Faye Brown’s ICD-9-CM Coding Chapter 7-Operations and Procedures – Flashcards
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The procedure is surgical in nature It carries an anesthetic risk-any anesthesia other that topical It carries a procedural risk-risk of functional impairment, physiological disturbance or possible trauma It requires specialized training
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The UHDDS requires all significant procedures to be reported. Significant procedures meet any of the following conditions:
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an integral part of a procedure. No code is assigned except in rare situations.
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The operative approach is usually considered to be
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closed and open. They are not all coded with a biopsy code.
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Biopsies can be both
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v64, Persons encountering health services for specific procedure not carried out NO PROCEDURE CODE ASSIGNED
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Coding CANCELLED procedures
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-contraindication V64.1 -patient decision V64.2 -scheduling problems V64.3 -illness of key staff V64.3
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Coding CANCELLED procedures with V codes-cancellation reasons include:
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When a planned procedure is begun but not completed code to the extent to which the procedure was performed according to following principles: -If incision only, code to incision of site (Pt. admitted for transurethral removal of ureteral stone. Scope was passed as far as the bladder, but unable to pass it into ureter. Code cystoscopy only) -If endoscopic approach is unable to reach site, code endoscopy only (Pt. admitted for cholecystectomy with exploration of common duct. When abdominal cavity was entered cancer was found. Procedure was discontinued and operative wound was closed. Assign 54.11 Exploratory Laparotomy) -If cavity or space was entered, code to exploration of site (Abdominal incision made for cholecystectomy; BP spikes, surgery discontinued, incision closed. Code 54.0 Incision of the abdomen wall
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An INCOMPLETE procedure with V code:
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-it did not achieve the hoped for results or because every objective of the procedure could not be accomplished, the procedure is coded as performed. -Failure to achieve the therapeutic objective is not classified as a complication of the procedure
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Coding a FAILED procedure
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-Found under main term CREATION, FORMATION, SHUNT
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Coding for SHUNT procedures
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Revision of a ventriculoperitoneal shunt-need to review operative report to determine which portion of shunt is involved -Only peritoneal site - 54.95 Incision of the peritoneum -Ventricular site - 02.42 Replacement of ventricular shunt -If both sites are involved code both -Externalization of shunt - Because of recurrent infection; performed bedside and involves incision of anterior chest wall; shunt is externalized and connected to external drainage system - 86.09 Other incision of skin and subcutaneous tissue
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Ventriculoperitoneal Shunts
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Drug-eluting stent and conventional, drug-covered, drug-coated stents (non drug-eluting stents) 36.06 Insertion of coronary artery stent 39.90 Insertion of non drug-eluting peripheral vessel stent 36.07 Insertion of drug-eluting coronary artery stent 00.55 Insertion of drug-eluting stent of other peripheral vessel
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Coding for STENT insertions
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Coronary angioplasty performed by ANY technique is inherent in the placement of a coronary stent -Angioplasty 00.66 or 36.03/Stent Insertion 36.06 or 36.07 -Peripheral vessel stent insertion 39.90 or 00.55 -Carotid artery 00.63 -Other extracranial arteries 00.64 -Intracranial vessels 00.65
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Intravascular Stent Insertion
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additional codes used to provide information: -number of vessels treated 00.40-00.43 -number of stents inserted 00.45-00.48 Codes apply to both coronary and peripheral vessels -vessel bifurcation 00.44
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Additional codes for stent insertion
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stents inserted into other locations: -Insertion of stent into bile duct 51.43; if endoscopic 51.87 -Pancreatic transhepatic insertion 51.98 -Colonic stent insertion 46.87; performed via endoscopy 46.86
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Other stents
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Performed as a treatment for brain lesions and tumors; treatment for atriovenous malformations; treatment for functional disorders such as Parkinson's, epilepsy, and intractable pain -93.59 Other immobilization, pressure, and attention to wound is assigned for placement of the head frame -Imaging studies may be coded separately -92.3 Stereotactic radiosurgery requires 4th digit (92.30-92.39) for the source of radiation
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Stereotactic Radiosurgery
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-for the specific diagnostic or therapeutic procedure performed along with a code from sub-category 00.3 -CAS is classified on the basis of the imaging modality used: Computed tomography 00.31 Magnetic resonance 00.32 Fluoroscopy 00.33 Imageless computer assisted surgery 00,34 Multiple data sets 00.35 Other modalities 00.39
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Computer assisted surgeries are coded:
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Classified by the basis of the approach: -Open 17.41 -Laparoscopic 17.42 -Percutaneous 17.43 -Endoscopic 17.44 -Thoracoscopic 17.45 -Other and unspecified 17.49 Code for the primary surgical procedure first, followed by the code specifying robotic approach
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Robotic assisted procedures
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procedure performed for definitive treatment rather than for diagnostic or exploratory purposes or one that is necessary to care for a complication
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Principle procedure
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-Procedure performed for definitive treatment of both principle and secondary diagnosis -Procedure performed for definitive treatment and diagnostic procedures performed for both principle and secondary diagnosis -A diagnostic procedure was performed for the principle diagnosis and a procedure was performed for definitive treatment of secondary diagnosis -No procedures performed that are related to principle diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis
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Selection of principle procedure in relation to principle diagnosis when more that one procedure is performed
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the name of the surgeon who developed the procedure
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Eponym
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the taking of tissue from a living person for microscopic study -when a lesion is removed for therapeutic purposes and sent to the lab for an exam a biopsy code is NOT assigned
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Biopsy
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Closed biopsies are performed percutaneously by NEEDLE, by BRUSH, by ASPIRATION or by ENDOSCOPY -biopsy of the urethra (58.23) does not indicate how it is performed. Assign code for endoscopic approach first and biopsy second
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Closed biopsy
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-When an open biopsy is performed via an incision, the incision is implicit in the biopsy code -When the approach is implied, as in a biopsy of bone, no additional code for the incision into the skin is required -When a biopsy is incidental to the removal of other tissue during a procedure, both the procedure and the biopsy are coded with the more definitive procedure sequenced first (biopsy of liver or pancreas during a colon resection or appendectomy -When a diagnostic exploratory procedure (exploratory transpleural thoracoscopy 34.21) is performed for diagnostic purposes-more than just an operative approach-along with a biopsy (thoracoscopic biopsy of the pleura 34.20) BOTH are coded
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Open biopsy
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-A NEEDLE biopsy for the removal of a small sample of tissue performed during an OPEN surgical procedure is coded as a CLOSED biopsy even though the cavity was open.
