HIM1257 Ambulatory Coding Module 05 Written Assignment - Coding Audit _09.10.23
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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)
- 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)
- Code should not be reported because It is
a separate procedure
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)
- Reporting the codes incorrectly can lead to audits and a
possibility of not being reimbursed due to missing or incorrect codes.
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)
The incorrect code would be 68810. It should be
68815
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 a procedure is
done bilaterally the correct modifier would be RT
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) – Reporting incorrectly can result in a loss of revenue and third
parties refusing to pay claims.
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.
Diagnosis:
Infected abscess, left ear.
Incised and drained.
The CPT Code reported was:
69000-LT
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1.
Identify the error in code assignment (3 points) -
The code is incomplete. There is a code missing
for the removal of cerumen with cerumen spoon
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) – 69210-LT needs to be reported as it is the
procedure that was performed.
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) – Improper coding can lead to improper billing. Coding incorrectly
will result in reimbursement delays, denials or claims only being partially paid.
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