Is there such a code? Patient is not having a prostatectomy at the same time, because I know then it’s included. I’m trying to avoid the unlisted codes any way I can.
HELP? Please?!
Thanks!
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Tag Archives: neck
Coding EXAM OF HEAD AND NECK
Hello and Happy Holidays to everyone,
I was wondering if someone can help me with some clarification. One of our providers did an US EXAM OF HEAD AND NECK in the office, however, it was coded as a radiology code 76536. Does anyone else know a correct CPT that does not involve Radiology? Please help!:confused:
Thank you!
Transvaginal Bladder Neck Closure
Looking for assistance in finding a CPT code for a transvaginal bladder neck closure with Acell graft. Can anyone help me with this?
Preoperative Diagnosis
urinary incontinence, NGB
Postoperative Diagnosis
same
Name of Operation
1. transvaginal bladder neck closure with Acell graft
2. cystoscopy with intravesical botox injection
3. SPT placement
Description of Operation Performed, Including Technique
The risks, benefits and alternatives were explained to the patient and informed consent obtained. She was brought to the OR and placed on the table in supine position. After undergoing adequate anesthesia, she was placed in the dorsal lithotomy position. She was prepped and draped in standard fashion. Prior to the beginning of the procedure, a timeout was performed to identify the patient. Perioperative antibiotics were given within 1 hour of incision.
A flexible cystoscopy was performed and the bladder was visualized. No stones, masses or diverticuli noted. The bladder was difficult to distend secondary to a patulous urethra. A botox sheath was placed through the scope and 100 units of botoz was injected into the bladder into 10 sites with a 27 g needle. The trigone was avoided. Hemostasis was evident. The scope was removed.
The bladder was filled with 150 ml of saline and a Lowsley tractor was placed through the urethra and advanced toward the abdominal wall. She was placed in steep trandelenburg position. A 1 cm incision was made just above the pubic symphysis and electrocautery was used to dissect down to the fascia. The Lowsley was palpated and the fascia was opened at the site of the Lowsley. The claws were opened once visualized and a 20F catheter was placed into the tractor and brought through the bladder out of the urethra. The tip of the catheter was grasped and placed into the bladder. 10 ml was placed in the balloon and the catheter was brought to the dome of the bladder. The subcutaneous tissue was closed with 2-0 vicryl suture. The SPT was secured with two 2-0 silk sutures to the skin.
A 16F foley was placed into the urethra with 30 ml placed into the balloon. The anterior vaginal wall was infiltrated with normal saline. A Lonestar retractor was placed for visualization. A circumferential incision was made around the urethra with a #15 blade. Metzenbaum scissors were used to dissect away the periurethral tissue circumferentially to perform a formal urethrolysis. Lateral vaginal wall flaps were developed for later closure. Once the entire urethra was mobilized the foley was removed. The urethra was closed with two 2-0 vicryl sutures in 2 layers. A piece of Acell graft was then soaked for 15 minutes in saline and placed over the urethra. It was secured to the periurethral tissue with interrupted 3-0 vicryl sutures. The urethra was then rotated anteriorly and secured to the tissue posterior to the pubic symphysis with multiple interrupted 3-0 vicryl sutures. The suture line was no longer visible. The wound was copiously irrigated with saline. The vaginal mucosa was closed with multiple running, locking 2-0 vicryl sutures. Hemostatis was evident. The vagina was irrigated and Kerlix packing with antibiotic ointment was placed in the vagina.
The sponge, needle and instrument counts were correct at the end of the procedure.
I was present and scrubbed for the entire case.
The patient tolerated the procedure well.
Description of Any Drains, Catheters, or Packing Left in Place
20F SPT, Kerlix vaginal packing
Findings
patulous urethra
I would appreciate any help on this – thank you in advance!
~Kara
control of bleed from previous wound of neck
patient was bleeding from a wound from a surgery 6 months ago, Dr had to control the bleed and close wound
would this be just a complicated wound closure?
thank you
would this be just a complicated wound closure?
thank you
Left neck wound debridement with removal of infected thyroplasty implant CPT CODE
Can anyone out there help me with coding something. This patient had a Left neck wound debridement with removal of infected thyroplasty implant. I have never coded for this in the past and I a little stumped. The full procedure is "Left neck wound debridement with removal of infected thyroplasty implant, with adjacent muscle flap transfer using the sternocleidomastoid muscle into the defect left by removal of thyroplasty implant". I have the flap code as 15733. One person in the office said maybe we can use a Foreign Body code 20520, one person said 20670 but that code is for a superficial implant with buried wire, pin or rod…. Can anyone else help with this one. The only other code I can think of would be an unlisted code 31599. I would appreciate anyone’s input on this one thanks.