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Open vs. Closed biopsy
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-Code the procedure first with additional code for the needle biopsy -total cholycystectomy by means of abdominal incision; needle biopsy of the pancreas done during the course of the procedure 51.22, 52.11 -Occasionally a biopsy is performed immediately before the definitive procedure is begun-code the therapeutic procedure first then the biopsy (open biopsy of breast tumor for rapid frozen section; no malignancy found; lumpectomy carried out 85.21, 85.12)
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Sequencing Biopsy vs. Definitive Procedure
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factors influencing health status and contact with heath services-are DIAGNOSIS codes
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V Codes
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-To advise the coder that individual components of a procedure, or two procedures that might be considered a unit, must be coded "code also any synchronous...." -13.1 intracapsular extraction of lens code also insertion of pseudophakos 13.71
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"Code also" convention #1
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-To advise the coder that an additional code is to be assigned when certain adjunct procedures are performed, or certain equipment is used
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"Code also" convention #2
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-removal of organ listed under EXCISION or RESECTION -removal of a lesion on an organ located under EXCISION, LESION
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Excision of organ or lesion
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operative approach is usually considered to be integral part of the procedure and is NOT CODED
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Coding operative approaches - OMIT CODE
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NOT CODED
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Codes for closure and anesthesia
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Approach is coded when an opening into a body cavity is followed only by a diagnostic procedure such as a biopsy
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Coding operative approach
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when conversion to an open approach becomes necessary, only the open procedure is coded; no code assigned for laparoscopic, thoracescopic, or arthroscopic approach V64.41 Laparoscopic procedure converted to open proc. V64.42 Thoracoscopic procedure converted to open proc. V64.43 Arthroscopic procedure converted to open proc. as additional diagnosis
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Shift from "scopic" procedure to open procedure
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77.86
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Arthrotomy of right knee with partial patellectomy
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01.59 (excision, lesion, site)
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Craniotomy Resection of brain tumor, right frontoparietal area
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80.51
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Laminectomy with excision of herniated lumbar disc
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45.62 (resection, intestine, small)
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Exploratory laparotomy with partial resection of small intestine with end-to-end anastomosis
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47.09
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Exploratory laparotomy with appendectomy
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56.0
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Transurethral removal of ureteral calculus
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60.94
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Urethroscopy to control postoperative hemorrhage, prostate
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87.74
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Cystoscopy with left retrograde ureteral pyelogram
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51.23
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Laparoscopic cholecystectomy
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51.22 V64.41
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Cholecystectomy, open, following attempt by laparoscopy
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85.45, 85.12
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Frozen-section examination of open biopsy of left breast mass followed by left radical mastectomy
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54.11, 52.11
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Exploratory laparotomy with needle biopsy of pancreas
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22.12
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Open biopsy of nasal sinus
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50.11
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Needle biopsy of liver
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57.33
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Transurethral biopsy of bladder
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60.11
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Percutaneous biopsy of prostate
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51.14
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Endoscopic biopsy of bile duct
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54.95
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Revision of peritoneal portion of ventriculoperitoneal shunt
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80.6, 77.66
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Arthrotomy of right knee with excision of right medial meniscus and patellar shaving
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01.6
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Right frontal craniotomy with resection of osteoma of frontal bone
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69.09, 67.12, 71.11
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Dilation and curettage, uterus Cervical biopsies, punch Multiple vulvar biopsies
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17.56, 99.10, 39.90, 00.45, 00.40
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Atherectomy of iliac artery with injection of thrombolytic agent and stent insertion
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42.24
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Esophagoscopy with biopsy of esophagus
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21.5
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Submucous septectomy, nasal, and nasal septoplasty
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51.22, 47.19, 87.53, 51.81, 51.51
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Exploratory laparotomy Cholecystectomy Incidental appendectomy Intraoperative cholangiogram Common bile duct exploration with dilation of sphincter of Oddi
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47.01
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Laparoscopic appendectomy
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54.61
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Reclosure of operative wound of abdominal wall
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51.24
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Partial laparoscopic cholecystectomy
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02.12
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Craniotomy with plastic repair of encephalocele cranioplasty
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00.66, 99.10, 36.06, 00.45, 00.40
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Single-vessel percutaneous coronary angioplasty with use of thrombolytic agent and insertion of stent
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52.93
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Endoscopic insertion of stent on pancreatic duct
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92.32, 93.59, 87.03
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Removal of acoustic neuroma via Stereotactic Cobalt-60 radiosurgery Placement of head frame Computerized axial tomography of brain
