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Claim denial for NCCI Edit- help please

Hello~

I am wondering if someone would be able to help me with a claim denial. Our practice billed out 99472 with a modifier 25 for the provider. The same day the same provider provided sedation; the sedation code billed out was 00635. The claim for 99472-25 was denied for NCCI edit. The insurance provider stated that it was most likely a wrong modifier?

Thank you, in advance of any suggestions or help you may be able to provide.

Medical Billing and Coding Forum

Need help with a colectomy procedure, please :)

WOULD YOU CODE AS 44143,44139?

PROCEDURE: Exploratory laparotomy. Rectosigmoid resection. Mobilization of the right colon, hepatic and splenic flexures. Debridement of right retroperitoneal space.

A standard midline incision was performed. Prior to entering the peritoneal cavity, there was a purulent infection noted coming from the right lower quadrant and right mid abdominal retroperitoneal space. Upon entering the abdominal cavity, there was murky peritoneal fluid but no obvious succus entericus identified. The omentum was matted and fixed to a pelvic inflammatory/neoplastic mass. The omentum was mobilized by dividing it between Kelly clamps and tying off with 0 silk suture. Loops of the terminal ileum or fixed to the mass as well but not incorporated by it. The inflammatory adhesions were taken down freeing the small intestine from the pelvic mass.
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Once it was decided that the the pelvic mass was the probable source of perforation and sepsis and resection was eminent, the right hemiabdomen was explored by mobilizing the right colon. There was evidence of a previous appendectomy. The right ureter was identified. There was a foul-smelling diffuse infectious process involving the soft tissues of the right retroperitoneum, incorporating the renal space. The hepatic flexure was mobilized and the duodenum exposed. There is no bile staining in the sub-hepatic space and the duodenum appeared intact and without inflammation as did the stomach and gallbladder. The NG tube was palpated. The liver appeared normal. There is a small hemangioma in the left hepatic lobe. The necrotic tissue of the right retroperitoneal space was excised.
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The small bowel was run from the ligament of Treitz to the ileocecal valve and there is no evidence of perforation or malignancy. The transverse colon was palpated and normal. The left colon–sigmoid colon junction was then divided with a TA stapler. Mesentery was scored medially and the left colon/sigmoid avascular line was incised to fully mobilize the left colon and sigmoid. The sigmoid colon mesentery was divided between Kelly clamps and tied off with 0 silk suture. Left ureter was identified and protected. The inflammatory–possibly neoplastic mass was then mobilized from the pelvic sidewall. Upon dividing the dense tissue surrounding the mass, a small colotomy was created. The posterior rectal space was entered allowing for isolation of the lateral stalks that were divided under direct vision using sharp dissection and cautery. The inflamed anterior space was entered as well allowing for the contour stapler to encompass the superior rectum for excision of the rectosigmoid. 0 Prolene sutures were placed on the lateral aspect of the superior rectum for future identification. The left colon was viable and mobilized to the splenic flexure.
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Anesthesia department reported difficulty maintaining the patient’s blood pressure despite maximum fluids and pressor agents. Therefore the decision was made to irrigate the abdomen with several liters of warm saline and to place an AB Thera device for closure and to take the patient back for a second look in 24-48 hours. There was diffuse oozing from the right retroperitoneal space. Upon mobilizing the liver by dividing the ligamentum teres, there was a small tear made in the left lobe that was cauterized and a small piece of Surgicel placed for hemostasis. Otherwise there is no significant bleeding. Sponge needle count was correct. The abdomen Ab Thera was placed to vacuum suction with a good seal. The patient was then taken to the intensive care unit intubated and stable but in critical condition.
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Medical Billing and Coding Forum

urgent help please on coding a stillborn delivery

New to INPT OB coding for the facility. I had a mom that was 16 weeks came in because of PROM, no fetal heart tones… So I have my principal dx as the missed abortion and I understand that you do not code the weeks of gestation and the outcome. However, patient was given cytotec, and stayed in hospital until she delivered the baby. I am looking only for what PCS code I should be using for this. Should I be coding the induction with cytotec 3EOP7GC and also a NSVD or a abortion code.. 10A07ZK

