Robyn Korn, MBA, RHIA, CPHQ

1
Medical Coding I Week 5Respiratory,
Cardiovascular and Heme/Lymphatic Systems

• Robyn Korn, MBA, RHIA, CPHQ

2
Respiratory - Nose

• Incision
• Excision
• Introduction only 3 codes
• Removal of foreign body
• Repair mainly cosmetic noncosmetic procedures
  need operative report to support procedure
• Destruction
• Other procedures

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Respiratory Accessory Sinuses

• Frontal
• Ethmoid
• Sphenoid
• Maxillary

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Respiratory Accessory Sinuses

• Incision- identify sinus and procedure
• Excision ethmoid and maxillary only
• Endoscopy unilateral modifier 50 used is
  bilateral
• Other procedures

5
Respiratory - endoscopy

• Diagnostic inspection of the entire nasal
  cavity
• Is included with surgical endoscopy
• Surgical nasal endoscopy used to complete
  surgical procedure
• Also includes sinusotomy if preformed

6
Respiratory - Larynx

• Excision
• Introduction
• Endoscopy direct and indirect type of scope
  and reason
• Repair reference repair, or larynx or
  laryngoplasty
• Destruction only one code 31595
• Other procedures

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Respiratory Trachea and Bronchi

• Incision planned, or emergency or fenestration
• Endoscopy no difference between rigid or
  flexible scopes fluoroscopic guidance is
  included
• Introduction catheterization and contrast
  material
• Repair site, type, reason, revision of
  tracheostomy scar
• Excision
• Other procedures

8
Respiratory - Bronchoscopy

• Codes are differentiated by
• With or without cell washing
• Brushing or protected brushings
• Bronchial alveolar lavage
• With biopsy
• Dilation
• Placement of stents
• Excision or destruction of tumors
• Placement of catheters
• Therapeutic aspiration
• Injection of contrast material

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Respiratory Lungs and Pleura

• Incision
• Excision
• Endoscopy
• Repair 4 codes
• Lung transplantation
• Surgical collapse therapy thoracoplasty
• Other procedures

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Respiratory - Endoscopy

• Diagnostic differentiated by
• Site
• Biopsy or no biopsy
• Surgical differentiated by
• Type of procedure performed via the scope
• Reference thoracoscopy, surgical, then type of
  procedure

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Respiratory - Transplant

• Three distinct components
• Removal of lung or lungs from cadaver
• Backbench work
• Transplant of lung into the recipient

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Case 1 - Respiratory

• Preoperative Diagnosis Mass on larynx
• Postoperative Diagnosis Pending pathology report
• Procedure Laryngoscopy
• The patient was prepped and draped in the usual
  fashion and placed in the supine position. The
  operating table was turned to 90 degrees, and a
  donut headrest was used for stabilization.
  Mirrors were placed for indirect visualization. A
  laryngoscope was inserted and suspended for
  visualization. The larynx and the surrounding
  area were inspected, and a biopsy of the larynx
  was taken. Hemostasis was verifi ed, and the
  scope was extracted. The patient tolerated the
• procedure and was sent to the recovery room.
• CPT code(s) _____________________________

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Respiratory Case 1 Answer

• Case 131510
• Rationale The laryngoscope was used to visualize
  the larynx. In addition, a biopsy of the larynx
  was taken. Reference the main term Larynx in the
  Index with the subterm biopsy.

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Case 2 - Respiratory

• Preoperative Diagnosis Foreign body in bronchus
• Postoperative Diagnosis Foreign body in bronchus
• Procedure Removal of foreign body in the
  bronchus of the left lung via scope
• The patient was consciously sedated, and a
  bronchoscope was introduced into the left nasal
  passage. There were no abnormal structures noted
  as the scope was placed into the left bronchial
  tree. In the left bronchial tree, there was a
  foreign body, and the bronchial tree appeared
  slightly inflamed. The foreign body was removed
  and sent to pathology for inspection. The scope
  was removed, and the patient tolerated the
  procedure and was sent to recovery in stable
  condition.
• CPT code(s) _________________________________

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Respiratory Case 2 Answer

• Case 231635
• Rationale Reference the main term Bronchi with
  the subterm endoscopy. Foreign body removal is
  located under Endoscopy.

