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 operative report accurately and efficiently.
Based on my 20 plus years of medical coding experience and observation, I believe those who are good at coding operative reports are the ones who usually get promoted to higher and better positions in the coding department. The simple reason is that surgical procedure codes either CPT for outpatient or PCS for inpatient will significantly impact hospital reimbursement. As a coder, understanding the operating report and coding them accurately are very important. It is one of the technical skills that will help you enhance and advance your coding career. Unfortunately, I didn't learn this valuable skill when I was in school for three reasons.
First, the teachers background and coding experience. Second, they don't have enough time to cover many aspects of coding in one or two semesters. And third is the lacking of real coding case samples for students to practice. practice and this is one of the main reason why I have created my YouTube channel to solve this problem. My plan is to share with you what I am coding every day so what you see in my videos are the real operator pre-post that I make some changes to protect the patient personal information and it is very time consuming so I just wanted to let you know.
With that in mind, today's video is about how to master your coding op report part 2. I will go over the homework and also give you more case to code. Sooner or later you will become a coding expert. Alright, without further ado, let's get right into it. Assuming you already watched my last video titled How to Master Your Coding Op Report Part 1, so I just wanted to give you a quick recap on what we have learned.
Every op report should include these standard elements. Pre-op diagnosis, post-op diagnosis, the name of the procedure, the narrative description of procedure, type of anesthesia, the surgeon name and signature, and last but not least is pathological findings. For the purpose of my training objective, I want you to just focus on first the poster of diagnosis.
You need this for the RC10-CM primary co-assignment. Next is the name of procedure. And this will give you an idea what they are planning to do to treat the condition Next is the narrative description of the 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. For each and every single operative report that I go over has some main points or key takeaways that you should take notes and learn. For example, The key takeaway you have learned from the operator report number one is CBD coating for wound debridement based on the depth of the tissue removal either subcutaneous tissue, muscle, fascia or bone.
and also the size of the wound starting from the first 20 square centimeters or less. So you should highlight these goals in your CPT book and take note the difference. On the op report number 2, The key takeaway is CBT has different codes for partial mastectomy 19301, simple mastectomy 19303, radical mastectomy 19305 and modified radical mastectomy 19307. So you should do the same. Open your CBT book, highlight these codes and make notes of that.
On the operative report number 3, the key takeaway that you have learned from this case is CPT has two different codes for neuroplasty, ulnar nerve at elbow 64718 and ulnar nerve at wrist 64719. So when you read the details of the op report, you need to find out where the incision is made, either at the epicondyle elbow or at the wrist level. Operative report number four. All right let's dissect this op report. Pre-operative diagnosis, right middle trigger finger. Post-operative diagnosis, right middle trigger finger.
And this is one of important element that I want you to focus on because it will help you find the right Acetan-CM diagnosis code and it could be designated as primary diagnosis if this is the main reason for this visit. Procedure performed, right middle finger released. This element is also very important because it gives you the idea What you are about to read is something they have to cut to release. In a patient with trigger finger, the A1 pulley becomes inflamed and thickened, making it harder for the flexor tendon to glide through it.
And it is very painful as the finger bends. So the goal of the procedure is to release the A1 pulley which is the pulley responsible for blocking tendon movement. After release, the flexor tendon can climb more easily through the tendon sheath, making the pain and clicking sensation go away.
Knowing this will make you read the body of the report with a laser focus. Next, the decryption of the procedure. As I mentioned in the last video, 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 here.
I just want you to scan the body of the opipode and find where it starts with the keyword incision. or any verbage that indicates the skin and tissue have been inside so that the surgeon has a full view of the structure or organ involved. In other words, they approach and start reading from there. And in our case, a longitudinal incision was made over the A1 pulley of the right middle finger. The radial incision is the same.
ulnar digital neurovascular bundles were identified and protected. The A1 pulley was identified and was divided. Approximately, the palmar pulley was in sight.
The tendons were carefully retracted and there was some nodular adherent to the flexor digitorum which was sharply deprived. The last paragraph usually tells you how the wound is closed so you should not waste your time here either. On another note, you do not call the debridement although it is documented, simply because it is considered a part of the main procedure.
In addition, you don't have a confirmed diagnosis to support the debridement code, for example, wound infection or tendinitis. Here is a general rule that you should take note. Every CPT code must be supported by a corresponding IC10-CM diagnosis code that supports medical necessity for the procedure that's what performed. I'll say it again.
Every CPT code must be supported by a corresponding IC10-CM diagnosis code that supports medical necessity for the procedure that's was performed. Now, you have already obtained all crucial information. In order to call this case, Post-op diagnosis, dry metal trigger finger, procedure performed, dry metal finger released.
So I put on a short 30 second music while waiting for you to open Yashii 10cm and CPT books and look up the codes. Please pause the video and do it now. Assuming you already looked up the codes in the ICT10CM and CPD books, so let's see how you did. In the index in the ICT10CM book, if you look under the main term, trigger finger, subterm middle finger, you will see m65.33-.
It means this code is not complete. The dash or hyphen indicates that. Additional characters are required. And as a rule of thumb, you always have to check the alphabetic index code in the table listing.
And here's what you find. M65.331, trigger finger, right middle finger. And this is the right code to report for this condition.
