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Tag Archives: Simple

Repair Simple, Intermediate, or Complex Repair Code

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Op report

After adequate anesthesia, legs were prepped with betadine, draped in a sterile fashion. The left thigh laceration was measured 27 cm in length and it arched over from the distal anterior thigh lateral across the knee joint and then inferior. There was a stated degloving and undermining of the skin over the knee. There was no fascial injury. This area was copiously irrigated with a liter of saline and then the skin was closed with running 2-0 nylon sutures over a 19-French Jackson-Pratt drain. Drain was brought out and sewn in place with a 2-0 silk. The laceration measured 27 cm. The right anterior tibial laceration measured 3 cm and then there was a puncture wound, which was controlled with interrupted 3-0 nylon stitches. This was irrigated out initially and the two areas connected just anterior to the tibia.
The right thigh laceration was extensive and included a laceration of the lateral aspect of the quadriceps fascia with bulging muscle. This are was copiously irrigated with a liter of warm saline. The fascia was reapproximated with a running 9 Vicryl stitch, returning the muscle belly underneath the fascia. This measured 20 cm. The skin laceration was then repaired, measured 24 cm and again there was some undermining of the skin. A drain was placed, brought out inferiorly, and sewn in place with a 2-0 silk. the skin was then closed with running 3-0 nylon. Mepliex dressings were applied and Ace bandages were applied, and drains were placed to suction. The patient tolerated the procedure well and was taken to recovery room in stable condition.

I choose codes 12002, 13121, and 13122 x 9. Can someone tell me if this is correct and if it’s not what would be the correct choice.

Thank you

Medical Billing and Coding Forum

Open Simple Retropubic Prostatectomy 55831?

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Any help with this would be much appreciated. I’ve been searching and everything comes up to laparoscopic. Would it be the 55831?

SIMPLE RETROPUBIC PROSTATECTOMY (for BPH,urinary retention)

After the induction of adequate General anesthesia, the patient was laid supine on the table, the genitalia and lower abdomen were prepped and draped in the usual fashion. 18 French Foley catheter was used to drain the bladder to empty and then removed. Low midline incision was made from the pubic symphysis to just below the umbilicus. Incision was carried down to the rectus fascia using electrocautery. Rectus fascia was sharply opened using electrocautery and midline placement was confirmed and the incision wasn’t opened up for the entirety of the rectus fascia. Blunt dissection was used to separate the peritoneum from the retroperitoneum and expose the pre-pubic space of Retzius. The Balfour retractor was then positioned into place with 2 narrow blades retracting the bladder and peritoneal contents cranially.

Stadium figure-of-8 sutures of 2-0 Vicryl were then placed in two rows over the anterior surface of the prostatic capsule. The 2 midline sutures were tagged with a snap. Approximately 15-20 sutures were used to complete the 2 rows of Stadium sutures. The lateral borders of the 2 rows of sutures were also tagged with figure-of-eight 2-0 Vicryl suture oriented vertically to prevent tearing of the prostatic capsule. Electrocautery was then used to open the prostatic capsule between the 2 rows of suture. The incision was carried down to the adenoma layer which was noted to be smooth and shiny versus the fibrous muscular capsule layer. Once the adenoma was reached then finger dissection was used to shell out the adenoma on either side away from the capsular layer. There was noted to be significantly sized median lobe which was also shelled out intact in continuity with the rest of the adenoma. At the apex of the adenoma the urethra was pinched transected. The adenoma was then passed off the table as specimen. There was minimal bleeding at this point. The posterior lip of bladder neck was then sutured down to the posterior prostatic fossa thereby creating a waterfall configuration for the bladder neck to open into the urethra. Ureteral orifices were well away from the bladder neck here. 22 French 3 Foley catheter was then passed into the bladder but not inflated at this point. The capsular incision was then closed with 2 separate 0 Vicryl sutures starting at the lateral aspect of the capsulotomy towards the midline. 2 sutures were then tied to each other at the midline over the incision. Catheter was reviewed and those found to be no leak. 40 mL of sterile water were placed into the balloon. A flat Jackson-Pratt drain was in place and the pre-vesicle space and brought out through separate stab incision left lower quadrant. This was connected to bulb suction. Rectus fascia was closed with a #1-0 PDS suture. Subcutaneous tissues were then infiltrated with 10 mL of half percent Marcaine plain. Skin was then closed with clips. Incision was clean and dried and dressed with a dry sterile dressing. Patient was awakened from anesthesia extubated uneventfully and transferred to PACU in stable condition having tolerated procedure well. No complications.

