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the procedure that is billable 48150-22 (Difficult due to lysis of adhesion) and omental flap 49905
Thank You
History of an abdominal GIST tumor s/p resection a few years ago. As part of her monitoring she was found to have a right lower lobe nodule. I saw the patient in the office and offered her surgery. The plan was to remove the nodule through a VATS approach. If it represented a new lung cancer, I would proceed with a completion lobectomy. Risks and benefits of the procedure were explained to the patient preoperatively. She understood the risks and agreed to proceed.
1. Right video assisted thoracoscopy
2. Right lower lobe wedge resection (via VATS) of lung nodule
3. Placement of left radial aline
The patient was brought to the operating room and his identity was confirmed using two methods. The procedure was also confirmed. The patient was placed in the supine position on the OR table. After the induction of general anesthesia, a left aline was placed by the first assistant. The patient was placed in the lateral decubitus position with the right side up. Three small incisions were made to access the mass. The first incision was made below the tip of the scapula, the second incision was made in the anterior axillary line in the 5th intercostal space and the third incision was made midway between these two incisions. Using the videoscope and a grasper, the inferior pulmonary ligament was first divided to help mobilize the lung. Next two graspers were used to palpate the lung. Eventually a hard lesion was found in the periphery of the lower lobe. This was held with one of the graspers, while a stapler was placed through the other incision. One firing of the 45 stapler was used to remove this lesion via a wedge resection. This was sent to pathology, where frozen section showed no malignancy. The pleural space was irrigated out with saline. All bleeding was controlled. A 28F chest tube was placed through one of the incisions to the apex. The other two incisions were closed in layers. The patient tolerated the procedure without difficulty.
I’ve been trying to explain why this is not how things work. If an auditor pulls the chart for review for the visit on 3/3/17, what is released is the documentation from 3/3/17. So if a diagnosis is coded on that visit that is not documented on that visit…. guess what..
I am a former Compliance Auditor under a CIA (Corporate Integrity Agreement) who now is on the facility side. When talking to my professional fee counter parts, they are told they can use the whole chart to code from.. (?) On the facility side we are confined to the account/stay that we are currently coding.
If anyone can provide reference either way as to the professional fee side, I’d appreciate the help. I’ve been looking under all the CMS literature but have been unsuccessful. Thanks in advance!
Diagnostic imaging is an umbrella term for a wide variety of scans, examinations and images that are used in the field of medicine. Technology today is extremely advanced and now physicians can call upon a variety of imaging techniques to help examine the inside of the body and therefore make an accurate diagnosis. Scans and images of the body can enable a host of health problems and abnormalities be seen that might otherwise go unnoticed as symptoms of serious illness does not always appear immediately. For anyone wishing to know more about the different type of diagnostic imaging used today and how they can help a patient, this article is for you.
Radiologic technology
This is much more commonly known as X-ray technology, and this is probably the most well known type of image taken of the body. A radiologic technologist is responsible for carrying out x-ray examinations, a procedure where a small dose of radiation passes through the body, some of the rays being absorbed as they go and all traveling at different speeds. These rays are projected onto special film which produces an image of the inside of the body. X-rays are most commonly used to look for fractures and broken bones although other conditions can be spotted from an X-ray. If a doctor notices something unusual in an X-ray then usually a further test such as an MRI scan or CT scan may be carried out. None of these are invasive procedures, and the patient can receive them on an outpatient basis. Scans such as these are often undertaken following a serious accident or trauma.
Ultrasound technology
Usually an ultrasound is the imaging solution for examining fetuses within the womb. Ultrasound technology can view body structures in a way that X-rays cannot and provides a clearer and more in depth picture. Although pregnancy is a common reason for using ultrasound technology, it can also be used to examine the muscles, joints, tendons, ligaments and internal organs within the body.
CT Scans
Also known as CAT Scans, these are a more advanced type of scan that can be used to examine the whole body from the brain to the ligaments. It too uses radiation in the same way that traditional X-rays do, however the multitude of images that get taken are processed by CT software to provide doctors with a 3D image of the body. In this way it is a very effective type of scan, capable of detecting most serious illnesses including the majority of cancers and tumors. It is a non-invasive procedure just like the X-ray and is particularly appropriate and often the imaging solution for anyone who has been involved in a serious trauma where there are no outward signs of serious injury. Internal bleeding or swelling of the brain could easily have occurred but would need a CT scan to detect.
MRI Scan
An MRI stands for magnetic resonance image and this too provides an incredibly accurate and effective way of scanning the body. Rather than using X-rays, an MRI consists of creating a magnetic field through which radio waves travel to the area of the body being examined. This makes the nuclei of the atoms in the specific region emit energy which can be detected by a computer. An image is created on the computer that can then be interpreted by a radiologist.
There are further examples of medical diagnostic imaging that are used every day by doctors throughout the world. There is no doubt that medical imaging solution technology plays a vital role in the diagnosis and treatment of patients suffering from serious illness. Scans such as those outlined above are important components of oncology solutions in particular as they may enable the cancer to be caught early and therefore treated more successfully. Scanned images coupled with modern technology and software are an efficient and reliable way to clearly see the interior of the body and are increasingly assisting medical teams in carrying out successful diagnoses and treatment .
Kathryn Dawson writes articles for Mirada Medical Limited, a leading provider of professionally developed medical diagnostic imaging solutions for a comprehensive and quantifiable analysis for the diagnosis, staging, treatment planning and assessment of treatment response in oncology. Mirada develops oncology solutions to help clinical oncologists understand and characterise a patient’s condition through a simple, yet powerful medical imaging solution
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