For the procedure, in the index indexing CPT book, If you look directly under the main term trigger finger repair, it will give you just one code 26055. So your next step is to double check this code in the tabular list and here's what you find 26055 tendons incision using 4 trigger finger and this is also the right code to use for this procedure That said, if you go this case correctly, then you should come up with M65.331 for the right trigger finger and CBT 26055 for trigger finger release with BF7 for the right middle finger. I hope you got it right. The key takeaway you have learned from this case is, CBT has only one code for trigger finger release, 26055, so you don't need to spend too much time to dig deep into the op report.
However, a patient can have more than one trigger finger and if that is the case, then you have to use the same code 26055 with appropriate modifiers F1 to F9 for each finger accordingly. Pre-operative diagnosis right upper water and pain. post-operative diagnosis calculus of gallbladder with chronic cholecystitis.
And this is one of important elements that I want you to focus on because it will help you find the right RCTEN-CM diagnosis code and it should be designated as the primary diagnosis. Next is the procedure performed. cholecystectomy.
Chole means gallbladder and ectomy means surgical excision. So cholecystectomy is surgical excision of the gallbladder. If you are new to coding and not familiar with any medical terms in this element, the procedure performed, then I strongly suggest that you should look it up in your medical dictionary or on google. so that you will have an idea what you are about to read in the body of the op report.
Also, if you have never coded this surgical procedure before, then you should know CBT. has different codes for open cholecystectomy versus laparoscopic cholecystectomy with or without cholangiogram. However, you cannot tell from the procedure performed because the physician forgot to say it. and it does happen sometimes. So your job is to read the description of the procedure and find out if this surgical procedure is performed openly or via laparoscopic approach.
Let's find out. As I already mentioned, 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 here. I want you to just scan the body of the op report and find where it starts 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 or organs involved. In other words, the approach and start reading from there. And in our case, through a 2 cm inframullicular incision, a hash and trochlea was placed into the peritoneal cavity and pneumoperitoneum.
was introduced without difficulty. Three 5mm plumb tip tool cars were then placed under direct visualization into a megastar space to ride up a wall and ride lower wall. And the key work tool car is exactly what I am looking for.
This is the photo of the tool cars. without place to the abdomen during laparoscopic surgery. The toe cap function as a portal for the placement of other inducements such as cutting device, grasper, seizure, stapler, etc. The keyword troca confirms this is a laparoscopic surgery. So your next step now is to find out if in fact the gallbladder was removed.
So let's continue reading. Adhesion to the gallbladder was sharply divided. The gallbladder was scrapped and its fundus retracted, C-flat. Then the triangle of callus was dissected out. with a combination of lung digestion and electrocautery.
Based on what I just read and highlighted, the gallbladder was grabbed, retracted and dissected out and I believe I now have all crucial information in order to call this case post-op diagnosis calculus of gallbladder with chronic cholecystectomy. Procedure performed, laparoscopic cholecystectomy. So you don't have to spend time and read the remaining text of the op report. Let's say you are taking a coding exam or coding this case at work. You can save yourself a lot of time.
Now you know, you will never waste your time to watch my videos. More or less, you learn something new. Alright, I will put on a short 30-second music while waiting for you to open Yashiten CM and CBT books and look up the code.
Please pause the video and do it now. Assuming you already looked up the codes in the RC10-SAM and CPT books, so let's see how you did. In the index in the RC10-SAM book, if you look under the main term calculus, subterm goal bladder with goalie 6 titles, you will see K0.10. Your next step is to double check this code in the tabular list and here's what you find. KA0.10 calculus of gallbladder with chronic cholecystitis without obstruction and this is the right code to use for this condition and it should be designated as the primary diagnosis.
In terms of the procedure, in the index in your CPT book if you under the mental cholecystectomy subterm laparoscopic it will give you a code range 47562. to 47564. So your next step is to check these codes in the top of the list and here's what you find. 47562, laparoscopic surgical cholecystectomy and these codes is the right code to use for this surgical procedure. Having said that, if you call this case correctly then you should come up with K0.10 is calculus of gallbladder with chronic cholecystitis and CPT-47562 for laparoscopic cholecystectomy. So the key takeaway that you have learned from this case Colicectomy can be done either openly which is more invasive requiring a large incision cutting into the skin so that the physician can access body tissue, organs or other internal parts.
All closed technique via laparoscopy and the key word for you to remember today is CHOCA. And here's your homework. Operative report number 6, pre-op diagnosis, post-coital bleeding, thickened posterior endometrial wall.
Post-op diagnosis, post-coital bleeding, thickened posterior endometrial wall. Procedure performed, diagnosis, heteroscopy, dilation and curative. And operating report number 7, pre-op diagnosis, small lung incision area, history of cholecystectomy, post-op diagnosis, incisional hernia without obstruction or gangrene, procedure performed, robotic, incisional, hernia repair wood mesh.
For the purpose of learning, I want you to take your time to read the entire operative 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 that is the beauty of learning. These are the real cases that I call every day and I just wanted to share it with you. Learning is the new beginning.
that we can give ourselves every day. If we end the day without knowing more than yesterday, then we should wonder. That is all for today.
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