Medical Billing and Coding Forum

Excision of left internal jugular lymph node help please

Operations:
#1. Left carotid artery endarterectomy with Hemashield patch closure 35301 LT
#2. Post endarterectomy duplex analysis with interpretation 93882 26
#3. Excision of left internal jugular lymph node at the C sent to pathology for permanent evaluation) ?
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Preoperative note: Patient is 63 y.o.-old female with severe left carotid artery disease now being taken to the operative for operative therapy.
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Operative findings:
#1. Duplex findings: Following the endarterectomy the carotid artery was scanned in longitudinal and transverse planes including the common, bifurcation, internal, and external vessels. There were no filling defects or obstructive findings involving any of the vessels on on this imaging. Doppler analysis was carried out and the velocities in the meters per second are as follows: Common 47/11, bifurcation 38/0, external 41/0, internal 102/9.
#2. Operative findings: There was a significantly enlarged left internal jugular lymph node at the level of the carotid bifurcation. The common carotid bifurcation was extremely calcified and diseased. Disease extended well into the left internal carotid artery. The internal carotid artery was quite small measuring roughly 5 mm in maximum diameter.
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Description of operation: The patient was placed on the operating table in a supine position and adequate general anesthesia was administered monitoring the arterial pressure, electrocardiogram, and oxygen saturation. The entire left neck was prepped and draped in a sterile manner. A skin incision was placed on the anterior border of the left neck and deepened down through the platysma. The facial vein was doubly ligated and divided. The common, bifurcation, internal, and external carotid vessels were dissected out. An enlarged left internal jugular lymph node was excised and sent for pathology. Heparin was administered. With a satisfactory ACT greater than 250 seconds, the vessels were occluded and a common carotid arteriotomy was constructed and carried onto the internal carotid artery beyond the disease endpoint. An indwelling shunt was then placed in the usual manner. The endarterectomy was then carried out in the usual meticulous manner under optical magnification. Following satisfactory endarterectomy, the arteriotomy was closed utilizing 7-0 Prolene and a Hemashield patch. Before placing the last few sutures, the shunt was removed, flushing sequence was carried out, and the final sutures were placed tied and cut. Duplex analysis was carried out and findings are described above. Protamine was administered and hemostasis was obtained. The wound was closed in layers. Sterile dressing was applied. The patient was extubated in the operating room and taken to the recovery room in stable neurologic condition.

Medical Billing and Coding Forum

Please read! Too complicated to title, thank you!

CTS performed a debridement and removal of sternal wires on patient with non-healing thoracotomy. Patient receives serial wound vac changes until wound is ready to close. Reconstructive Plastics specialist performs myocutaneous muscle flaps to close and CTS is the assist. Operative note states pt will be admitted under CTS service. Since the CTS only assisted can he bill for subsequent daily visits or is he still bound by the global surgery rules? Haven’t been able to find any sources that address this particular scenario.

Thanks in advance for your help!

Erin E

Medical Billing and Coding Forum

Debridemen Code- Please help

Hello,

I am not familiar with debridements, which code would I select. Thank you in advance :)

Indications: She is a month after post-mastectomy radiation therapy, having completed chemotherapy for high risk left-sided breast cancer. Then she had a minor separation medially with apparent evacuation of secondarily infected seroma with MRSA. She is not toxic. I advised gentle debridement with the expectation that this would be a small pocket, closed over a drain and anticipated rapid healing.
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Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia with IV antibiotic. The left torso is prepped with chlorhexidine draped after 3 minutes. The small opening is sounded, extends inferiorly beneath the flap 6 cm but the upper flap is attached. I open the incision slightly laterally and remove stringy material and there is a white covering with no visualized fascia or muscle. The stringy material is followed more laterally, tissues easily separate until ultimately the entire transverse 15 cm mastectomy scar is reopened. We debride with a avulsion technique, then used a curette but still impregnated white devascularized tissue throughout that we used the Versajet. Once this is clean, I then use half of unrolled Kerlix lightly impregnated with Betadine to lay on all the surfaces and the rest folded over and then a dry dressing applied. I did infiltrate 30 mL 0.5% Marcaine with epinephrine into the upper and lower flaps, medially and laterally for postoperative pain control. Skin is cleansed and dry dressings applied. She is awakened and extubated. Blood loss is negligible, no intraoperative cultures. She is taken to PACU.
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Medical Billing and Coding Forum