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Case 3 - Respiratory

• This 32-year-old female was brought to the
  emergency department by her sister with right
  side chest pain. Patient states pain is between 9
  and 10 on the pain scale. She is having shortness
  of breath for the last four hours. She was fine
  yesterday except for a little fatigue. The pain
  started when she woke up this morning. A chest
  x-ray showed some pleural effusion at the left
  base. At this time it was determined that a
  pneumocentesis is necessary to aspirate the fluid
  and make the patient more comfortable. This
  procedure was performed, and the patient is
  resting and much more comfortable. The patient
  states that the pain is now at a 4 out of 10.
• CPT code(s) ____________________________

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Respiratory Case 3 Answer

• Case 332420
• Rationale Reference Pneumocentesis in the Index.

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Case 4 - Respiratory

• This 24-year-old patient was brought to the
  emergency room with difficulty breathing after
  being stung by a bee. The patient is experiencing
  a severe reaction to the bee sting. She was able
  to administer the EpiPen but she is still in need
  of breathing assistance. An emergency
  tracheostomy was performed, after which the
  patient was resting comfortably.
• CPT code(s) _________________________

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Respiratory Case 4 Answer

• Case 431603
• Rationale Reference Tracheostomy in the Index,
  then the subterm emergency, which gives you a
  code range to reference.

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Case 5 - Respiratory

• Preoperative Diagnosis Small unidentified mass
  in the right lung
• Postoperative Diagnosis Same
• Procedure Bronchoscopy with biopsy with washings
• Conscious sedation of Fentanyl, 20 mcg, and 2 mg
  of Versed was administered to this patient.
  Bronchoscope was introduced through the left
  nostril and moved down past normal vocal cord
  structure and into the bronchial tree on the
  right side. There were no ulcerations of the
  mucosa. Fluoroscopic guidance allowed for the
  bronchoscope to move into the upper lobe of the
  right lung. Endobronchial biopsy of a small mass
  was noted, and washings and brushings were taken.
  The sample was sent for histology. The patient
  tolerated the procedure well.
• CPT code(s) ________________________________

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Respiratory Case 5 Answer

• Case 531625, 31623
• Rationale In the Index, reference Bronchoscopy,
  then biopsy. Code 31625 is used for biopsy of
  single or multiple sites with or without cell
  washing. Also add code 31623 for brushing.

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Cardiovascular Procedures

• Notation at beginning of section important to
  read
• Special rules for assigning pacemaker procedures
• Note procedures completed with or without bypass

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Cardiovascular Coronary Artery Bypass Grafts
(CABG)

• Venous grafting only number of grafts
• Combined arterial-venous correct number and who
  harvested the graft (modifier 80) and who
  performs the bypass (add-on codes)
• Arterial grafting
• Anomaly repair aorta, pulmonary artery, and or
  septal and ventricular defects
• Reference name of procedure and then anomaly

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Cardiovascular Heart/Lung Transplant

• Cadaver donor cardiectomy with or without
  pneumonectomy
• Backbench work
• Transplantation of heart with or without lung
  allotransplantation

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Cardiovascular Arteries and Veins

• Embolectomy/Thrombectomy select code by vessel
  and approach/method
• Venous reconstruction type of reconstruction
  dictates codes
• Transposition
• Grafts
• Anastomosis
• Sutures

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Cardiovascular - Aneurysm

• READ notations detailed information is in code
  book regarding code assignments
• Site of surgery is essential
• Codes are differentiated by
• Aneurysm and associated occlusive disease
• Ruptured aneurysm
• An aneurysm, pseudoaneurysm and associated
  occlusive disease

