Lecture Notes: Mastering Coding for Operative Reports (Part 2)

Introduction

• Speaker: Hong, coding expert
• Audience: Aspiring coders, particularly those taking CPC, COC, CCS, or CCSP exams.
• Main Message: Understanding and accurately coding operative reports is essential for advancing in a medical coding career.

Importance of Coding Operative Reports

• Significance: Surgical procedure codes impact hospital reimbursement significantly.
• Career Impact: Proficiency in coding operative reports often leads to promotions within the coding department.
• Challenges in Learning: Many schools lack proper training in coding operative reports due to various reasons.
• Channel Purpose: Hong's YouTube channel aims to provide real-world coding case samples for practice.

Key Elements in an Operative Report

• *Standard Elements Include:
  • Pre-op diagnosis
  • Post-op diagnosis
  • Name of the procedure
  • Narrative description of the procedure
  • Type of anesthesia
  • Surgeon’s name and signature
  • Pathological findings

Focus of Today's Lecture

• Homework Review: Discuss previous cases and new practice cases.
• Objective: Focus on understanding and extracting crucial elements from operative reports for accurate coding.

Previous Cases Recap

1. Op Report 1: Wound Debridement
   • Key Takeaway: CPT coding is based on the depth of tissue removal and size of the wound.
2. Op Report 2: Mastectomy
   • Key Takeaway: Different CPT codes for various types of mastectomy (Partial, Simple, Radical, Modified Radical).
3. Op Report 3: Neuroplasty
   • Key Takeaway: CPT has different codes for neuroplasty depending on the location (elbow vs. wrist).

Detailed Analysis of Current Cases

Case 1: Trigger Finger Release

Pre-Op and Post-Op Diagnosis

• Condition: Right middle trigger finger
• Procedure Performed: Right middle finger release

Coding Insights

• Narrative Description: Helps validate and support the procedure codes.
• Key Points: Identify keywords like incision to know where to focus while reading the report.
• General Rule: Every CPT code must match a corresponding ICD-10-CM code for medical necessity.

Codes Used

• M65.331 for right middle trigger finger
• CPT 26055 for trigger finger release
• Modifiers: F1 to F9 might be needed for multiple fingers.

Case 2: Cholecystectomy

Pre-Op and Post-Op Diagnosis

• Condition: Calculus of gallbladder with chronic cholecystitis

Coding Insights

• Procedure Performed: Laparoscopic cholecystectomy
• Keyword: Trocar indicates laparoscopic approach.

Codes Used

• K80.10 for calculus of gallbladder with chronic cholecystitis
• CPT 47562 for laparoscopic cholecystectomy
• Types of Procedure: Open vs. Laparoscopic (keyword: Trocar)

Homework

1. Operative Report 6: Hysteroscopy and Curettage
   • Diagnosis: Post-coital bleeding, thickened posterior endometrial wall
   • Procedure: Diagnostic hysteroscopy, dilation & curettage
2. Operative Report 7: Hernia Repair
   • Diagnosis: Incisional hernia, history of cholecystectomy
   • Procedure: Robotic incisional hernia repair with mesh

• Objective: Read the entire report to understand the procedures.

Concluding Remarks

• Learning Outcome: Mastering real-world operative report coding through practice.
• Encouragement: Keep learning and striving for career advancement.
• Channel Support: Like, subscribe, and share to support Hong’s educational efforts.
• Well Wishes: Gratitude and good wishes for the New Year.