49615 (Repair of ventral hernia), 49623 (Removal of non-infected mesh)

Knowledge of Medical Terms: Essential for understanding operative reports
ICD-10-CM: Same code for initial and recurrent hernia
CPT Codes: Separate codes for initial and recurrent hernia repair; new codes for anterior abdominal hernia repairs
Category 3 Codes: Temporary codes for emerging technologies (e.g., Aquaplasia)

Operating Report #10:
- Pre-op Diagnosis: BPH associated with nocturia
- Post-op Diagnosis: Same
- Procedure Performed: Cystoscopy with insertion of urolift implant
Operating Report #11:
- Pre-op Diagnosis: BPH, urinary retention
- Post-op Diagnosis: Same
- Procedure Performed: TURP and cystoscopy with insertion of urolift implants

End of Lecture Notes