Hi everyone, how are you today? Welcome back and if you are new here, welcome to my channel where you can learn the real-world coding experience and this is Hong, the coding expert. If you want to be a great coder or want to pass the CBC, COC, CCS or CCS PSM, then besides understanding coding rules and guidelines, you must know how to code an operating report accurately and efficiently. As you already know, innovation in technology has been happening in the medical field for decades, from robotics, 3D printing to virtual reality. For example, the device used in hospitals today have made it easier for physicians to perform a procedure with amazing precision and efficiency.
As a coder, you have to keep up with trends in the coding industry. and stay up to date with new technologies and procedures. I really want to encourage you to continue learning in any capacity that excites you and pushes you forward.
I understand it can be overwhelming with so much information for you to learn out there but you still always come out a better version of yourself. Remember persistence is still the key to success. Try again and again. And yet again until you pass the coding exam one after another in order to find your dream job or to get promoted at work.
In today's video, I'll go over the homework and some CPT code changes relating to hernia repairs in 2023 just in case they may come up in the coding exam this year. I also will give you more homework to do so without further ado. Let's get started. Elements of an operating report.
Assuming you already watched my last three videos titled how to master your coding op report part 1, part 2 and part 3. So you should know by now that every op report should include these standard elements. The pre-op diagnosis, the post-op diagnosis, the name of the procedure. the narrative description of procedure, the type of anesthesia, the search name and signature, and last but not least is the pathological findings.
For the purpose of my training objectives, I want you to focus on first the post-op diagnosis. This will help you find the accidentian primary co-assignment. Next is the name of the procedure and this will give you an idea. what they are planning to do to treat the current condition.
Next is the narrative decryption of procedure and this is the most important element of the op report simply because it will validate and support any procedure code or codes that you assign either in CPT or PCS. And last equally important element is pathological findings. It provides crucial information for diagnosis and procedure call assignment. I just want to let you know that each and every single op report that I go over has some main points or key takeaways that you should take notes and learn.
Alright let's go over the homework shall we? Operator report number eight pre-op diagnosis benign prostatic hyperplasia with urinary obstruction, bladder calculi. Post-op diagnosis, the same, benign prostatic hyperplasia with urinary obstruction, bladder calculi. And this is one of the important elements that I want you to focus on, simply because this will help you find the right RC10-CM diagnosis and it should be designated as the primary diagnosis after findings.
Specifically in our case, the patient presents with two different conditions. First benign prostatic hyperplasia with urinary obstruction and second stone in the bladder. Procedure performed aquaplasia, citolytolapasy. This element is also important because it will give you the idea what they are planning to do. to treat the condition and in this case two separate procedures.
First aqua operation Aqua means water and ablation means a surgical removal of body tissue. So aquaplation means a procedure that use the power of water to remove a body tissue and in our case to remove excess prostate tissue to treat the PPS condition benign prostatic hyperplasia. Second, Cyctolitholapacylitholapacy. Cyctolitholapacy means urinary bladder. Litho means stone, so litholapacy means a procedure of removing bladder stone by crushing them and extracting, booting them all together.
Cyctolitholapacylitholapacy means a procedure to break up and remove stone in the urinary bladder. Knowing the meaning of these medical terms will help you read and understand the details of the op report. Next is the decryption of the procedure and this is the most important element of the op report simply because it will validate and support any procedure code or codes that you assign either CBD code for outpatient or PCS code for inpatient.
As you already learned from my last three videos, usually in the first paragraph or the first few sentences, They will tell you how the anesthesia was given and since this is a closed procedure so there is no incision involved. That said you should start reading from here. I proceeded to perform cytoscopy using the 22 frame cytoscope. I then took the 26 frame continuous flow reset the scope safe and under direct vision.
was able to enter the bladder. Using the laser bridge, I then proceeded to use the 550 homium laser fiber and with setting up 1 joules and 60 hertz, the stone was fragmented into very small tiny pieces. Once both stones were fragmented, I then used the setting of 2 joules and 10 hertz and fragmented the chunks of stone into small pieces.
The small fragments were then removed using the electric evacuator. So based on what I just read and underlined, the scitolitholapacy is performed first in which a laser was used to break bladder stones into small pieces and then was removed using an evacuator. Let's continue reading to find out how the aquaplacent is performed.
The bladder neck and virulomontanum were marked and confirmed in the treatment contour. The aquaplacian treatment was then started following the rejection contour confirmed under ultrasound guidance. Total aquaplacian time initially was 3 minutes and 7 seconds.
