Digestive system, hemic/lymphatic system, and mediastinum/diaphragm



Digestive system, hemic/lymphatic system, and mediastinum/diaphragm




Digestive system


Digestive system complaints are common and are treated by a wide variety of physicians. The gastrointestinal tract includes the items indicated in Figure 7-1. Common gastrointestinal symptoms are abdominal pain, nausea, vomiting, difficulty swallowing, heartburn, indigestion, bleeding, diarrhea, and constipation. Common conditions are stomatitis, peptic ulcer, gastroesophageal reflux, hemorrhoids, diverticulitis, bowel obstruction, gastritis, appendicitis, and colorectal cancer.


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FIGURE 7–1 Gastrointestinal tract.

Conditions of the liver, gallbladder, and bile ducts are part of the gastrointestinal system; common signs or symptoms include jaundice, ascites (fluid in the abdominal cavity), and abnormal liver function tests. Common conditions of the liver are cirrhosis, hepatitis, and hyperbilirubinemia; of the gallbladder, gallstones and cholecystitis; of the pancreas, pancreatitis and carcinomas.


A physician who specializes in the diagnoses and treatment of the digestive system is a gastroenterologist. These specialists provide operative services using various approaches, such as rectal, endoscopic, laparoscopic, and open surgical procedures. The approach will be a determining factor in the code you choose.


General surgeons often use digestive system codes because they perform many of the abdominal procedures. For example, a gastroenterologist would diagnose a patient with appendicitis, and the general surgeon would remove the appendix. The gastroenterologist usually does the endoscopic procedures (through the mouth or the anus) and diagnoses gastrointestinal system conditions; if the conditions require surgery, the general surgeon would do the laparoscopic (through the abdomen) and open (incisional) procedures.


Not all of the codes in the Digestive System subsection are for procedures that you consider as being in the gastrointestinal system; for example, the Abdomen, Peritoneum, and Omentum (49000-49999), in which you will find codes such as those for laparotomy (49000-49010), subdiaphragmatic and retroperitoneal abscess drainage (49020-49062), laparoscopy (49320-49329), and abdominal insertion procedures, just to name a few. When an abdominal laparoscopic procedure is performed for diagnostic purposes and no procedure is conducted, you would report the diagnostic procedure with a Digestive section code. For example, the surgeon performs a diagnostic laparoscopy (49320) for the purpose of examining the adrenal gland. The surgeon takes a biopsy of a suspicious lesion on the adrenal gland, and the procedure becomes a surgical laparoscopy (60650). Read the notes above 60650, and you will find that the note refers you to 49320, depending on whether the laparoscopy was diagnostic or surgical.


The Introduction, Revision, and/or Removal (49400-49465) contains codes for insertion, revision, replacement, or removal of air, contrast, catheter, or shunt into the abdomen (peritoneal/ intraperitoneal cavity). For example, placement (insertion) of a dialysis catheter for peritoneal hemodialysis.



E/M services


Report 7-1A is a surgical consultation for a patient with a bowel obstruction. A bowel obstruction is a blockage of the small or large intestine. Postoperative adhesions are the most common cause of bowel obstruction of the small intestine, with hernias and neoplasms also being common. Cancer is the most common cause of large intestine obstruction; volvulus (twisting of intestine) and diverticulitis are also common. Clinical presentations would often be abdominal pain, nausea, vomiting, or bloating. Clinical findings include blood in the stool, fever (especially if the bowel is perforated), absence of bowel sounds or a tinkling sound, and abdominal tenderness. No laboratory tests are available that can be used to indicate bowel obstruction. X-ray, contrast studies, and CT scan are the main tests that the physician would use to assist in the diagnostic process.


If the diagnosis is obstructed bowel, a general surgeon would usually perform an open surgical procedure, and nearly all complete obstructions require surgery. After an abdominal surgery, although uncommon, the anastomosis can leak and allow air and bowel contents into the abdominal cavity, possibly placing the patient in an emergency situation requiring immediate attention.



Intestinal obstruction


Obstruction of the intestinal tract can occur in a variety of ways. Intussusception (K56.1/560.0) is the prolapse of part of the intestine into another adjacent part of the intestine.