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Cardiovascular

• Fistula differentiated by site
• Direct repair of blood vessel site
• Repair of vessel with vein graft site
• Repair of vessel with graft other than vein
  site
• Thromboendarterectomy artery on which procedure
  is completed
• Angioscopy add on code with therapeutic
  intervention
• Transluminal angioplasty location and approach
• Transluminal artherectomy location and approach
• Bypass graft differentiated by vein used

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Cardiovascular Vascular Injections

• Selective catheter moves into one of the great
  vessels off the aorta
• Movement from one vascular family is reported
  separately
• Radiology services performed in conjunction with
  catheter movement is coded separately
• Nonselective catheter is functioning and does
  not go into another vessel

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Cardiovascular Arterial and Arteriovenous

• Arterial punctures and catheterization
• Hemodialysis access, cannulation, shunt
  insertion
• Numerous notations read carefully
• Many are separate procedures and coded if no
  other procedure is completed
• Transcatheter - Read notations
• Endoscopy 2 codes
• Ligation type of procedure and type

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Case 1 Cardiovascular

• Procedure Replacement of pacemaker generator
• The patient was brought to the operating room and
  was prepped and draped in the usual fashion. The
  patient was consciously sedated. The previous
  subcutaneous right infraclavicular skin pocket
  was identified, and an incision was made in this
  area to remove the previously inserted generator.
  The atrial and ventricular leads were checked.
  Since the pocket was clean, it was determined
  that the same pocket could be used for the
  reinsertion of a new generator. A pulse
  generator was placed and tested. Noting no
  complications, the physician sutured the site.
  The patient was found to be in stable condition
  and was returned to the recovery room in
  satisfactory condition.
• CPT code(s) _____________________________

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Cardiovascular Case 1 Answer

• Case 133213, 33233
• Rationale Replacement of the pulse generator.
  The atrial and ventricular leads identify this as
  a dual chamber. Both the removal and replacement
  are coded.

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Case 2 - Cardiovascular

• Preoperative Diagnosis Leukemia, in remission
• Postoperative Diagnosis Same
• Procedure Tunneled venous access port removal
• Reason for Procedure This eight-year-old male
  completed chemotherapy.
• The patient was prepped and draped in the normal
  sterile fashion. His right side was anesthetized,
  and an incision was made above the port area. The
  port was a tunneled device with a subcutaneous
  port that was peripherally inserted. The incision
  was taken down to the device, which was freed.
  The retention sutures were identified and cut.
  After confirmation that the device was free, it
  was removed. Hemostasis was obtained, and the
  wound was closed in layers using 3-0 nylon. A
  sterile dressing was applied to the area. Patient
  vitals were taken, and the patient was noted to
  be stable. He was sent to the recovery room in
  stable condition.
• CPT code(s) __________________________________

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Cardiovascular Case 2 Answer

• Case 236590
• Rationale In this case, the use of the venous
  access device is the starting point for finding
  this code. The coder should reference Removal and
  subterm infusion pump, intravenous in the Index

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Case 3 Cardiovascular

• Pre- and postperative diagnosis Excessive fluid
  in pericardial sac
• Procedure Initial removal of fluid from
  pericardial sac . After the patient was prepped
  and draped in the usual fashion, general
  anesthesia was administered. Using the sternum as
  an anatomical landmark, a long needle was placed
  below the sternum. The needle was advanced into
  the pericardial sac. Five cc of fluid were
  removed and sent to pathology for review. The
  patient was stable, and the wound was dressed.
  Patient was sent to the recovery area in
  satisfactory condition.
• CPT code(s)

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Case 3 Cardiovascular Answer

• Case 333010
• Rationale In the Index, reference the main term
  Pericardiocentesis. Code range 3301033011 is
  listed. Reference the code range in the main
  section of the CPT manual.

