Sample Coded Medical Coding Charts for Practice

Report 1

REASON FOR STUDY: Left testicular pain

CLINICAL HISTORY: Pain

COMPARISON: None.

TECHNIQUE:
This study was performed in an ACR accredited facility. A sonogram of the 
scrotal sac was performed utilizing gray-scale, color, and pulsed Doppler flow.

Sample Coded Medical Coding Charts for Practice


FINDINGS:
Right Hemiscrotum: The testicle is normal in size and echotexture. The
epididymis appears normal. There is no hydrocele or varicocele. Doppler
evaluation shows normal arterial and venous flow.
Left Hemiscrotum: The testicle is normal in size and echotexture. The
epididymis appears normal. There is no hydrocele or varicocele. Doppler
evaluation shows normal arterial and venous flow.

IMPRESSION:
1. Normal testicular sonogram. No evidence of mass, inflammation, or torsion


CPT- 93976
768707
ICD – N50.82


Report 2

REASON FOR STUDY: ABDOMINAL PAIN GENERALIZED

CLINICAL HISTORY: Abdominal pain.


COMPARISON: None.

TECHNIQUE:
The study was performed in an ACR accredited facility. Multiple transverse and
longitudinal views of the abdomen were obtained.

FINDINGS:
Liver: Normal in size and echotexture.
Spleen: Unremarkable.
Gallbladder: Echo-free without evidence of gallstones or sludge.
Biliary ducts: No evidence of biliary dilatation. The common bile duct
measures 2 mm.
Kidneys: No masses or hydronephrosis.
Pancreas: Unremarkable.
Free fluid: None.
Aorta: Unremarkable.
Inferior vena cava: Unremarkable.

IMPRESSION:
1. Unremarkable abdominal sonogram.

CPT- 76700
ICD – R10.84 Generalized abdominal pain


Report 3

REASON FOR STUDY: CONGENITAL HYDRONEPHROSIS

CLINICAL HISTORY: Hydronephrosis

COMPARISON: None.

TECHNIQUE:
The study was performed in an ACR accredited facility. Multiple transverse and
longitudinal sonographic images of the kidneys and urinary bladder were
performed.

FINDINGS:
Renal Echogenicity: The kidneys demonstrate normal renal echotexture
bilaterally without evidence for renal mass.
Pelvic Collecting System: Normal fullness in the renal collecting systems
is noted bilaterally unchanged since prior exam.
Renal Size: The right kidney measures 6.1 cm. The left kidney measures 6.
8 cm.
Bladder: The urinary bladder is unremarkable.


IMPRESSION:
1. Persistent minimal fullness of the intrarenal collecting system.


CPT -76770
ICD 10 - N13.30 Unspecified hydronephrosis


Report 4

REASON FOR STUDY: GROWTH EVALUATION

CLINICAL HISTORY: Gross evaluation

COMPARISON: None.

TECHNIQUE: Single view of the left hand was obtained

FINDINGS:
The patient's chronologic age is 8 years 4 months. Standard deviation at this
age is 8.8 months. The patient's skeletal age most closely approximates that
of the male standard #15 skeletal age 6 years.

IMPRESSION:
1. Patient's skeletal age is greater than 2 standard deviations below
chronologic age.

CPT - 77072
ICD 10 -R62.50


Coding tips for Antenatal Screening of Mother in ICD 10


Screening codes have to be used very carefully. If you really want to be perfect in ICD 10 coding, you need to use Encounter codes carefully. Always use Encounter codes as primary diagnosis. We all know that pregnancy codes are very specific in ICD 10. Even for coding weeks of gestation, we have separate Z3A category codes in ICD 10. We have already learnt about normal and outcome of delivery codes in pregnancy previously.Today we will check the use of coding Screening codes for mother.
 Coding tips for Antenatal Screening of Mother in ICD 10


Sample chart for antenatal screening of Mother
Below I have shared an antenatal screening procedure chart for mother. Earlier we have already seen coding of normal pregnancy ICD 10 codes. By reading below chart, you can easily understand when we should report Z36, encounter for antenatal screening of Mother. Also, you can go through the CPT or procedure code 76805

REASON FOR STUDY: encounter for antenatal screening of mother z36 


CLINICAL HISTORY: Antenatal screening 


COMPARISON: None. 


TECHNIQUE: The study was performed in an ACR accredited facility. 


