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the anesthesia section

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is a specialized section that is used by an anesthesiologist, anesthetist, or other physician to report the provision of anesthesia services

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types of anesthesia

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general, local, or monitored anesthesia care (MAC)

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(MAC) moderate (conscious) sedation

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is not reported with anesthesia codes but rather is reported with medicine cods

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some of more commonly used anesthesia terms are:

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endotracheal, epidural, regional, and patient-controlled analgesia

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endotracheal

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anesthesia is accomplished by insertion into nose or mouth, and passing the tube into the trachea for ventilation.

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epidural

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anesthesia in injection of an anesthetic agent into epidural space between the vertebrae

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spinal

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or intraspinal anesthesia refers to anesthesia produced by an injection of local anesthetic into the subarachnoid space around the spinal cord

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general anesthesia

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is a state of unconsciousness that is accomplished by the use of a drug or combination of drugs administered intramuscularly, intravenously, or by inhalation

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regional anesthesia

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interrupts the sensory nerve conductivity in a region of the body and its produces by field block (forming a wall of anesthesia around the site by means of local injection) or nerve block (injection of the area close to the site) nerve block also known as block, block anesthesia, or conduction anesthesia

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EBP

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epidural blood patch

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local anesthesia

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can be accomplished by means of an anesthetic agent such as lidocaine placed directly to an area involved

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moderate or conscious sedation

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is a type of sedation that can be provided by a sergeon or the surgeon staff while the surgeon is performing the procedure; it provides a decrease of level of consciousness that does not put the patient completely to a sleep

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anesthesia is paid based on

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base unit + time units+ modifying unit

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CMS's base unit

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the RVG is not a fee schedule (a list of charges for services) but instead compares anesthesia services with each other. a team of physician with expertise in anesthesiology developed the comparison and assigned numerical value to each service, termed base unit value

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T is for time

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anesthesia services are provided base on time during wich the anesthesia was administered and calculated in total minute.

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M for modifying unit

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as the name implies, modifying unit reflect circumstances or condition that change or modify the environment in which anesthesia service provided

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*two base modifying factors:

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qualifying circumstances codes and physical status modifiers

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the qualifying circumstances codes

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began with 99 and are considered adjunct codes which means that codes never reported alone

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the qualifying circumstances codes:

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reported in addition to the anesthesia procedure codes; located in two places in the CPT manual: the medicine section and anesthesia section guidelines.

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physical statues modifiers

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the second type of modifying unit used the anesthesia section is physical status modifier these modifiers indicate the patient condition at the time anesthesia was administered and identify the level of complexity of the service provided to the patient

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conversation factor

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is the dollar value of each unit. each third party payer issued a list of conversation factors. the lists is vary with geographic location because the cost of practicing medicine varies from one region to another

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must surgery subsections defined according

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to medical specialty or body system

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parentheses

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additional information is enclosed in___ called parenthetical phase or expressions they follow the code or group of codes and provides further information

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when you using an unlisted procedure code to report a surgical services

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a special report describing the procedure most accompany the claim

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pertinent information (in the special report) should include

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an adequate or description of the nature, extent, and the need for the procedure, and the time, effort, and the equipment necessary to provide the service

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"separate procedures"

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are consider minor procedures that are reported only when services performed or when they are performed with another major procedure but at a different site or unrelated to major procedure

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the CPT manual describes the surgical package as

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including the operation itself, local anesthesia, and "typical postoperative follow up care", one related E/M encounter prior to the procedure, and immediate follow up care, including WRITTEN REPORT

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surgical package containers :

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preoperative visits, intraoperative services, complication following surgery, post-operative visits, supply, miscellaneous services- dressing changes, catheter removal, etc

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global (post-operative) surgery

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the period of time following each surgery that is included surgery package is established by the third party payer it is usually 10 days for minor procedure or 90 days for major procedural