Medical Billing and Coding Forum

Simple Mastectomy and removal if implants

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New to Mastectomy ..

Do I have the right codes: 19303-50

or am I missing something??

PREOPERATIVE DIAGNOSIS:
Left breast carcinoma, upper outer quadrant with bilateral subglandular
implants.

POSTOPERATIVE DIAGNOSIS:
Left breast carcinoma, upper outer quadrant with bilateral subglandular
implants.

PROCEDURE:
1. Right simple mastectomy and removal of implant.
2. Left simple mastectomy with removal of implant and removal of axillary tail.
This patient had prior lymph node dissection. There was very little to no
tissue in the axilla as this had been stripped in the prior axillary node
dissection.

ASSISTANT:
xxxxxx

ANESTHESIA:
General.

ANESTHESIOLOGIST:
Dr. English.

ESTIMATED BLOOD LOSS:
Minimal.

PROCEDURE IN DETAIL:
The patient was placed on the operating table in supine position. After
administering general anesthesia, the patient’s upper chest, arms, and down to
the elbow were prepped along with the neck, prepped and draped in usual
fashion. Time-out was performed. Attention was turned to the right side,
which was benign. The oblique elliptical incision was made, sharply carried
down to subcutaneous tissue with the cautery. Then, utilizing a Gorney
scissors, skin flaps were created appropriate thickness, approximately 8-7 inch
and slightly less superiorly to the clavicle, medially to the sternum, inferiorly to the rectus, laterally to the latissimus dorsi. The breast tissue
was reflected from medial to lateral along with the implant, which was
subglandular, muscle was left intact. After this was removed, the area was
thoroughly irrigated, thorough hemostasis obtained and then a Blake drain was
placed and brought out to the inferior mammary line, sutured in position. The
skin was then closed with staples. Attention was then turned to the left
breast. Again, oblique incision was made. The patient had a prior lumpectomy
with an incision at the inferior mammary line. An oblique incision was marked.
The skin incision made and utilizing a Gorney scissors, skin flaps were
created of appropriate areas. The clavicle superiorly, latissimus dorsi and
laterally, rectus inferiorly and the sternal border medially. Then, there was
breast tissue along with the implant, was reflected from medial to lateral. It
should be noted the axillary tail was removed with the breast. There was very
little axillary tissue noted. The nerves were easily visible along with the
axillary vein. There appeared to be no lymphatic tissue present. There were
no positive palpable issues or actually very little fat in that area. Whatever
was there was removed with the axillary tail. The wound was then thoroughly
irrigated. Hemostasis obtained. A Blake drain was placed, brought out
inferiorly and sutured in position. After obtaining thorough hemostasis and
irrigation, the skin was closed with staples. Firm pressure dressings
including a breast binder were applied. Final sponge, needle, and instrument
count were correct. Sterile dressing was placed. The patient was transferred
to recovery in satisfactory condition.

Help please

Medical Billing and Coding Forum

Five simple tips to help healthcare organizations prevent fraud

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Five simple tips to help healthcare organizations prevent fraud

by Elizabeth Stepp, senior counsel at Oberheiden Law Group, in Dallas

It’s impossible to calculate the amount of healthcare fraud that exists, as much of it slips under the radar. However, healthcare fraud poses a serious problem, putting the health and welfare of beneficiaries at risk while costing taxpayers billions of dollars.

Preventing healthcare fraud and abuse is challenging, especially for hospitals, hospices, and other similar organizations. While there are a lot of honest and well-intentioned healthcare providers, there are quite a few perpetrators?ranging from street criminals to large companies. As such, owners of healthcare organizations need to be on their guard at all times. After all, allegations of fraud and abuse against low-level or top brass employees can affect the reputation of any healthcare organization.