FINDINGS:
A single living fetus is identified. 


Fetal Position: Oblique head and left lower quadrant 
Placenta: Posterior, no previa 
Amniotic Fluid: Normal 
Cervix: 2.4 cm in length 
Uterus and Adnexa: Unremarkable 



BIOMETRIC DATA: 
Biparietal Diameter: Sonographic Age: 19 weeks, 3 days 
Head Circumference: Sonographic Age: 18 weeks, 6 days 
Abdominal Circumference: Sonographic Age: 18 weeks, 4 days 
Femur Length: Sonographic Age: 15 weeks, 3 days 



Composite Sonographic Age: 18 weeks, 6 days, for a sonographic EDD of October 
28, 2017. 



Estimated Fetal Weight: 247 grams +/- 37 grams 



The age by last menstrual period or provided adjusted EDD is weeks, days giving 
an associated EDD of . 



Fetal Anatomy: 
Cerebral Ventricles: Unremarkable 
Cavum Septum Pellucidum: Unremarkable 
Posterior Fossa: Unremarkable 
Four Chamber Heart: Unremarkable 
Ventricular outflow tracts: Unremarkable 
Three vessel View: Unremarkable 
Spine: Unremarkable 
Stomach: Unremarkable 
Renal Region: Unremarkable 
Urinary Bladder: Unremarkable 
Face and Lips: Unremarkable 
Umbilical Cord: 3 Vessel, Unremarkable 
Abdominal Wall: Unremarkable 
Extremities: Unremarkable 



ADDITIONAL COMMENTS (if any): 
None. 



IMPRESSION:
1. Single living fetus with composite sonographic age of 18 weeks, 6 days. 
Age by last menstrual period is 18 weeks, 6 days. Estimated fetal weight is 
247 grams. 


CPT code: 76805
ICD 10- Z36 – Encounter for antenatal Screening of Mother

Rationale- Since the procedure was performed on second trimester (18 weeks) the CPT code 76805 is reported. Here, pregnancy CPT codes should be coded carefully, since we have separate CPT code for detailed examination of fetus as well (76811- routine fetal ultrasound which includes all of the components (CPT code 76805), plus a detailed fetal anatomical survey)

For ICD 10 codes, since the reason for encounter is antenatal screening of mother, Z36 should be reported.

When Should I use 59 modifier in Surgery?: 3 Common Scenarios

CCI edits can create a lot of problem if you miss to bypass the procedure  using a modifier. In such situation the billing for the procedure codes will be affected. We know that the coding guidelines should be followed throughout the medical coding facilities. The use of modifier should be done very intelligently. Yes, some modifiers are really tricky to use but with experience, you will become familiar with these modifiers. Now, coming to the topic I am just gonna share few cases where the coders face CCI edits very frequently. Use of 59 or X{EPSU} modifier should be done very carefully in these cases.

3 common CCI edits Medical Coders Face


First case

In interventional radiology, their is lot of use of CPT codes. The procedures sometimes start as diagnostic and ends with a therapeutic procedure. So, here if a Fine Needle aspiration is performed and along with a core biopsy on same lesion, we can only code a core biopsy CPT code. Since, the exam is same lesion, FNA will get included in the core biopsy. Now, when both FNA and core biopsy are performed on different lesion, the FNA need to be reported with 59 or X modifier along with core biopsy. Now, you can understand how CCI edits should be used for using 59 modifiers. Even the anatomic site is important for use the modifiers. Also in some exceptional case, the physician sometimes performs core biopsy and then again perform a FNA on same lesion if he or she is not satisfied with core biopsy result. In this scenario we can use the  59 or X modifier along with FNA procedure code. This is the major confusion among surgery coders.


Second Case

Now, for coding Vascular procedures in interventional radiology, you will come across for coding same CPT code again and again. For example, if you are coding selective catheterization through separate access, you might have to use same CPT code, like 36245 and 36245-59 for first order arteries. It is very common in Selective and Non-Selective Catheterization procedures. Also, if you are coding different order as well with two separate access, you have code the lower first order (36245) with 59 modifier along with first second arteries 36246. For same access procedures  the highest order 36247 includes the lower order 36246 and 36245 procedure code.