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Case 4 Cardiovascular

• Preoperative diagnosis Malignant carcinoma of
  breast
• Postoperative diagnosis Same
• This 39-year-old female presents today for
  insertion of catheter for central venous access
  for chemotherapy. The patient was placed in the
  supine position and sterile prep occurred.
  Lidocaine was injected into the right clavicular
  area. A needle was inserted into the right
  subclavain vein, and a J-wire was then passed
  into place. A tunnel was created from the area
  over the clavicle to the venotomy site, and a
  dilator was placed over the wire and then
  dilated. The catheter was then placed into the
  subclavian vein and secured. The area was
  flushed, and incisions were sutured. There was
  minimal blood loss, and the patient was stable
  and sent to the recovery area.
• CPT code(s)

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Case 4 Cardiovascular Answer

• Case 436558
• Rationale In the Index, reference the main term
  Insertion, then catheter, then venous. Review the
  range listed in the main section of the CPT
  manual.

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Case 5 Cardiovascular

• Preoperative diagnosis Possible hemorrhage
• Postoperative diagnosis Abdominal hemorrhage of
  previous operative area
• This patient underwent abdominal surgery 36 hours
  ago. An exploration of the abdominal incision
  site is planned. After being placed under
  general anesthesia, the original abdominal
  incision site was reopened. A small bleeding site
  was noted, and electrocautery was used. The wound
  was closed. The patient tolerated the procedure
  and was sent to the recovery area.
• CPT code(s)

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Case 5 Cardiovascular Answer

• Case 535840
• Rationale In the Index, reference the main term
  Exploration, then blood vessel, then abdomen.

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Hemic Lymphatic Systems

• The hemic and lymphatic systems often are viewed
  as subsystems of the circulatory system.
• The repair of a ruptured spleen is also known as
  a splenorrhaphy.
• The spleen is located in the left upper quadrant
  of the abdomen, behind the stomach and just below
  the diaphragm.
• The lymphatic channels, or vessels, transport
  fluid away from the tissues of the body and
  toward the thoracic cavity.

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Hemic Lymphatic Systems

• Lymph nodes, also known as lymph glands, are
  located at various areas along the lymphatic
  vessels.
• In an autologous bone marrow transplant, cells
  are cultivated from the patient's own marrow.
• In an allogenic bone marrow transplant, cells are
  taken from a donor and then transplanted.
• There are four major concentrations of lymph
  nodes cervical lymph nodes, submandibular lymph
  nodes, axillary lymph nodes, and inguinal lymph
  nodes.

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Lymphatic Case 1

• Preoperative diagnosis Enlarged lymph node in
  left axillary area
• Postoperative diagnosis Left axillary
  lymphadenitis
• Procedure Excision of one axillary lymph node
• The patient was prepped and draped in the usual
  fashion and sedated via IV. The left axillary
  area was cleansed with Betadine, and 1 Xylocaine
  was injected. An incision was made through the
  skin, and the enlarged node was identified deep
  in the fascia. The surrounding vessels in the
  area were clamped, and the deep node was excised.
  The node, measuring 2.3 by 2.5 cm, was sent to
  pathology for further analysis. The subcutaneous
  tissue and skin were closed. There was minimal
  blood loss, and the patient tolerated the
  procedure in good condition and was sent to the
  recovery room.
• CPT code(s)

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Lymphatic Case 1 Answer

• Case 138525-LT
• Rationale In the Index, reference the main term
  Excision, then lymph nodes. Review the codes
  listed in the main section of the CPT manual, and
  select code 38525 because the documentation
  states that the excision occurred in the
  fascia.