Intussusception may be enteric (ileoileal, jejunoileal, jejunojejunal), colic (colocolic), or intracolic (ileocecal, ileocolic). See Figure 7-2. Usually this causes strangulation of the blood supply (causing ischemic colon, gangrene) and is most common in infants. Paralytic ileus (K56.0/560.1) is the loss of the peristaltic action of the intestine. Usually this occurs after intestinal trauma or a gastrointestinal surgical procedure (complication code K91.89/997.49) and can occur in the large and small intestines. Volvulus (K56.2/560.2) is the twisting of a segment of the intestine (also known as torsion) and is most common in the large intestine of the elderly. See Figure 7-3. Impaction of the intestine can occur through fecal material impacted in the colon (K56.4/560.30), gallstone obstruction of the intestine (K56.3/560.31), or other types of obstruction (K56.4/560.39) such as enterolith. Other specified types of intestinal obstructions, such as intestinal or peritoneal adhesions, occur after an operation or an infection (K56.5/560.81). Unspecified intestinal obstruction (K56.60/560.9) is assigned to those obstructions where there is no clear indication of the type of obstruction.


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FIGURE 7–2 Types of intussusception.

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FIGURE 7–3 Volvulus.


CASE 7-1   7-1A Inpatient Consultation


CASE 7-1



7-1A  Inpatient consultation


The patient had a gastrointestinal operation 4 weeks ago, but the report does not clearly indicate that the current obstruction is due to the surgical procedure, therefore, a “complication of surgery” code would not be appropriate in this case.


LOCATION: Inpatient, Hospital


PATIENT: Martin Newwell


PHYSICIAN: Alma Naraquist, MD


CONSULTANT: Daniel Olanka, MD


HISTORY OF PRESENT ILLNESS: This patient was operated on by Dr. Sanchez approximately 4 weeks ago for a misdiagnosis of appendicitis. He underwent ileocecal resection. He has had a variety of problems in the postoperative period, including renal failure, respiratory failure, tracheostomy, etc. He is currently under the care of Dr. Naraquist and is off the ventilator and breathing through the tracheostomy. He has been intermittently fed through small-bowel Cor-Flo tube, but this has the appearance of a bowel obstruction. Dr. Naraquist has asked me to evaluate the patient for his possible bowel obstruction. The family has also requested that another surgeon get involved in his care, and so I have been tagged to review his case.


PHYSICAL EXAMINATION: On examination, the patient is resting comfortably in bed. He does have a tracheostomy in place. He is alert and does respond. The chest is clear to auscultation. There is a catheter in place for dialysis, although the patient is not currently on dialysis. The abdomen is markedly distended. It is tympanitic. Tinkling bowel sounds are heard. There are no rashes. The midline scar is well healed. There is no particular focal tenderness, and no hernias are appreciated.


Review of the patient’s films shows marked dilatation of the small bowel. Review of the CT (computerized tomography) scan shows marked dilatation of the small bowel with what appears to be a transition zone in the distal ileum. The colon is deflated.


DISCUSSION: By physical examination, this patient has chronic bowel obstruction, at least partial in nature. Certainly his x-rays support that there is a major problem intra-abdominally. My recommendation would be that the patient should be considered for re-exploration for bowel obstruction. I do not know whether the problem is at the anastomosis or near the anastomosis. I think patient would benefit from some total parenteral nutrition (TPN) and aggressive hydration over the next few days, and then we will plan to take him to the operating room next week.




External procedures


External procedures are those that can be performed in the area of the rectum, such as drainage of rectal abscess or hemorrhoidectomy. These external procedures performed with an anoscope, as illustrated in Figure 7-4, are reported with endoscopy codes. The anoscope codes are located in the Endoscopy subcategory (46600-46615) of the Anus category. The stand-alone code 46600 states “Anoscopy; . . . ” and is then followed by the indented codes based on the procedure performed, such as biopsy, foreign body removal, or control of bleeding. Note that there is a distinction made for the method of removal of tumors (46610-46611); 46612 is for removal of multiple tumors, polyps, or lesions using hot biopsy forceps, cautery, or snare. This means that if one tumor was removed with cautery, you would code 46610, and if multiple tumors were removed, you would code with 46612. It would not be appropriate to list the single tumor removal code with modifier -51 on the second code (i.e., 46610 and 46610-51); rather, you must list only 46612 to report the multiple removal.


