Please help code report. We just acquired a Neurosurgeon and this is a report from his procedure. Any help would be greatly appreciated!! Report is attached!! 😎
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CMS invites Medicare Part A providers to learn new Medicare Cost Report e-filing system
Please Help! CFA/SFA/Profunda/Iliac Endarterectomy? Confused! OP Report Included
Good Morning All!
I’m struggling with this OP report today, I could use ANY opinions or advice on which CPT-4 codes to use for this.
The common femoral artery itself was large and a little bit bulbous. The patient was systemically heparinized to the profunda femoris as well as the distal external iliac artery were clamped. A profunda clamp was used for the profunda artery with smaller branches controlled with red vessel loops and the distal external iliac was controlled with a Derra clamp. I then used an 11 blade to cut through the middle of the preexisting Gore patch that was on the common femoral artery. There was fresh thrombus that we took of the entire lumen of the common femoral artery. I was able to remove all of this thrombus burden. Using a #4 embolectomy catheter, I passed it down the superficial femoral artery and after about 3 passes. Finally, we returned a large amount of thrombus. There was then good backbleeding from the superficial femoral artery. I then passed the Fogarty embolectomy down the profunda. There was no additional clot burden there and there was good backbleeding, so that was re-controlled with a profunda clamp. I then checked my inflow and I did not have good inflow. The embolectomy catheter was passed proximally up the iliac artery. I got small pieces of plaque, but no fresh thrombus; however, as I pulled a Fogarty balloon down the iliac, it did seem to get caught up as though there was a significant stenosis at the top edge of the preexisting patch. I extended my arteriotomy a bit more proximally and I did find significant intimal hyperplasia there and it did look like there was an inflow stenosis, it made me wonder if this was the cause of the artery thrombosing initially. I ended up sharply excise in most of that preexisting Gore patch. An extensive endarterectomy was performed from the distal external iliac artery down to the distal common femoral artery, I took great care to make sure that the origins of both the superficial femoral artery and the profunda were free and clear of any residual plaque. I then chose a 2 x 9 cm bovine pericardial patch essentially the entire length of that was required to patch the endarterectomized segment of the artery. This was done with a running 5-0 Prolene suture. Prior to the completion of the anastomosis, all branches were backbled. I did not have good bleeding from the superficial femoral artery until the #4 embolectomy catheter was passed down it again. At this time, I withdrew almost a cast from it and there was now robust backbleeding. Everything was flushed with heparinized saline. The anastomosis was complete.
To me it sounds like it was performed on all Iliac, Common Fem, Superficial Fem, Profunda. I don’t know if this OP falls under an iliofemoral (33533), or Common Femoral (35371)..
I also know about "contiguous VS non-contiguous" would all these arteries fall under contiguous therefore only one code should be report??:confused:
PLEASE HELP :confused:
Thank you!!
Katie
Op report vs path report – dx & cpt?
Hi,
I’ve a case where:
Operative report mentions Wrist volar/antebrachial fascia cyst and H&P report mentions "It was a source of local discomfort left wrist". The patient also has Carpal tunnel syndrome.
The surgeon made an incision for CTR procedure and then extended it proximally to gain access to the cyst (0.5 cm) which was within the antebrachial fascia, removed it and submitted to pathology. Then, he went on and released the carpal tunnel.
Pathology report mentions: benign fibroadipose tissue
Now, since the path report doesn’t mention cyst or any other abnormal finding (let alone tumor) I’m not sure what I should code for Dx and CPT. I’ve narrowed it down to the following:
1. Dx – pain wrist left; CPT – Biopsy, soft tissue of wrist; deep
2. Dx – other disease fascia; CPT – Excision, tumor, soft tissue wrist, subfascial; less than 3 cm
I’m more inclined towards the first option as there is no abnormal pathology.
Could anybody help me on this?
Thanks!
Amber
Op Report Required Elements
Hello there!
Finally have time to get a little more in depth with the quality of all of our documentation. I am curious if anyone has any good resources to confirm CMS requirements for the components of an op report, specifically for colonoscopies. At this time we are watching out for the obvious (sedation, consent) as well as withdrawal time, scope used, bowel preparation score (typically boston). I’m wondering if there is anything we are missing along the way. I am also wondering if it is required to give an actual number for the bowel preparation score or if saying that the bowel prep was "adequate" or something along those lines is enough? We have one or two providers who tend to leave off scores and give an impression instead. Any advice is appreciated
Finally have time to get a little more in depth with the quality of all of our documentation. I am curious if anyone has any good resources to confirm CMS requirements for the components of an op report, specifically for colonoscopies. At this time we are watching out for the obvious (sedation, consent) as well as withdrawal time, scope used, bowel preparation score (typically boston). I’m wondering if there is anything we are missing along the way. I am also wondering if it is required to give an actual number for the bowel preparation score or if saying that the bowel prep was "adequate" or something along those lines is enough? We have one or two providers who tend to leave off scores and give an impression instead. Any advice is appreciated
How to Report Impactful Audit Results
Answer six questions to provide a concise audit that is purposeful, corrective, and educational. You’ve reviewed the records and analyzed the results. Now, it’s time to prepare for what may be the most challenging aspect of the audit process: presenting the results in a way that makes sense and generates the change needed to ensure […]
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Using a definitive dx from the EGD report vs signs/symptoms from Consultant’s note
Hi all,
I understand that when it comes to pathology and diagnosis coding, the provider can wait for the pathology report to come back in order to supply a definitive diagnosis. Likewise, as a coder you can code from the path report.