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fine needle aspiration

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a fine needle aspiration is used to withdraw fluid that contains individuals cell. the needle is inserted into the area being biopsied and moved several times to take multiple samples without withdrawing the needle

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needle core

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a core of suspicious tissue removed for examination

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the subcutaneous integumentary contains the subheading

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skin, subcutaneous, and accessory glands; nails; pilonidal cyst; introduction; repair; destruction; breast;

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each subheading in integumentary system divided into:

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interdiction and removal; incision and drainage; debridement; paring or cutting; biopsy; removal skin tags; shaving of epidermal or dermal lesion; excision -benign lesions; excision- malignant lesion

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incision and drainage codes

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are divided according to the condition for which the I&D is being performed

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when a physician use incision and drainage?

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acne surgery, abscess, carbuncle, boil, cyst, hematoma, and wound infection

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puncture aspiration

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the physician opens the lesion to allow drainage which is describes inserting a needle into a lesion and withdrawing the fluid

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debridement

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is the removal of infection, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound; the goal of debridement is it to cleanse the wound, reduce bacterial contamination

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types of treatment of lesion of the skin

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paring ( peeling or scraping), shaving ( slicing), excision (cutting removal) and destruction ( ablation)

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what you need to know to code excised lesion?

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site, number and the size of the excised lesion, as well as whether the lesion is malignant or benign

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destruction of the lesions

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destroys the lesion, leaving no available tissue for biopsy therefore there will be no pathology report for lesion

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what you do if multiple lesions are treated

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code the most complex lesion procedure first followed by the other using modifier -51

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scissors removal of skin tag

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is often used for tissue column lesion. the forceps grasps the column, and the physician snips the lesion off at its base

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ligature strangulation

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a thread is tied at the base of the lesion and left there until the tissue die the lesion then drops off

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three factors most consider when you reporting integumentary wound repair:

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length of the repair; complexity of the repair; site of the wound repair

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three components (parts) of integumentary wound repair

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simple ligation; simple exploration; and normal debridement

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recipient site

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is the area of defect that receive the graft

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donor site

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is the area from which the healthy skin has been taken for grafting

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adjacent tissue transfer:

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are reported according to the size of the recipient. the size measured in square centimeters. simple repair donor site including the tissue transfer code and is not reported separately, unless if it complex

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what the different between split thickness and full thickness

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split thickness is epidermis and parts of the dermis; full thickness epidermis and all dermis

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a pinch graft

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is a small, split thickness repair. often a split thickness graft is a referred to in the patient record as STSG and full thickness skin graft as FTSG

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what the different between autografts and allografts

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autografts are graft that are taken from the patient body; allografts (homograft) are grafts that are taken from a human donor

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acellular dermal replacement

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is the skin replacement products based on the location and size of repair

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temporary allografts

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are also reported based on the location and size of the repair. temporary grafts are also to protect defect site while healing is taking place

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delayed graft

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a portion of the skin is lefted and separated from the tissue below but it stays connected to blood vessels at one end. this keeps skin viable while it is being moved from one area to another

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open treatment

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of a fracture is made when a surgery is performed in which the fracture is exposed by an incision made over the fracture and the fractured bone is visualized

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closed treatment

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is performed when the physician repairs the fracture without directly visualizing the fracture

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closed treatment

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this terminology is used to describe procedure that treat fracture by one of three methods: 1 without manipulation 2 with manipulation or 3 with or ith out traction

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percutaneous skeletal fixation

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this fracture is not open to view but fixation is placed across the fracture site usually under x ray imagining.

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dislocation

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is the displacement of a bone from its normal location in a joint, and the treatment of the dislocation is to return the bone to its normal location

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insertion of wires or pins

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is a procedure often used by orthopedic physician. the procedure is performed using local or general anesthetic the bone drilled through with a power drill and pins and/or wires are placed through a holes in the bone and allowed to emerge through the skin on each side of the bone

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ORIF

answer

open reduction with internal fixation

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