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FIGURE 7–4 Anoscope.

A fistula (K60.3/565.1) is an abnormal channel that connects two places that would ordinarily not be connected, for example, an anal fistula in which a channel leads from the anal canal into the tissue surrounding the channel. The channel then becomes clogged with fecal material, and often an abscess (K61.0/566) will form at the end of the channel. The channel can be closed with sutures or excised. Codes to report the excision of anal fistula are in the Excision subcategory (46200-46320). If a diagnostic anoscopy were performed (46600) as well as the surgical excision of a fistula, each would be coded separately with modifier -51 added to the exploration anoscope. This is because the anoscopy is performed by using a scope and the removal of the fistula is by surgical excision. If both a fistula and an abscess are present, each is reported separately. Packing placed into an abscessed area is not reported separately.


Some gastroenterologists perform these anal procedures, or a general surgeon may be called in to perform the procedure at the request of the gastroenterologist or other physician who diagnosed the condition. Most gastroenterologists perform the procedures that use an endoscope and refer the open abdominal procedures to a general surgeon. Smaller facilities have no gastrointestinal specialists, and these procedures are performed by general surgeons.


If an abscess is simply lanced and drained, report the services with an incision code (46020-46083).



CASE 7-2   7-2A Operative Report, Anal Fistula


CASE 7-2



7-2A  Operative report, anal fistula


LOCATION: Inpatient, Hospital


PATIENT: Russell Cornwall


SURGEON: Larry P. Friendly, MD


PREOPERATIVE DIAGNOSIS: Anal fistula


POSTOPERATIVE DIAGNOSIS: Anal fistula


TITLE OF PROCEDURE:



ANESTHESIA: General


INDICATIONS: The patient is a 46-year-old male with fever of unknown origin whom I had seen several months ago with perianal fistula. Since that time, he has had decreased drainage but still has pain and fevers. He presents today for elective fistulotomy, and he understands the risk of bleeding and infection and the possible risk of damage to the sphincter muscle, and he wishes to proceed with procedure.


The patient was brought to the operating room, placed under spinal anesthesia, placed in the jackknife position, and prepped and draped sterilely. Digital rectal examination was first performed, and there were no masses. Anoscopy was then performed, and there was no internal anal fistulous opening. At the 4 o’clock position, we could feel this hard, indurated mass that drained purulent material. We then opened this with a no. 15 blade and debrided a necrotic capsule from this area. We then cauterized the base, injected it with 30 cc of 0.5% Sensorcaine with epinephrine solution, and packed it with 4 × 4 gauze. The patient tolerated this well and was taken to the postanesthesia recovery room in stable condition.




CASE 7-3   7-3A Operative Report, Intersphincteric Abscess


CASE 7-3



7-3A  Operative report, intersphincteric abscess


LOCATION: Inpatient, Hospital


PATIENT: Mortica Kellogg


PHYSICIAN: Ronald Green, MD


SURGEON: Larry P. Friendly, MD


PREOPERATIVE DIAGNOSIS: Rectal pain


POSTOPERATIVE DIAGNOSIS: Intersphincteric abscess


OPERATIVE PROCEDURE: Examination under anesthesia and drainage of perirectal abscess


OPERATIVE NOTE: The patient was placed under general anesthesia and was placed in the lithotomy position. The rectal area was prepped and draped in a sterile manner. Examination of the external anus showed no evidence of a fissure or obvious perirectal abscess. I palpated around the anus carefully and could not really appreciate any pathology. We then proceeded to dilate the anus to three fingers and introduced the bivalve speculum. While carefully inspecting the inner lining of the anus in the lithotomy position proximally at the 6 or 7 o’clock location, we encountered a fluctuant feeling area, which with mild pressure from the finger ruptured and drained purulent material. This was cultured. We were then in a small abscess cavity, which appeared to be in an intersphincteric location in between the subcutaneous and the deep sphincters. This was completely drained and then irrigated with some saline. We then packed the area with gauze. The patient tolerated the procedure well and was discharged to the recovery room in stable condition.




CASE 7-4   7-4A Operative Report, Perirectal Fistulectomies


CASE 7-4



7-4A  Operative report, perirectal fistulectomies


In this case a fistula is removed with no mention of an abscess.