Bladder Neck Contracture Dilation / attempted contracture incision
Looking for some advice on the following:
PREOPERATIVE DIAGNOSIS: Bladder neck contracture.
POSTOPERATIVE DIAGNOSIS: Bladder neck contracture.
OPERATION: Cystoscopy, bladder neck dilation, Foley placement,
attempted bladder neck incision.
INDICATIONS FOR SURGERY:
The patient has a history of TURP in the past with bladder neck contracture and hematuria. The patient also has obstructive urinary symptoms, comes in for bladder neck incision,
ended up with dilation, see below.
DESCRIPTION OF OPERATION:
The patient was identified in the waiting room and brought into the
OR. Preoperative antibiotics were provided. Anesthesia was
administered. The patient was placed in lithotomy position, then
prepped and draped in a standard sterile surgical fashion. Time-out
was performed. Consent was verified. Next, a 19-French cystoscope
with a 30-degree lens was inserted into the urethra. No strictures
in the anterior urethra. Prostatic fossa appeared open. The
bladder neck was very tight and contracted. I could not easily pass
the scope. Next, a Sensor wire was passed through the scope into
the bladder. The scope was removed. Next, I decided to dilate the
bladder neck a little bit so I can pass the urethra tome with the
Collins knife using blue plastic dilators. I slowly dilated the
bladder neck from size 18 to size 24, which was the biggest dilator
I had. The Collins knife was only available to use with the
26-French sheath and obturator. I removed the wire and slowly tried
to pass the 26 sheath with an internal obturator. I did meet some
resistance at the bladder neck. I then stopped. Inserted a camera.
I could see the bladder neck opening, but also the patient appeared
to have a false passage to the right side at the level of the
prostate. I then decided to just leave a Foley catheter. Again, I
placed a 19-French scope, passed a wire into the bladder. I again
passed a dilator. The 24-French dilator passed easily into the
bladder without resistance. A 22-French Council tip Foley catheter
was then passed over the wire into the bladder. Balloon inflated
with 15 mL of sterile water. Urine output was clear. No hematuria
was noted. The patient tolerated the procedure well, was sent to
recovery room in stable condition.
At first, I was planning to just bill 52281 for the contracture dilation, but since the intent was to initially do the incision, would it be more appropriate to bill as 52276-52? I have read articles from the AUA’s Michael Ferragamo stating 52276 is appropriate for contracture incisions secondary to prostatectomies. Any help would be appreciated. Thanks in advance.
1995 E/M Guidelines Neck and Chest
When auditing E/M’s how many of you are including Chest and Neck in scoring? They’re listed under Body Area on our audit worksheets but I’m reading through and looking at AAPC’s audit sheet. I realize that they include both 95 and 97 guidelines on their audit worksheet. On our internal sheet, Neck and Chest are under Body Areas.
Also, AAPC indicates that tracheal placement can be included under Neck exam.
Neck Pain – When To Get Prompt Medical Treatment
Neck pain is common, affecting approximately sixty five million men and women yearly throughout the United States alone. The causes or causes of neck discomfort can be difficult to determine, but are usually due largely to lifestyle. Tension, sitting or standing in one position for a long time, lousy eating habits, poor sleep habits and incorrect posture are the most common reasons.
The correct neck pain treatment, when offered in a reasonable way, can be effective for curing neck pain as well as eliminating future problems. Neck pain relief exercises, chiropractic treatment, laser or ultrasound therapy, acupuncture and also naturopathic products are only a few popular procedures that many men and women find useful.
However, some types of neck discomfort should be reason for alarm and could require prompt medical assistance and further treatment. The issue is that it may be hard to discern “day-to-day” neck discomfort attacks from the ones that signal a real medical emergency.
Two major problems might be indicated whenever neck discomfort occurs: meningitis and spinal trauma. Both of these conditions can lead to long-term impairment and even death if overlooked or not dealt with quickly enough.