E/M Risk Help Please :-)

Office visit for established patient – 2 acute sprains due to MVA, one of neck and one back. Doc orders massage therapy, ice and script for naproxen 500mg and methocarbamol 500 MG.

Is this low risk because of the level of acuity of sprain and the massage therapy/ice…or does the level bump up because of script for naproxen and methocarbamol?

Thank you in advance!

Medical Billing and Coding Forum

Please help aaa

Postoperative diagnosis:
#1 ascending aortic dissection
#2 acute ischemic stroke with a right hemi–deficit
#3 moderate pulmonary hypertension
#4 cardiomegaly with left ventricular hypertrophy

33864
33866
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Procedure:
#1 replacement of ascending aorta with 32 mm hemashield graft
#2 replacement of the aortic arch using a 24 mm Gelweave graft
#3 interposition bypass to the left carotid using a 6 mm Dacron graft
#4 interposition graft to the innominate artery using an 8 mm Dacron graft
#5 deep hypothermic circulatory arrest (69 minutes)
#6 resuspension of the aortic valve
#7 cutdown and exposure of the right axillary artery with placement of 8 mm end-to-side graft
#8 right femoral arterial cutdown with direct cannulation using a 23 mm femoral cannula
#9 primary repair of the right femoral artery
#10 management of coagulopathy (90 minutes)
#11 cardiopulmonary bypass
#12 bilateral cerebral Somanetics
#13 TEE with visualization and interpretation ×2

Indication:
48-year-old African-American male presenting with syncope and right-sided transient neurologic deficits. Patient underwent code stroke evaluation and was ultimately given TPA given his presentation. CTA of the head, neck, chest, abdomen, and pelvis revealed an ascending aortic dissection. I discussed the risk and benefits of surgery extensively with the patient, and they understand the high risks, risk of morbidity and mortality, without definitive guarantee of neurologic improvement. He is being taken to surgery emergently for repair.
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Intraoperative findings:
The patient had an ascending aortic aneurysm that originated at the level of the sinotubular junction, and measured approximately 4.8 cm in size. The aorta tapered to a normal caliber leading up to the arch. The aortic intimal/media tear likely originated in the aortic arch. Upon placing the patient on cardiopulmonary bypass using right axillary artery cannulation, high pressures were met in a poor index flow of 1.8 resulted in termination of bypass use via the right axillary and the patient was transitioned the femoral cannulation. Upon evaluating the arch under circulatory arrest, the arch vessels had the media completely detached with invagination of the media into the aortic arch. The aortic arch had to be resected up to the level of the left subclavian. The patient had a bovine arch and the left carotid along with the innominate artery had to be individually grafted and implanted into the neo-ascending aortic graft.
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Pre-bypass TEE:
Pre-bypass TEE showed normal left ventricular function. Ejection fraction was greater than 55%. There were no regional wall motion abnormalities identified. There was moderate left ventricular hypertrophy. There was trace mitral regurgitation with a normal mitral valve apparatus. The left atrial appendage was free of thrombus. There was no echogenic smoke within the left atrium. Right ventricular function was normal. There was trace tricuspid regurgitation. The aortic valve was a trileaflet valve with trace central insufficiency at the zone of coaptation. The dissection was identified extending to the level of the sinotubular junction. Next
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Post-bypass TEE:
Post-bypass TEE showed preservation of ventricular function. There was no alteration of valvular function. Right ventricular function was normal. The aortic valve was competent with trace central insufficiency at the zone of coaptation, completely unchanged from previous TEE. There was no dissection flap identified within the root.

