cdome_Mod5CodingAudit_121423

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Jan 9, 2024

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Module 05 ICD-10-PCS coding audit assignment – Answers (20 Points) Instructions: Each operative report audit is worth a potential 10 points. Points in parentheses are for each operative report. Read each operative report and review the assigned codes. Identify the error in code assignment (3 points) Identify the coding guideline 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 ICD-10-PCS codes reported were: 0TJB8ZZ (Inspection), 0T7D8ZZ (Dilation) 1. Identify the error in code assignment (3 points) a. 0T7D8ZZ 2. Identify the coding guideline that applies and explain why the code(s) should or should not be reported as listed (3 points) a. Coding guideline B3.1b b. The code identified above should not be coded separately, as the dilation is a necessary step to perform the intended inspection. 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) a. Codes reported incorrectly could impact the benchmark percentage of a coder and lead to additional training or disciplinary action. Incorrectly reported codes could also cause issues with third-party payment of claims, i.e. insurance companies rejecting claims due to incorrect information or refusing payment for a non-covered procedure that should not have been coded as it was part of a “surgical package”. Operative report #2 OPERATIVE DIAGNOSIS: Left chest wall mass and ovarian cancer POSTOPERATIVE DIAGNOSIS: Left chest wall mass of unknown behavior and ovarian cancer PROCEDURES: Diagnostic bronchoscopy with evaluation of the bronchial tree tube, a left video assisted thoracoscopy, and a resection of the anterior chest wall mass with some resection of the pleura. PROCEDURE NOTE: General sedation was administered by oral endotracheal tube. The bronchoscope was inserted. The right upper lobe, middle lobe, and lower lobe were normal. No endobronchial lesions were seen. The scope was inserted in the left upper lingual lobe and segments were normal. The left chest was prepped and draped in normal sterile fashion. An incision was made and the thoracoscope was inserted . Under direct vision, additional lateral port was placed. Dissection was then carried down. The mass was identified within the chest wall. It was confined to the

pleura. This appeared to be a large plaque, approximately 10x4cm. A separate satellite mass was present. Using the Bovie electrocautery, the pleura was then dissected from the chest wall. The entire chest wall mass was resected including the pleural lesion. It was then placed in the EndoCath and removed and sent to pathology for evaluation. No other areas were seen in the pleura. Hemostasis was obtained. A chest tube was placed to the apex and anchored with heavy silk. The lung was re-expanded with no significant air leak. The wound was then closed in layers with absorbable sutures. The patient tolerated the procedure well with no complications. The ICD 10 PCS Codes reported were: 0BJ08ZZ, 0WB84ZX 1. Identify the error in code assignment (3 points) a. Codes assigned are missing a third code- 0BBP4ZZ 2. Identify the coding guideline that applies and explain why the code(s) should or should not be reported as listed (3 points) a. Coding guideline B3.2 b. The same root operation is performed on two distinct body parts- the chest wall and the left pluera- which requires coding as two distinct 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) a. Leaving out a code could result in underpayment for the procedure, as well as impacting the benchmark percentage of the coder. This could result in additional training or disciplinary action.

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