Meningitis: This happens when the meninges (the protective membranes which cover the brain and spinal-cord) become infected and inflamed. This condition may result in death and so should be identified and taken care of as soon as possible.
Meningitis has got a number of warning signs, one of these could be neck pain. Generally, the pain is severe and unexpected. Nevertheless, its onset is often slow, and therefore it is mistaken for stress or some other problem.
In the event you experience neck discomfort along with one or more of the following other indicators, you need to see a doctor promptly:
* Pain in the back/spinal cord.
* Lightheadedness, nausea, throwing up or weariness.
* Headache.
* Rash.
* Tightness in the neck (not able to move the neck frontward as you normally can).
* Sensitivity to light.
* Unexpected onset of neck or back discomfort not caused by trauma.
Many cases of meningitis can be successfully dealt with if detected quickly.
Injury: Neck pain that’s the consequence of injury to the head, neck or back needs to be handled immediately. You need to remember that head injury (a whack to the head) does not always lead to instantaneous neck pain. The fact is, there have already been cases of head trauma in which neck pain develops hours and also days following the original trauma.
In the event you develop neck ache which seems to come from nowhere, think back over the past few days. In the event you received a blow to the head, you should go to the medical doctor about your neck discomfort. Furthermore, watch out for symptoms such as:
* A fever.
* Vertigo.
* Blurred vision.
* Trouble hearing or ringing in the ears.
* Abnormal taste sensation or lack of ability to taste.
* Clicking noise or feeling in the cervical spine (neck) area.
* Throwing up.
* Loss of muscle control.
* Bafflement.
* Sleepiness or difficulty waking up.
The more quickly you have your neck discomfort identified, the greater your chances will be to make a complete recovery.
Find answers for your Neck Pain and finally get Neck Pain Relief. Many Neck Pain Treatment techniques.
Related Medical Coding Articles
confusion on how to code nuchal cord around neck in OB charts.
Hi Guys. While coding OB charts, I came across nuchal cord around neck 1. While leading through 3M there is two option to choose which is "with compression" and "with out compression". Some of my co-workers suggest that if it is around neck we have to code it as "with compression" some suggests until unless provider dose not document with compression we are not suppose to code with compression. I am very confused please any one help me with this. And how to interpret nuchal cord was tight.
Thank you.
Thank you.
Femoral neck fracture treated with percutaneous cement injection
Hello, any advice on what code to use for this procedure of percutaneous cement injection into femoral neck due to stress fracture? The closest code I’m coming up with are CPT 27235 percutaneous skeletal fixation femoral neck, but this involves pins and not cement.
Any info would be greatly appreciated, thank you.
1. CT-guided biopsy of the femoral neck.
2. Internal fixation of the femoral neck with bone cement.
HISTORY: The patient with a 7-month history of right hip
pain, which likely started as a stress fracture. However, he has not been
healing despite multiple attempts to rest and nonweightbearing.
DESCRIPTION OF PROCEDURE:
The right hip was prepped and draped in standard, sterile fashion.
Local anesthesia was performed with 2% lidocaine and bupivacaine.
Preliminary CT was performed. Under CT guidance, a 9-gauge bone biopsy needle
was then introduced laterally into the femoral neck. The CT with multiple
reconstructions performed in the room confirmed position of the needle in the
right femoral neck.
Single biopsy was then performed. Subsequently, approximately 6 mL of bone
cement with hydroxyapatite were then injected in the femoral neck. We were
careful to avoid placing the cement too close to the cartilage. The cement was
injected under CT
guidance with multiple intermittent fluoroscopies. Postprocedure CT was then
performed demonstrating a good amount of cement in good position in the right
femoral neck. The patient tolerated the procedure well, and there were no
immediate
complications.
INTERPRETATION: Preliminary CT demonstrated a small amount of periosteal
reaction in the lower portion of the femoral neck consistent with stress
fracture. No linear fracture was noted. CT confirmed position of the needle in
the femoral neck. CT was
injected during cement administration. Post procedure CT demonstrated a good
amount of cement in the femoral neck without extravasation of cement.
IMPRESSION:
1. Successful CT-guided biopsy of the abnormal area seen on the MRI in the
femoral neck.
2. Successful internal fixation femoral neck with bone cement.