Procedure in detail:
After consent was obtained from the family, the patient was taken emergently to the operating suite and placed on the operating table. Gen. anesthesia was induced with endotracheal intubation. Monitoring lines were placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Next
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Pre-bypass TEE was performed with findings as described. Once this was completed, a right horizontal subclavicular incision was made. The soft tissues were divided. The pectoralis major muscle was released from its clavicular attachments. The underlying pectoralis minor muscle was retracted laterally. Several crossing small venous and arterial branches were clipped and incised. The underlying axillary artery was identified. It was encircled with a vessel loop proximally and distally. The patient was given 5000 units of heparin. Again, should be noted that patient did receive TPA prior to surgery. Proximal distal vascular clamps were placed for hemostatic control. A longitudinal arteriotomy was made. An 8 mm graft was then anastomosed to the subclavian artery in an end to side fashion using 5-0 Prolene. A 23 French arterial cannula was placed within the graft. De-airing of the graft was then performed.
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Sternal incision was made. The soft tissues were divided. Sternotomy was performed in standard fashion. The sternal tables were cauterized for hemostasis and bone wax was placed. The anterior mediastinal soft tissue was divided. The pericardium was opened and teed off along the diaphragm. Stay sutures were placed create a pericardial well. Gross observation of the ascending aorta revealed an aortic aneurysm at the level of the sinotubular junction, but it was measuring 4.8 cm by CT scan and this was consistent with gross observation. The aorta had a bright red hue throughout its ascending portion. The patient was fully heparinized and ACT was found be therapeutic for full cannulation and bypass.
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Dual stage venous cannula was then placed in the right atrium. Reverse autologous priming of the pump was performed. The patient was then placed on full cardiopulmonary bypass. After going on full flow, my perfusionist reported elevated arterial perfusion pressures and can only run at an index of 1.8. Decision was made to reinitiate ventilation and wean the heart off of bypass. Decision was made to perform femoral cannulation to improve flows.
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Incision was then made in the right inguinal region. Cutdown to the right femoral artery was performed using electrocautery with division of the soft tissues. The femoral sheath was opened. The underlying femoral artery was identified and encircled with a vessel loop. A 5-0 Prolene was then used to create a pursestring on the anterior wall the femoral artery. Needle was inserted into the femoral artery and guidewire was advanced without difficulty. Serial dilation the femoral artery was performed and then finally, the 23 French femoral arterial cannula was placed and secured. The arterial line was de-aired. Again, her pulmonary bypass was initiated with much improvement in the flows. This also allowed for improved cerebral Somanetics, with the cerebral Somanetics improving to the 60 and 70th percentile.
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The patient was then systemically cooled to 18°C. During this time, retrograde cardioplegia cannula was placed through the free wall the right atrium and positioned in the coronary sinus. Cross-clamp was then placed and cold retrograde cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum. Ice was placed over the right ventricle.

