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 CPC, COC, CCS or CCSP exam, then besides understanding coding rules and guidelines, you must know how to code an operator report accurately and efficiently. First of all, I am really sorry that I didn't have time to go over the homework any sooner. I have been so busy with work.
However, I always remember you. And that is why anytime I come across a good operator report while I am coding, I always save it so that I can share with you later. The more you practice coding these surgical cases, the better and sooner you will advance your coding profession.
If you stay consistent and keep learning, you will pass the coding exam eventually and get a job. Then you will appreciate the time that you spend. with me to code these surgical procedures.
In today's video, I will go over the homework and some CBD 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. Element of an operator report. Assuming you already watched my last two videos title how to master your coding op report part 1 and part 2. So I just wanted to refresh your memory.
Every op report should include these standard elements pre-op diagnosis post-op diagnosis the name of procedure the narrative description of procedure the time of anesthesia the search and name and signature and last but not least is pathological findings For the purpose of my training objectives I want you to focus on first The poster of diagnosis, you need this for the RC10-CM primary call assignment. Next, is the name of the procedure and this will give you an idea what they are planning to do to treat the condition. Next, is the narrative description of procedure and this is the most important element of the OP report simply because It will validate and support the procedure code or codes that you assign.
And the last equally important element is pathological findings. It provides crucial information for diagnosis and procedure co-assignment. I wanted to remind you that each and every single OP report I go over has some main points or key takeaways that you should take notes and learn. Alright, let me go over the homework that I gave you in the last video. OP report number 6 Pre-op diagnosis post-coital bleeding thickened posterior endometrial wall.
Post-op diagnosis the same post-coital bleeding thickened posterior endometrial wall. And this is one of important element that I want you to focus on. because it will help you find the right accident CM diagnosis code and it should be designated as a primary diagnosis after findings. Procedure performed.
Diagnosis, Heteroscopy, Dilation and Curative. This element is also very important because it will give you the idea what they are planning to do to treat the condition and in this case a hysteroscopic dilation and curvature. No indecision is made for this procedure. because it is conducted through a heteroscope, a type of endoscope that allows the physician to view the inside of the uterine cavity and also take samples of the endometrium. Knowing this will make you read and easily understand the body of the opipode.
Next is the decryption of the procedure. As I mentioned in the last two videos, usually in the first paragraph or the first few sentences, it will tell you how the analysis was given so you should not waste your time here. Since this is a closed procedure and there is no incision involved, so you should start reading from here.
A diagnosis heteroscopy was performed for the above procedure. Subcortics were then done for a large amount of tissue, which was sent to pathology. Repeat hysteroscopy showed a normal appearance cavity and the procedure was terminated. The tenaculum and speculum were all removed and the patient left the OR in stable condition.
At time of surgery, the patient had normal appearing endometrial cavity except for a thickened posterior wall and lower urine segments. There was no obvious fibroid or polyps. Now you have already obtained all crucial information in order to call this case. Post-op diagnosis, post-cold bleeding and thickened posterior endometrial wall, procedure performed, diagnosis, heteroscopy with dilation and colitis.
So I will put on a 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. Assuming you already looked up the codes in the IC10CM and CPT book, so let's see how you did.
In the index in the IC10CM book, if you look under the main term bleeding post-coital, you will see N93.0. Your next step is always to double check the alphabetic index code in the tabular list and here's what you find. N93.0 post-coital and contact bleeding and this is the right code to use for this report.
Similarly, in the index in the Yashitenshin book, if you look under the main term thickening endometrium, you will see N93.89. Again, you have to double check this code in the tabular list and here's what you find. R93.89 abnormal findings on diagnosis imaging of other specified body structures and this is also the right code to use in this case for the procedure in your CPT book. If you look under the main term, Hystereoscopy, surgical with biopsy, it will show you just one code, 58558. Your next step is the same as you do in the IC10-CM, which is to double check this code in the tabular list and here's what you find. 58558, Hystereoscopy, surgical with sampling of endometrium with or without DNC.
and this is also the right code to use for this procedure. That said, if you code this case correctly, then you should come up with N93.0 for post-coital bleeding. R93.89 for thickening posterior endometrial wall and CBT585-5A for hysteroscopy with dilation and colitis.
I hope you got it right. The key takeaway that I want you to learn from this case is CBT has only one code for hysteroscopy with dilation and colitis, biopsy and polypectomy, in other words, remove a uterine polyp. So you can use this code 58558, even no biopsy or polypectomy is performed.
as long as the physician use a heteroscopy to inspect the uterus and perform a DNC cervical dilation and curative. Operative report number seven. This is a two-page report.
Pre-op diagnosis, small lung incision area, history of cholecystectomy, post-operative diagnosis, incision of hernia without obstruction or gangrene. This is one of important elements that I want you to focus on because it will help you find the right acutensia diagnosis code. Procedure performed, robotic incision of hernia repair wood mesh. This element is also very important because it will let you know what they are planning to do to treat the condition and in this case a robotic surgery to repair an incisional hernia like laparoscopic surgery. Robotic surgery uses a laparoscope.
and is performed in the same manner, small incision, a tiny camera, inflation of the abdomen and projecting the inside of the abdomen onto television screens. Knowing this, we make you read and easily understand the body of the opipode. Next is the description of the procedure.