Once the aquaplacian rejection was completed, I thought it was best to perform a second pass from the bladder neck. to the microstatic area and this also took roughly 3 minutes and 11 seconds. Subsequently, the contour was then adjusted to conform to the intended rejection margin prior to performing the second pass. Once this was completed, I then removed the 24 frames aqua beam handpiece. There was no significant hemorrhage noted.
Once this was completed, A 22 French 3-way Cuddle catheter was placed in the bladder and the bladder was placed on light traction with continuous normal saline irrigation. The patient was subsequently awakened and taken to recovery in stable condition. Findings to bladder calculate one measure roughly 5 cm in diameter and the other measures roughly 3 cm in diameter. Last prostate measuring 61 grams. For the purpose of learning, except the anesthesia portion, I read every single word in the description of the procedure just to help you understand how it is done.
And once you are familiar with this procedure, you don't have to read that much in details, just to focus on a few important elements. For example in this case, First, the stone was fragmented to verify the siptolitho labacy was done. And next, the aquaplasia research was completed to verify the second procedure was also performed in addition to the size of the stone which is 5 cm after findings. Now, you have already obtained all crucial information in order to call this case.
Post-op diagnosis, benign prostatic hyperplasia with urinary obstruction and bladder calculi. Procedure performed, aquaplacian and cittolitholapacy. I will put on a short 30 second music while waiting for you to look up the codes in the RC10CM and CPT books. Please pause the video and do it now. Assuming you already looked up the codes in the ICTEN-CM and CBT books, so let's see how you did.
In the index in the ICTEN-CM book, if you look under the main term, hyperplasia, prostate with lower urinary tract symptoms, you will see N40.1. Your next step is always to double check the alphabetic index code in the top of the list and here's what you find. N40.1 benign prostatic hyperplasia with lower urinary tract symptoms and this is the right call to report for benign hyperplasia with urinary obstruction. Follow the same step in the index in the IC10 same book.
If you look under the main term calculus, calculi, calculus, bladder, you will see N21.0 again. You have to double check this code in the top of the list and here's what you find. N21.0 calculus in bladder and this is also the right code to use for bladder calculates or stone in the bladder. For the CBT procedure code, if you look under the main term sictolitholapacy, you will not find it so you should start with the main term litholapacy.
It will give you a cold range 53217 to 53218. Your next step is to double check this cold range in the tabular list and here's what you find. 53218 litholapacy, crushing or fragmentation of calculates, large over 2.5 cm. And this is the right cold to use for cytolitholapacy of a stone in the bladder.
Measure. 5cm. For the second procedure, aquaplacent, as you probably know that technology such as surgical robots, artificial intelligence, 3D or new imaging methods are already changing the way surgical procedures are performed. Aquaplacent is the new emerging procedure that uses a water jet controlled by robotic technology to remove the prostate and because It is a new procedure.
CBT has a temporary set of codes for this emerging technology, service and procedure. That said, you probably will not find the main term aquaplacent in the index. Instead, in your CBT book, there is a section called category 3 codes and they are listed in numerical order instead of anatomical location. If you have time, I recommend that you should take a look at these codes and have an idea what they are for. If your book is current, then you should find these codes.
0421T transurethral water jet operation of prostate including control of post-operative bleeding including ultrasound guidance complete. You will notice that All CPT category 3 codes have 5 characters. The first 4 characters are numeric and the last character T stands for temporary. You should know this for your coding exam. That all being said, if you code this case correctly, then you should come up with N40.0 for benign prostatic hyperplasia.
with urinary obstruction and 21.0 for calculus in bladder, CPT 53218 for schizolitholapacy 5 cm bladder stone and U2421T for aquaplasia. I hope you got it right. Let's move on to the next case.
Operating report number 9, pre-op diagnosis. Recurrent ventral hernia, post-op diagnosis the same, recurrent ventral hernia and this element will help you find the right accidential diagnosis code and this should be designated as the primary diagnosis. Procedure performed, laparoscopic ventral hernia repair, mesh explained. This element will give you an idea what they are planning to do to treat that condition mentioned above. Decryption of procedure, this is the most important element of the op report simply because it will validate and support any procedure code or codes that you assign either CPT code for outpatient or PCS code for inpatient.
As you already know by now, to save your time you should skip the first paragraph where it describes how the anesthesia is given. and start where the incision is made or where the cavity is accessed for endoscopic procedure. And in this case you should start here. The peritoneal cavity accessed under direct vision using a left upper Warren 5 mm OptiView port.
We insufflated the peritoneal cavity to 10 mm as she was CO2 and under direct vision placed to millimeter robotic post in the left abdomen. The defect was noted to be 9x9 centimeter with a significant diastasis. The diastasis was re-approximated utilizing a running V-lock 180 suture up to the point of the defect itself.