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Lymphatic Case 2

• Preoperative diagnosis Pain over spleen after
  falling down stairs
• Postoperative diagnosis Ruptured spleen
• Indications for surgery This 78-year-old male
  fell while completing yard work. It is felt that
  his spleen was ruptured due to this injury.
• Procedure This 78-year-old male was prepped and
  draped in the usual fashion. General
• anesthesia was administered, and he was placed in
  the supine position. An incision was made
• in the upper midline area. Retractors were then
  placed. The splenic ligaments and the gastric
• veins were located and divided so that the left
  upper quadrant of the abdomen could be viewed.
• The spleen was ruptured. The splenic hilum was
  dissected, and the splenic artery and vein were
• identified and double ligated. They were then
  suture ligated and divided. Removal of the spleen
• occurred, and hemostasis was achieved. A drain
  was placed, and the area was closed in layers.
• There was minimal blood loss. The patients
  vitals were taken, and then he was sent to the
• postop recovery room in stable condition.
• CPT code(s)

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Lymphatic Case 2 Answer

• Case 238100
• Rationale In the Index, reference the main term
  Spleen, then the subterm excision. Review the
  codes listed in the main section of the CPT
  manual.

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Lymphatic Case 3

• Preoperative diagnosis Non-Hodgkins lymphoma
• Postoperative diagnosis Non-Hodgkins lymphoma
• Procedure Bone marrow biopsy and bone marrow
  aspiration
• Indications for surgery Non-Hodgkins lymphoma
• Procedure This 25-year-old male was placed in
  the prone position on the operating table.
  Posterior superior iliac spines were prepped and
  draped in the usual sterile fashion. 1 Lidocaine
  was administered to anesthetize the area. The
  needle was inserted into the left iliac spinal
  region, rotated to the right, then left, and
  removed. The needle was then inserted into the
  left iliac spinal region at a 45 degree angle,
  and the procedure was repeated. Bone marrow
  aspiration and biopsy were performed and sent for
  contingent flow and contingent cytogenetics. The
  patient tolerated the procedure well and will
  return for follow-up and results.
• CPT code(s)

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Lymphatic Case 3 Answer

• Case 338221
• Rationale In this case, the aspiration is part
  of obtaining the biopsy, so one code is used to
  reflect the biopsy. As the guidelines at the
  start of this section state, Each code may be
  reported only once per day regardless of the
  quantity of bone marrow/stem cells manipulated.
  In the Index, reference the main term Biopsy,
  then bone marrow.

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Lymphatic Case 4

• This 42-year-old female presents today with an
  abscess in the right inguinal area. The patient
  is not suffering from fever or chills but is in
  pain in this area from the abscess. The options
  were explained to the patient, and she decided to
  proceed with an incision and drainage of the
  lymph node. All risks and benefits were
  explained, after which the patient did sign the
  consent form for the procedure.
• Procedure After the patient was made comfortable
  on the procedure table, the right inguinal area
  was prepped and draped in the usual sterile
  fashion. An incision was made over the abscess
  and carried down through until the lymph node was
  visualized. The lymph node was identified, and
  the syringe was inserted. At this time 6 cc of
  fluid was removed from the node and sent to
  pathology. Pressure was applied to the area until
  the bleeding stopped, and the area was closed
  with Steri-Strips. The patient tolerated the
  procedure well and will return in 10 days for
  follow-up.
• CPT code(s)

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Lymphatic Case 4 Answer

• Case 438300
• Rationale In the case fluid was removed but the
  node itself was not. In the Index, reference the
  main term Lymph Node, then abscess, then incision
  and drainage.

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Lymphatic Case 5

• This 54-year-old male presents with an enlarged
  cervical lymph node that is deep within the fat
  pad. The node has been enlarged for the last 6
  months and has been painful. Various treatments
  occurred with no success.
• Procedure The cervical area was anesthetized,
  and an incision was made to identify the node.
  The node was deep within the fat layer and
  enlarged. The node was excised with additional
  excision of the scalene fat pad. After bleeding
  was controlled, the area was sutured. The patient
  was sent to the recovery area in stable
  condition.
• CPT code(s)

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Lymphatic Case 5 Answer

• Case 538520
• Rationale In the Index, reference the main term
  Excision, then lymph node. Review the codes
  listed in the main section of the CPT manual.

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