But if you’re the owner of a small or large healthcare organization, don’t let this worry you. The following are some tips to help you prevent your organization’s reputation from taking a hit, and to avoid costly lawsuits.

 

Perform background checks before hiring

Pre-employment screening for employees, as well as contingent or temporary workers, is a common best practice for healthcare organizations. That being said, not all organizations have the time and resources to perform thorough background checks. Add to this a shortage of quality caregivers plus an increase in the number of patients, and employers find it easy to rely on trust instead of facts.

Since a single scam artist can taint your organization’s reputation, avoid employing or hiring individuals just because they appear to be trustworthy. Make sure pre-employment background checks include the following:

  • Education verification: Verify training and accreditation.
  • Employment verification: Crosscheck length of employment, position, and performance with previous companies. Note reasons for leaving and analyze gaps in employment history.
  • Record verification: Ensure that civil records are clean and confirm that there are no criminal records.

 

Additionally, check personal references, verify Social Security numbers, and have individuals undergo drug tests.

 

Have policies and procedures in place

Formalized policies and procedures promote regulatory compliance and workplace safety, and above all guarantee safe and quality patient care. Healthcare organizations also need to have policies and procedures in place to safeguard protected information. Start with defining access and authorization controls, and separate duties in order to reduce opportunities of fraud.

Make sure that policies and procedures are up-to-date and well written, so as to reduce practice variability. Practice that varies from one person to another can lead to sub-standard care and reliance on memory, which in turn can cause errors and oversights. Apart from this, organizations should have a defined set of internal controls to produce accurate financial reports, help comply with laws and regulations, oversee asset protection, and so on.

If you’re not sure about which policies to implement, getting in touch with a healthcare fraud defense attorney will be helpful. These lawyers can defend your case, and they know what it takes to prevent becoming a victim of fraud.

 

Perform audits regularly

Accurate and complete clinical documentation is important if you want to provide quality healthcare. The best way to improve documentation, and the care that your organization provides, is to conduct regular medical audits. Medical audits can also improve the financial health of your organization, and determine areas that need corrections and improvements.

Ensure that medical auditing and monitoring in your healthcare organizations is:

  • A regular and ongoing process
  • Conducted by qualified professionals who lay emphasis on government enforcement actions and ensure compliance with internal, state, and federal rules and regulations
  • Performed by keeping senior officials and board members in the loop

 

Protect data

For healthcare organizations, protecting data can mean reducing the number of emergent care cases, improving patient outcomes, providing better oversight and care, and increasing revenue. This makes it necessary for all healthcare organizations?big and small?to protect data. That being said, a lot of small- and mid-sized healthcare organizations think spending on data protection is pointless, as even organizations that take the appropriate steps are attacked by fraudsters.

Sure, data breaches keep happening. But, if you do what’s right, you can definitely protect your organization from being an easy target?and healthcare abusers like easy targets.

Here are some things to keep in mind:

  • Dumping data in the trash can gives dumpster divers an opportunity to steal and sell private data. Make a point to shred all data before it is discarded.
  • Conduct a risk assessment in accordance with government regulations to help you review security policies, identify threats posed to your organization, and expose system vulnerabilities.
  • Remind employees to keep a watchful eye on data and to never leave electronic devices or records unattended.
  • Encryption technology known as SSL, or Secure Socket Layer, can prevent data breaches.
  • Keep a note of who can access records and manage user identities. Also, allow employees access to information that is pertinent to their position.
  • Use complex passwords and two-factor authentication where possible.
  • Have a guest wireless network that’s separate from the main corporate network to offer additional protection.
  • Get in touch with a cloud vendor or a local security firm to host information systems. Clarify if you’ll be paying for a suite of services or just certain parts, such as encryption or threat management.
  • If you can’t afford to spend on data protection, turn to free open-source tools.

 

Make it easy to report fraud

Reporting fraud and abuse?or any suspicious activity­?should be an easy process. You’ll also have to set up a system so that vendors, employees, and patients and their family members can report abuse anonymously.

Most importantly, take required action on all complaints received. By addressing issues promptly, you’ll instill confidence among your employees and patients.