After ventricular fibrillation was induced, the ascending aorta was opened with Metzenbaum scissors. Dissection flap was clearly visualized and appeared to terminate a millimeter or 2 beyond the commissures of the aortic valve. The aortic root was uninvolved. It was at this point, that resuspension of the aortic valve was performed. A pledgeted 5-0 Prolene was placed along all 3 of the commissure to resuspend the valve. Pledgeted sutures were then placed along the sinotubular junction in order to anchor the intima and media to the adventitia.
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Once the patient had been at 18 or 19° for approximately 20 minutes, the head was packed in ice. Decision was made to perform circulatory arrest. Once this was performed, the clamp was released and drop sucker was placed within the aorta. The ascending aorta was resected. And submitted to pathology. The aortic arch was evaluated and it was quite evident that the aortic arch was heavily involved. Each had vessel appeared to be completely detached from the media. I suspect, that the tear may have originated in the arch, but this was not definitive. The aortic arch was then resected to the level of the left subclavian artery. This was also submitted to pathology. The left carotid artery at its takeoff had no media. The left carotid artery was resected back until the media was identified. The innominate artery also had no media at the level of the takeoff. It was resected back to the level of the bifurcation between the right subclavian and right carotid.
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Individual interposition grafts were placed to the carotid and innominate artery. A 6 mm Dacron graft was then sewn end-to-end to the left carotid artery. An 8 mm Dacron graft was sewn end-to-end to the innominate artery. Once this was completed, a 24 mm Gelweave graft was sewn to the distal aortic arch, just proximal to the left subclavian takeoff. Pledgeted sutures were used to tack the media to the wall of the left subclavian and create patency. An outer felt strip was used to reinforce this anastomosis. Once this was completed, the 6 mm and 8 mm graft were each sewn to the neo-ascending aorta graft. Once a 6 mm graft was anastomosed to the aortic graft, de-airing was performed and the cross-clamp was placed to allow for antegrade cerebral perfusion via the left carotid artery. During circulatory arrest which lasted 69 minutes, the cerebral Somanetics dip to the high 30th percentile, but quickly improved to greater than 50th percentile with the antegrade cerebral perfusion. The 8 mm graft was then sewn to the aorta. Flows were lowered and the cross-clamp was then removed and positioned more proximally on the aortic graft to allow for bilateral cerebral perfusion. Next, the patient was rewarmed to 32°C.
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There was a significant discrepancy between the sinotubular junction size and the 24 mm graft which had been placed on the distal arch. A 32 mm Dacron graft was then anastomosed to the sinotubular junction with outer felt strip reinforcement in order to conform sinotubular junction to a size reduction. The grafts were then contoured and then anastomosed together using 4-0 Prolene. A needle vent was placed in the graft and placed on high suction. The patient was then fully rewarmed. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. Next
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The heart was defibrillated to establish a sinus rhythm. Pacing wires were placed on the right ventricle brought out the level of the skin. Anastomoses were found to be relatively hemostatic. There were several areas that were oversewn with 4-0 Prolene or 5-0 Prolene. Once this is completed, the lungs were ventilated. After full rewarming, the heart was weaned from cardiopulmonary bypass without difficulty. Final TEE was performed with findings as described.

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The next 90 minutes were dedicated to reversal of the coagulopathy. Protamine was delivered to reverse the effects of heparin. The patient received 2 rounds of bleeding protocol which included packed red cells, platelets, FFP, as well as cryoprecipitate. After hemostasis was achieved, CoSeal was sprayed over the aortic anastomoses. The mediastinum had been irrigated with saline as well as antibiotic irrigation multiple times to the procedure. A right angle chest tube was placed on the diaphragm as well as in the right pleural cavity. A 32 French straight chest tube was placed in the mediastinum. The sternum was reapproximated with #7 wires. It also had double wires used secondary to the patient’s obesity. This. Abdominal fascia was reapproximated with 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Next
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The right axillary artery graft was clipped twice proximally to allow for a small residual stump. The remainder of the graft was excised and it was then oversewn with 5-0 Prolene. The soft tissues reapproximated with 2-0 Vicryl. Skin was closed with 4-0 Monocryl.
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During the time in which coagulopathy was being corrected, the right femoral artery cannula was removed. The pursestring was cinched to achieve partial hemostasis. 2 figure-of-eight’s were then placed using 5-0 Prolene to achieve full hemostasis. The femoral artery was palpated distal to the primary repair and found to have a good pulse. The soft tissues reapproximated with 2-0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Next
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The patient tolerated procedure well and was transferred to CVRU in critical condition.
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Specimens: Ascending aorta
estimated blood loss: 650 mL
blood replaced: 2 rounds of transfusion protocol, please see official records
drains: Chest tubes as described
implants: 24 mm Gelweave graft to the ascending aorta, 32 mm Dacron graft for the proximal ascending aorta, 6 and 8 mm Dacron graft for interposition grafts
condition at completion of procedure: Critical

Medical Billing and Coding Forum