Saturday, August 29, 2009

The subtle nuances of coding......

Another week has flown by, and this week was full of coding subtlety. I had the opportunity to work with a coder who has around 20 years of experience in OB/GYN coding and we were able to share our ideas and thoughts...

First up, we discussed the usage of modifier 22 and 59 in the coding scenario below. We were presented with a well documented case, and probably 5 coders all looked at it, and came up with different answers. However, in the end we all came to consensus...

In this scenario, the provider documented a Lap assist vag hysterectomy w/extensive adhesiolysis, and a monarch sling repair.... Initially, it looked very straightforward but we thought we might add a mod 22 to the lap assist vag hyst to cover the extensive adhesiolysis.

however, as we dug deeper into the actual verbiage of the case... the adhesiolysis was performed laparoscopically, then the case was converted over to a straightforward vaginal hysterectomy, and a monarch bladder sling....

Learning lesson... Always dig deeper, and ask the opinion of other coders around you!!! WOW what a great learning moment.

Then I got to work with a physician on improving his documentation for the E&M Discharge code 99238 and 99239... I reviewed the requirements for billing the 99238... CPT has clarified what has to be documented fodr the 99238. No longer can you simply state that you discharged the patient to home.... Again.. another situation where I got to witness an "a-ha, I get it now" moment.

And to finish up the week, one of my favorite neurosurgery coders sent me an op to look at as she wasn't sure she was on the right track.... In this scenario, the provider was performing a nerve decompression, but the operative note read nearly like a neuroplasty... It was an amazing case to review, and I am so glad that she shared it with me!

So... as for the "coding coach" part of this weeks blog... I guess all I can say is, take the time and really read and review your operative notes, and if you're unsure... Spread the love, and ask the opinion of other coders around you! It's amazing what you both can learn from each other!

Keep Learning, Keep Coding, and have fun!!!!

Sunday, August 23, 2009

Keloids and Umbilical Granuloma ??? Say What???

This weeks blog is based after recieving a couple of e-mails regarding Keloids and Granulomas. I've shared below for you with the appropriate answers... In addition I also provided the definitions and terminology for you to review too. HAPPY CODING!

Q: Can you help me? Keloid?- what CPT should I use? The note is below….

Note: Keloid. Per pt request, injected 0.3 mL of steroid into the two keloids on the abdomen. The wounds covered with bandages and pt advised to return as needed. A dermatology referral was also placed.

A. Keloid's are scars or cicatrix's DX 701.4 CPT code 11900 Report it only once. as CPT states that code 11900 is for up to and including the 7th lesion. The medication (steroid) should be reported with the appropriate "J" HCPCS code for what medication (steroid) was injected. If your provider is injecting more than seven lesions, then you should use code 11901 which states more than 7 lesions.


Q How do I code this procedure? I can’t seem to find where it fits…I’m guessing maybe the destruction code 17000, but I also saw code 17250. Am I on the right track?

Note: Six-week-old male infant was brought to the office by his mother. During a diaper change, mom noted a lesion in the bellybutton area. . On examination, there was a soft, red mass at the base of the umbilicus. The lesion was slightly moist, no foul discharge or purulent drainage was present. The surrounding skin was not red, warm, or swollen. I determined this to be an umbilical pyogenic granuloma. Silver nitrate applied and mom to bring child back for follow up x 1 wk.

The correct CPT code to use is the 17250, Which CPT defines as the chemical cauterization of granulation tissue, proud flesh, sinus or fistula. In the scenario above you would want to code dx 701.5 as “other abnormal granulation tissue”



Keloid: A keloid (also known as a "keloidal scar” is a type of scar with mainly type I and some type III collagen which results in an overgrowth of tissue at the site of a healed skin injury. Keloids are firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to flesh-colored or red to dark brown in color. A keloid scar is benign, non-contagious, and can be accompanied by severe itchiness, sharp pains, and/or changes in texture. In severe cases, it can affect movement of skin or it’s elasticity.

Granuloma: is a medical term for a ball-like collection of immune cells which forms when the immune system attempts to wall off substances that it perceives as foreign but is unable to eliminate. Such substances include infectious organisms such as bacteria and fungi as well as other materials such as keratin, suture fragments and vegetable particles. A granuloma is therefore a special type of inflammatory reaction that can occur in a wide variety of diseases, both infectious and non-infectious. The adjective "granulomatous" refers to diseases or inflammatory reactions that are characterized by granulomas.

Umbilical granuloma
is the most common umbilical abnormality in neonates, causing inflammation and drainage.
Pyogenic Granuloma: The appearance of pyogenic granuloma is usually a color ranging from red/pink to purple, and can be smooth or lobulated. Younger lesions are more likely to be red because of the high number of blood vessels. Older lesions begin to change into a pink color. Size ranges from a few millimeters to centimeters. It can be painful, especially if located in an area of the body where it is constantly disturbed. Pyogenic granulomas can grow rapidly and will often bleed profusely with little or no trauma.

*terminology definitions provided by Wikipedia, the free encyclopedia