I then repaired the posterior rectal shaft by suturing them together. Prior to finishing the posterior rectal shaft closure, we placed the mesh in the extraperitoneal space. We then excite and the old scar and make an approximately 4cm midline incision in the peri-umbilical region and remove the mesh to this. The old mesh blood was significantly adherent to the subcutaneous tissue and this was also removed.
clean up the S-optic fascia and re-approximate with the 0VLOC 180 sutures. We then remove the port under direct vision and allow the CO2 to escape. No drain was left.
The subcutaneous fascia and deep dermis were closed with a series of interrupted 2.0 microsutures, followed by all of the skin side being closed with subcuticular, 4-0, monocry and dermabond. The patient tolerated the procedure well and there were no complications. He was slapped in the hands of the anesthesia team for a tap block which went off without a hinge.
He was transferred to the recovery room in good condition, finding a 9cm circular midline defect with all intraperitoneal mesh covered with omentum requiring rejection of the portion of the omentum stuck to the mesh. Now you already have all crucial information in order to code this case, the post-op diagnosis recurrent ventral hernia, procedure performed, laparoscopic ventral hernia with mesh removal. I'll book on the short 30-second music while waiting for you to look up the codes in the IC10CM and CPT books. Please pause the video and do it now.
Alright, let's see how you did in the index in GRC 10-7 book if you're under the main term. hernia ventral recurrent, it will instruct you to see hernia incisional. Follow the instruction, you look under the mental hernia incisional, you will see K43.2.
Your next step is the only way to double check the alphabetic index code in the tabular list and here's what you find. K43.2 incisional hernia without obstruction organ green. And this is the right code to report for a recurrent ventral hernia. You notice that the code description does not mention initial or recurrent hernia. So in RC10CM, it doesn't matter initial or recurrent ventral hernia, you will use the same code.
In contrast, CBT has separate codes for initial and recurrent ventral hernia repair. So you should take note. That's it. In your CBT book, if you look under the main term hernia ventral, it will give you a whole bunch of codes.
The code range 49591 to 49596, 49613, 49614, 49615, 49616, 49617, 49618, mesh prosthetic removal, urine repair, 49623. Your next step is to always duplicate this code in the tabular list and find out which code best describes the procedure performed. For those of you who already watched my last two videos about how to master your coding op report, took notes and tap your book, then you should go directly to the page that contains all the new codes relating to the anterior abdominal hormonal repair 49591 to 49623 and here's what you find. 49615 repair of ventral hernia recurrent 3 to 10 centimeter reducible and based on the op report the old mesh was also removed during the hernia repair and CPT has an add-on code to report this extra work 49623 If you are a new student, then you must know that the plus sign symbol indicates this is an add-on code so you should never report it as a standalone code.
A primary code must be assigned first followed by the add-on code. I hope you will remember this. That said, if you go this case correctly, then you should come up with K43.2. for a recurrent ventral hernia, CPT-49615 for a repair of recurrent ventral hernia 9cm reducible and an add-on code 49623 for a removal of a total or near total non-infected mesh at the time of repair.
The key takeaway in this case is due to the CPT code change in 2023 relating to anterior abdominal hernia repairs. You don't have to worry about whether it is open or laparoscopic approach, whether it is performed with or without a mesh. All you need to focus is first if it is an initial or recurring hernia, second it is reducible or insaturated, third either size of the defect less than or greater than three centimeters and last but not least is whether or not an old mesh is removed at the time of the repair.
I hope that you have learned something new in this video and your time is well spent here. And this is your homework. Operative report number 10. Pre-op diagnosis.
PPH associated with nocturia. Post-op diagnosis the same. BPH associated with nocturia, procedure performed, cystoscopy with insertion of urolip implant.
Operating report number 11, pre-op diagnosis BPH, benign prostatic hyperplasia, urinary retention, post-op diagnosis the same, PPH, urinary retention. Versace Buffon TURP Trans Urito Recession of the prostate, Cytoscopy with insertion of urolip implant time 4. Please note that these are new procedure and real operative reports that I am coding every day. I just want to share with you.
Please take your time to read and understand how it is done. Next time if you come across any of these new surgical procedure you know what to look for and able to call it efficiently. And that is the beauty of learning. That is all for today.
Thank you so much for watching, for liking and sharing this video. If you find this video helpful, informative and easy to learn with this format or if you have any suggestion, then please leave me a comment below just to let me know. I really appreciate it. I'll go over the homework in the next video.
Until next time, have a great day.