If Dr. A sees the patient at 9am, and Dr. B performs the EGD at 1pm. The coder doesn’t code the notes until 14 days later (long after the patient has been discharged from the hospital). Can the coder still pull the diagnosis from the EGD report for Dr. A’s claim or would the coder have to report the signs/symptoms for Dr. As claim because technically the patient didnt have a definitive diagnosis at 9am??…If this logic is true, it just seems to contradict the pathology rules.
I’m speaking from the pro-fee inpatient side.
CARDIAC CATH REPORT… help!!
My office manager codes all of the procedures and she’s on vacation… She also took our coding books with her so I can’t look anything up. My first time coding procedures and I need help with one! I’m having trouble choosing the correct codes by the EMR program descriptions. Does anyone have a cheat sheet or can direct me any helpful links? The report is as follows…
Procedure Type
*
Diagnostic procedure: Venous Graft Angiography, LIMA Graft Angiography,
Coronary Angiography
Miscellaneous: Closure Device Insertion
Registration Data
Registration Date: 07/02/2018 Registration Time: 09:28
*
Medical History
Allergies
– NKA:Sensitivity: Allergy.
*
Procedure Data
Procedure Date
Date: 07/02/2018Start: 13:15End: 14:35
*
The procedure was explained in detail to the patient. Risks, complications
and alternative treatments were reviewed. Written consent was obtained.
*
Diagnostic Cath Status: Elective
*
Entry Locations
– Retrograde Percutaneous access was performed through the Right Femoral
artery (Primary location). A 4 Fr sheath was inserted. This was
exchanged for a 6 Fr sheath. Hemostasis was successfully obtained using
Perclose ProGlide (Abbott).
*
Procedure Medications
– Versed/Midazolam I.V. 0.5 mg.
*
– Fentanyl/Sublimaze I.V. 25 mcg.
*
– Fentanyl/Sublimaze I.V. 25 mcg.
*
– Versed/Midazolam I.V. 0.5 mg.
*
– Fentanyl/Sublimaze I.V. 25 mcg.
*
– Lidocaine 2% S.Q. 10 ml.
*
Diagnostic Catheters
– A6 FrCordis 6F Infiniti JL4 100cmwas used for:*Left coronary
angiography.
*
– A6 FrCordis 6F Infiniti JR4 100cmwas used for:*Right coronary
angiography.
*
– A6 FrCordis 6F Infiniti JR4 100cmwas used for:*SVG.
*
– ACordis 6F Infiniti IM 100cm.was used for:*LIMA.
*
Complications: *No Complications.
*
Specimens Removed:
Contrast Material
– Visipaque (92002)105 ml
*
Fluoroscopy Time: Diagnostic: 11:21 minutes. Total: 11:21 minutes.
*
cGycm2 (T/R/F)7739/4152/3587 Cath Lab Rm #CCL 5
Primary ProcDiagnostic Air Kerma1018mGy
Patient Arrived Fromcau Patient Sent Toccl holding
*
Hemodynamics
Condition: Rest
O2 Consumption: Estimated: 258.65Heart Rate: 61 bpm
Pressures (mmHg)
+—–+——————————————————————–+
!Site !Pressure (mmHg) !
+—–+——————————————————————–+
!AO !163/62 (96) !
+—–+——————————————————————–+
*
Shunts
*
Oxygen Values
O2 Capacity 145.52 O2 Consumption 258.65
Aorta Findings
Angiographic Findings
Cardiac Arteries and Lesion Findings
LAD:
The LAD is a moderate caliber vessel. The 1st diagonal branch is small.
Immediately after the 1st diagonal branch, there is a long "apple core" 99%
stenosis. Competitive flow is seen in the remainder of the LAD and the large
2nd diagonal branch. Distal LAD subtended by patent LIMA graft.
Lesion on Mid LAD: 99% stenosis 8 mm length.
LCx:
Circumflex is a large caliber vessel. There is mild disease in the proximal
portion. First obtuse marginal is subtotally occluded. Distally, there is a
large posterolateral branch. The left PDA is small in caliber. There is
moderate diffuse disease but no obstructive lesions.
Lesion on 1st Ob Marg: Ostial.100% stenosis.
RCA:
The RCA small and nondominant.
*
Cardiac Grafts
– There is a graft that originates at the Aorta Left and attaches to the
1st Ob Marg. Widely patent
– There is a graft that originates at the Aorta Left and attaches to the
2nd Diag. Widely patent
– There is a graft that originates at the LIMA and attaches to the Dist
LAD. Widely patent
Coronary Tree
Dominance: Left
Conclusions
Procedure Summary
Indication: Severe aortic stenosis
Coronary angiography performed via right femoral approach revealed
presence of a left dominant system. The LAD is subtotally occluded in the
midportion. First obtuse marginal is subtotally occluded at the ostium.
Circumflex is widely patent otherwise. The RCA small and not dominant.
There are 3 patent grafts including LIMA to LAD, SVG to 2nd diagonal and
SVG to 1st obtuse marginal.
Recommendations
Proceed with TAVR evaluation
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