Module 05 Coding Audit Worksheet_MM (2)aan
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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 0TJB8ZZ,OT7D8ZZ
.
The CPT codes reported were: 52000, 52281
•
Identify the error in code assignment (3 points) •
Code OTJB8ZZ should not be coded The root operation and cystoscopy for inspection should be
coded separately
.
•
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) •
Guidline B3.11A
•
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) •
Coding incorrectly impact the patient care, can effect the insurance or any payment if the coder coded wrong.
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
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