Before reading the detail of this op report, I want you to know that one of the biggest changes in CPD code this year 2023 is related to hernia repairs. This is a snapshot of new CPD codes in 2023. 18 codes are being deleted and replaced by 14 new codes. As you already know, The new procedure code are marked with red dot.
Let's find out what have been changed in 2023. 49591 Repair of anterior abdominal hernias i.e. be gastric, incisional, ventral, umbilical, spagelian, any approach i.e. open, laparoscopic, robotic, initial, including implantation of mesh or other prosthesis when performed, total length of defects less than 3 cm reducible. 49593 less than 3 centimeters, insaturated or strangulated. 49563 3 centimeters to 10 centimeters, reducible. 49613 repair of anterior abdominal hernia.
i.e. epigastric, incisional, ventral, umbilical, subaxialian, any approach i.e. open, laparoscopic, robotic, recurrent, including implantation of mesh or other prosthesis when performed, total length of defect less than trisomita, reducible. This code is exactly the same as 49591 except the keyword recurrent. The rest of them are identical so they are the same as 49693 except the size is bigger and whether it is reducible or insaturated. So based on what I just underlined, you can tell, instead of breaking down by the specific hernia type and approach as they were in 2022, this year the course will include all anterior abdominal hernias, epigastric, incisional, ventral, umbilical, spasialis. Any approach, open, laparoscopic or robotic.
So what you have to focus now is first whether it is initial or recurrent, second reducible versus insaturated or strangulated, and third is the length of the defect less than 3cm, 3 to 10cm and greater than 10cm. It is important to know that the cold decryption contains hernias and defects. in blue reform so it means that if multiple abdominal hernias are repaired, the total length of those defects could be added together and only one CPT code should be reported to cover all repairs performed. Also, all your hernia CPT codes also includes the implantation of mesh, so CPT-4956A has been deleted with no replacement code. Alright, let's go back to our case.
Due to CBD code changes in 2023 as I just mentioned, so what you have to focus now is first to find out if the incisional hernia is initial or recurrent. Based on the pre-op and post-op diagnosis, there is no mention of recurrent hernia. so it is considered initial hernia.
Second, whether it is reducible, versed, insaturated, or strangulated. And third is the length of the defect, either less than or greater than 3 cm. So let's read the description of the procedure and find out. As you already know, usually in the first paragraph or the first few sentences, It will tell you how the anesthesia was given so you should not waste your time reading this.
I want you to just scan the body of the opipode and find waist size with the keyword incision or any verbiage that indicates the skin and tissue have been inside so that the surgeon has a full view of the structure organs or body cavities. In other words, the approach is to start reading from there. And in our case, A stab incision was made with a knife in the left upper quadrant and two of these virus needles were played.
Pneumoperitoneum was achieved. Then under direct vision three 8 millimeter robotic ports were placed. Specifically, ones were in the left upper quadrant, one in the left mid abdomen and one in the left lower quadrant.
Care was taken to not injure the intra-abdominal viscera upon insertion. The patient incision hernia was identified in the peri-umbilical area and did have exacerbated omentum. It's great that the hernia is documented and insaturated. In other words, the contents of the hernia are not able to be reduced, then it is considered insaturated.
The last piece of information is the sign of the defect. So let's continue reading. There was no bowel content within the hernia sac.
After the omentum was reduced, the incision of hernia was slowed primarily. The defect was approximately 3 cm inside. You already got all the information that you need to call this case. It is an initial incision of hernia.
It is insaturated and the defect size is 3 cm. So I don't want you to waste your time and read the remaining off the off report. I will put on a short 30 second music while waiting for you to look up the codes in Yashi 10 cm and CPT books.
Please pause the video and do it now. Assuming you already looked up the codes in Yashiten CM and CBD books, so let's see how you did. In the index in Yashiten CM book, if you look under the main term, insaturation, hernia, it will direct you to see also hernia by sight with obstruction. So follow the instruction, you look under the main term, hernia, incisional, With obstruction, you will see K43.0.
Your next step is to always double check the alphabetic code in the tabular list and here what you find. K43.0, insaturated incisional hernia without gangrene and this is the right code to report for this patient condition. Similarly, in the index in your CPT book, If you look under the main term hernia repair incisional you will see a cone range 49591 to 49596. Your next step is to double check these codes in the top of the list and here's what you find. 49593 repair of incisional hernia any approach initial 3 to 10 centimeter incisorated If you call this case correctly then you should come up with K43.0 for insaturated incisional hernia with darkened green and CPT 49593 for robotic incisional hernia repair with mesh. I hope you got it right.
The key takeaway in this case is due to CBD 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 reducible or insaturated and third is the size of the defect less than or greater than three centimeters. I hope you take note and here's your homework.
Operating report number eight, 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, systolethrolapacy.
Operative report number nine, pre-op diagnosis, recurrent ventral hernia, post-op diagnosis, recurrent ventral hernia, procedural form, laparoscopic ventral hernia repair, mesh explant. For the purpose of learning, I want you to take your time and read the entire operating report and try to understand how it is performed. Next time, if you come across any of these surgical procedures, you will know what to look for and able to call it efficiently. And that is the beauty of learning.
These are the real operating reports that I call every day. and because they are relating to new CPT code changes in 2023. So I just wanted to share with you. That is all for today. Thank you so much for watching, for liking and sharing this video. If you find this video is 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 will go over the homework in the next video. Until next time, have a great day.