Module 05 Coding Audit Worksheet_MM (1)

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Rasmussen College, Minneapolis *

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HIM1258C

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Mechanical Engineering

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Feb 20, 2024

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HIM1257 Ambulatory Coding Module 05 Written Assignment - Coding Audit Instructions: Each operative report audit is worth a potential 10 points. Points in parentheses are for each operative report. This assignment is worth a total of 30 points. Read each operative report and review the assigned codes. Identify the error in code assignment (3 points) Identify the coding guideline or instructional note that applies and explain why the code(s) should or should not be reported as listed (3 points) Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding. (4 points) Operative report #1 PREOPERATIVE DIAGNOSES: 1. Interstitial cystitis. 2. Urethral stenosis. POSTOPERATIVE DIAGNOSES: 1. Interstitial cystitis. 2. Urethral stenosis. Procedures: 1. Cystoscopy. 2. Urethral dilation and hydrodilation. Description of Procedure: Urethra was tight at 26-French and dilated with 32-French. Bladder neck is normal. Ureteral orifice is normal size, shape and position, effluxing clear bilaterally. Bladder mucosa is normal. Bladder capacity is 700 mL under anesthesia. There is moderate glomerulation consistent with interstitial cystitis at the end of hydrodilation. Residual urine was 150 mL.

The patient was brought to the cystoscopy suite and placed on the table in lithotomy position. The patient was prepped and draped in the usual sterile fashion. A 21 Olympus cystoscope was inserted and the bladder was viewed with 12- and 70-degree lenses. Bladder was filled by gravity to capacity, emptied and again cystoscopy was performed with findings as above. Urethra was then calibrated with 32-French. The patient was taken to the recovery room in stable condition. The CPT codes reported were: 52000, 52281 1. Identify the error in code assignment (3 points) The error in the code assignment is that the CPT code 52281 is not necessary in this case. The dilation of the urethra is already included in the CPT code 52000. 2. Identify the instructional note or coding guideline that applies and explain why the code(s) should or should not be reported as listed (3 points) CPT manual’s instruction on “separate procedures” 3. Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding. (4 points) it is crucial to ensure accurate and compliant coding in healthcare to avoid these potential issues. Operative report #2 PREOPERATIVE DIAGNOSIS: Right nasal lacrimal duct obstruction. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Right dacryocystorhinostomy. INDICATIONS: The patient is a 42-year-old lady with the chronic epiphora from the right eye. This has been worked up by the Ophthalmology Dept. and the diagnosis of functional nasolacrimal duct obstruction was made. A dacryocystorhinostomy was indicated. DESCRIPTION OF PROCEDURE: After general endotracheal anesthesia was established, the patient's face was prepped and draped in a sterile field. A curvilinear incision was made at the right medial canthus. This was deepened down to the nasal bone. Then using a Freer elevator, the periosteum was reflected laterally exposing the lacrimal fossa and posterior aspect of the lacrimal sac. Using a burr, a 1 cm. opening was made in the lateral nasal bone obliterating also the lacrimal crest. The nose had previously been packed with cocaine soaked cottonoids. An opening was then made in the nasal mucosa. The puncta were then dilated with a series of lacrimal probes. With a probe in place through the lower punctum, the back wall of

the lacrimal sac was opened. The contents of the sac were clear. There was no evidence of tumor in the sac. The opening in the sac was then enlarged and Quickert-Dreyden tubes were passed through both puncta through the opening into the nose. The tubes were then tied within the nose with a silk suture and cut short and allowed to retract in the nose. The skin incision was then closed with running 6-0 nylon suture. Bleeding throughout the procedure was controlled with bipolar cautery. A corneal shield was placed during the procedure to protect the globe. The patient tolerated this procedure well. Blood loss was negligible. She was taken to the recovery room in good condition. The CPT Codes reported were: 68810-50, 68720-50 1. Identify the error in code assignment (3 points) 68810-50 is the code for probing of nasolacrimal duct, bilateral. 68720-50 is the code for “Dacryocystorhinostomy, external, bilateral” The correct CPT code is 68720-RT 2. Identify the instructional note or coding guideline that applies and explain why the code(s) should or should not be reported as listed (3 points) Modifier -50 is used when indicating a bilateral procedure, Modifier =RT and -LT are used to indicate procedure performed on right and left side of the body. 3. Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding. (4 points) In this case, using the incorrect modifier could lead to the procedure being incorrectly recorded as having been performed on both sides, which could potentially impact future treatment decisions for the patient. Procedure note #3 Chief Complaint: Lump, left ear. History, Physical, and Treatment: This 20-year-old male notes a lump which has developed anterior to his left ear over the last week. It is painful to him. Denies fever or chills. States he had a problem similar to this in the past. Inspection of the ear area reveals a 2 cm size lump just in the pre-auricular area of the external ear. It is tender to palpation, it is fluctuant. No cellulitis or erythema is present. Area was cleansed, local infiltration with 1% Xylocaine for anesthesia was performed. Area was incised with a #11 blade. A large amount of purulent material was expressed. Samples taken for culture and sensitivity. Loculations were broken up. Incision was irrigated and Iodoform was packed. Bandaid applied. The patient also complained of pain in the left ear. Impacted cerumen was noted. This was removed with a cerumen spoon without difficulty. Routine ear wash was advised. Patient is to return tomorrow for removal of packing.

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Diagnosis: Infected abscess, left ear. Incised and drained. The CPT Code reported was: 69000-LT 1. Identify the error in code assignment (3 points) The CPT (Current Procedural Terminology) code reported, 69000-LT, is for "Drainage external ear lesion; simple". However, the procedure performed was not just a simple drainage. The physician also incised the abscess, expressed purulent material, broke up loculations, and packed the incision with Iodoform. 2. Identify the instructional note or coding guideline that applies and explain why the code(s) should or should not be reported as listed (3 points) According to the CPT coding guidelines, the code 69000-LT is not appropriate for this procedure. The correct code should be 10060-LT, which is for "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single". This code better describes the procedure performed, which included incision, drainage, and packing of the abscess. 3. Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding. (4 points) I ncorrect coding can lead to under-billing or over-billing. In this case, the procedure was more complex than the code suggests, potentially leading to under-billing and loss of revenue.