Third case

This is quite simple and still many medical coders does errors in that. For coding guidance in multiple surgery procedures, the CPT codes comes under CCI edits. For example, if you code a breast biopsy procedure with ultrasound guidance along with a liver biopsy exam performed under guidance. Now, here the breast biopsy procedure code includes the ultrasound guidance code 76942, hence it should not be reported. But, if you see the Liver biopsy has been done on same day with ultrasound guidance. Now, when you code breast biopsy, liver biopsy and ultrasound guidance together, you will definitely get a CCI edit mentioning that the ultrasound guidance is present in breast biopsy. Now, here you to add 59 modifier to 76942 cpt code, to show that this guidance is performed for liver biopsy which need to be billed separately. If you do not add the 59 modifier, the payer will not pay for the guidance, since they will assume that it is included in breast biopsy. Hence, it is really important to use modifier correctly using CCI edit tools.

Become Expert in Coding CPT code 97597, 97598 and 97602


We have already learnt a lot in surgery coding. We are now updated with the new spinal epidural injection codes of 2017. To become a perfect in coding, coders really need to remain updated with each and every CPT code. Medical coders need to be more perfect in coding diagnostic and interventional radiology cpt codes. Every year their have been lot of new codes added in the procedure coding. Hence, coders need to be more focused while coding new codes. Earlier we have learnt about selective and non-selective catheterization of veins. We have going to learn more about selective and non-selective techniques in coding debridement procedure.

Coding guidelines for CPT code 97597, 97598 and 97602

There are two types of debridement, selective and non-selective. In Selective debridement techniques, the provider has complete control over the tissue which is being removed. These techniques include the use of high pressure waterjet with or without suction. Also, the use of scissors, a scalpel or forceps is required for selective debridement. We have separate CPT codes for these types of debridement. CPT code 97597 and 97598 are used for coding selective debridement.  These codes are used when the debridement is done on epidermis and/or dermis level of skin only. While the non-selective debridement which involves removal of devitalized tissue from the wound.  These debridement techniques are done without anesthesia and do not involve the use of sharp objects. If you can see the code description, it will include the topical application, dressing, larval therapy as well. CPT code 97602 is used for coding these non-selective debridement procedures. These procedures may require more than one visit.



CPT code description for 97597, 97598 and 97602


97597: Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

97598; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

(Use 97598 in conjunction with 97597);

97602: Removal of devitalized tissue from wound(s), nonselective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

Non-selective debridement is used to promote healing using non-selective debridement techniques. These are also sometimes referred as mechanical debridement. This technique includes wet to moist dressing, enzymatic chemicals, abrasion and larval therapy. There is not surface area specified for coding 97602 CPT code.


Use CPT code 11043-11046 for coding debridement of muscle. Only when the epidermis and dermis portion of the skin is debrided, use active wound care management CPT Code 97597 & 97598.

Become perfect in Coding CT colonography CPT codes


The virtual colonoscopy is also referred as CT colonography. You must be aware of coding screening colonoscopy, but for coding CT colonography we have separate codes in radiology section. Same like MRI procedurecodes, CT codes also have to be coded with contrast and without contrast. Till now we have learnt about the ultrasound cpt code, X ray procedures, MRI exam etc. in radiology. But, still few procedure codes were missed to share and today we will learn the procedure codes for Computed tomography colonography.

CT colonography CPT code 74261, 74262 and 74263


Code description of CT Colonography


Since, we are here to gain knowledgein medical coding, the description of CPT codes will be easy to understand these exams very well. Unlike, the diagnostic exam of Lumbar Puncture or arthrocentesis in IVR, these codes are very straight. Here, you don’t need to worry about any ultrasound guidance or fluoroscopy codes. These procedures require only one code to define the exam. Below is the code description of these procedure codes.

74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material

74262         with contrast material(s) including non-contrast images, if performed

74263 Computed tomographic (CT) colonography, screening, including image postprocessing

When to report CPT code 74261 and 74262


This exam helps in the detection of colon polyps and colon cancer. It is diagnostic exam which is performed only after checking the patient’s past medical history and physical examination. CPT code 74261 and 74262 are used frequently for coding these procedures. Presence or absence of intravenous contrast differentiate these procedure codes. The third cpt code 74263 is used specially for screening CT colonography. Interpretation of the full exam should be performed in order to report this procedure code.

Do code report code 76463 in conjunction with codes 72192-72194, 74150-74170, 74261, 74262, 76376, and 76377.