 

Protect your healthcare organization today

As an honest healthcare provider, you’d certainly want your healthcare organization to be free of fraud and abuse. Having the right intentions alone won’t be able to help you achieve your goals; you’ll have to take the necessary steps too.

With the information given here, you now know what you need to do to ensure that your healthcare organization is safe. Implement these tips right away, and say goodbye to fraud and abuse!

HCPro.com – Credentialing and Peer Review Legal Insider

Simple VS Intermediate Repair

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If a patient comes in for a simple laceration and a simple repair was done, does the repair become an intermediate repair because the laceration was caused by a dog bite? Does the fact that the wound is heavily contaminated from the dogs mouth mean that this goes from a simple repair to an intermediate? Also when deciding on which repair type to choose is the level of risk a factor in making the decision?
Thanks!

Medical Billing and Coding Forum

Family psychotherapy codes 90847 – simple question I promise!

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Hello all,

A provider sees siblings both patients of this provider at the same time/visit The visit entails the true definition of 90847. The provider provides individual face to face assessments then has the siblings join together to observe behavioral interaction. Can the provider bill 90847 for each sibling? I tried to find something out there in cyber space but could not find a resourceful answer. Any help would be appreciated. Thank you! :confused:

Definition of 90847

The therapist provides 50 minutes (Excludes Service times of less than 26 minutes) of family psychotherapy in a setting where the care provider meets with the patient and the patient’s family jointly. The family is part of the patient evaluation and treatment process. Family dynamics as they relate to the patient’s mental status and behavior are a main focus of the sessions. Attention is also given to the impact the patient’s condition has on the family, with therapy aimed at improving the interaction between the patient and family members. Reviewing records, communicating with other providers, observing and interpreting patterns of behavior and communication between the patient and family members, and decision making regarding treatment, including medication management or any physical exam related to the medication, is included.
• 90846 – Family psychotherapy WITHOUT patient present, 50 minutes
• 90847 – Family psychotherapy (conjoint) WITH patient present, 50 minutes

Medical Billing and Coding Forum

Robotic Simple Prostatectomy

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My question is regarding a Robotic SIMPLE Prostatectomy. There is only one robotic CPT code for a prostatectomy in the CPT book and that code reads:

55866- Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance when preformed.

Since a simple prostatectomy does not include everything listed in the description of CPT code 55866, I have been adding a 52 modifier for reduced services. Is this correct or should I be billing something different? My docs are worried we are missing out on money by adding a 52 modifier.

Any input will be greatly appreciated!

Medical Billing and Coding Forum

Simple repair with Intermediate repair?

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Laceration is 17 cm in total length. 5 cm of which go through to the fascial sheath.

The repair is a 2 layered repair. 5 cm of fascial and subcutaneous and then 17 cm simple closer of the surface layer.

My question is would this be a 12035 or 12032, 12005-59?

Thank You.

Medical Billing and Coding Forum

home health visits by LPT doing a simple dressin change

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We are looking at LPT’s making home health visits for joint replacement followup care, and possibly having to do a simple dressing change. I am having difficulty in locating a CPT code for this procedure. What we have been looking at is the fact that when the LPT makes their visits for joint replacement therapy in the home, sometimes they may need to change a simple dressing. Instead of having a skilled nurse make a visit, we were thinking that the LPT could change the dressing. This would save the patient the need for another person in their home and Medicare costs as well, possibly.
I did find a CPT code, but I do not know if it will work. 99600 which is for an unlisted home visit service or procedure. Would this need a modifier?
Thanks in advance for any help!

Medical Billing and Coding Forum

One Simple Way a Radiology Group Added Value to Their Hospital Relationship

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One Simple Way a Radiology Group Added Value to Their Hospital Relationship

If you follow the leading voices in the radiology community, you know that the topic of “value” is a recurring theme of current conversations. It is a core concept behind Imaging 3.0 and has dominated recent seminars, webinars, social media chatter and more for months thanks to MACRA and the many changes it is bringing to provider compensation models. And whatever changes the next wave of governmental healthcare policy washes into the boardrooms of group practices, when the murky waters recede, it is a safe bet that proof-of-value will still remain on the table as a mandate for radiologists going forward. 


Radiology Billing and Coding Blog