LOCATION: Inpatient, Hospital


PATIENT: George Papenfuss


SURGEON: Larry Friendly, MD


PREOPERATIVE DIAGNOSIS: Perirectal fistulas


POSTOPERATIVE DIAGNOSIS: Perirectal fistulas


PROCEDURE PERFORMED: Perirectal fistulectomies


ANESTHESIA: General anesthetic.


INDICATIONS FOR SURGERY: The patient is a 61-year-old white male who had draining perirectal fistulas, which had been incised and drained in the past. The patient is now being admitted for incision of these fistulas.


DESCRIPTION OF PROCEDURE: The patient was placed in a jackknife position. He was prepped and draped in the usual manner. The patient was given a general anesthetic. The fistulous tracts were in the 2 and 11 o’clock positions. The fistulous tracts were excised; one had an abscessed pocket, which was excised in its entirety. The tracts continued over the 12 o’clock midline position over into about the 2 o’clock position. All these tracts were combined into one large incision, and all the inflammatory tissue was excised sharply. The rectum was also dilated up and examined. No evidence of any tract could be seen draining directly into the rectum at this time, and no induration was seen. The inflammatory tissue present on the outer skin area was completely excised. The operative area was thoroughly irrigated. Hemostasis was obtained using Bovie cautery. The wounds were left open, and dressings were applied. The patient tolerated the operation and returned to recovery in stable condition.




Hemorrhoids


Hemorrhoids (piles) are caused by increased pressure on the hemorrhoid veins, such as constipation, straining during heavy lifting, lesions, or pregnancy. This pressure causes the hemorrhoid vein to bulge (like a varicose vein), causing anal bleeding, itching, and/or pain. See Figure 7-5. Hemorrhoids are graded, similar to how ulcers are graded.


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FIGURE 7–5 Hemorrhoids.


The complexity of the procedure depends on the type of hemorrhoid and the complexity of repair.


A common term when speaking of hemorrhoids is thrombosed, which means one containing clotted blood.


The diagnosis code for hemorrhoids is (K64.9).



CASE 7-5   7-5A Operative Report, Hemorrhoidectomy


CASE 7-5



7-5A  Operative report, hemorrhoidectomy


LOCATION: Outpatient, Hospital


PATIENT: Pricilla Stephanopolis


PHYSICIAN: Gary Sanchez, MD


SURGEON: Ronald Ripple, MD


PREOPERATIVE DIAGNOSIS: Symptomatic internal hemorrhoid, grade II


POSTOPERATIVE DIAGNOSIS: Symptomatic internal hemorrhoid, grade II


PROCEDURE PERFORMED: Hemorrhoidectomy (excision of single internal hemorrhoid). This is the largest and the only bleeding hemorrhoid.


ANESTHESIA: General endotracheal anesthesia plus 30 cc (cubic centimeter) of 0.5% Marcaine with epinephrine


The patient, on examination under anesthesia, had other smaller, Grade I hemorrhoids that were higher up in the anal canal, but the decision was made not to excise these because they were not bleeding.


PROCEDURE IN DETAIL: After good general endotracheal anesthesia, the patient was carefully placed in the prone position. After this, a total of 30 cc of Marcaine was infiltrated into the area around the hemorrhoid. The hemorrhoid was grasped with an Allis clamp, and a straight clamp was placed across the base. A running stitch was then placed below the clamp for hemostasis. Next the hemorrhoid was excised above the clamp, and a running stitch going in the opposite direction was then looped over the straight clamp. The straight clamp was removed, and the looped stitch was then tightened up. Another layer of suture was then run down the length of the excised hemorrhoid. Hemostasis was obtained with this maneuver. No other large thrombosed or extruding hemorrhoids were noted. After this, Vaseline gauze was placed over the wound. ABD (Adriamycin, bleomycin, dacarbazine) dressing and knit mesh pants were placed on the patient to hold the dressing in place. She was returned to the recovery room in good condition.



ICD-10-CM: A fourth character indicates with or without complications, and a fifth character indicates bleeding, prolapsed, strangulated, or ulcerated.


ICD-9-CM: The fourth-digit subcategories indicate internal, external, unspecified, and those with or without mention of complication or thrombosed.


If the hemorrhoid occurs during pregnancy, O22.4-/671.8-, Other venous complications, is used to report the diagnosis.



Catheters


Intraperitoneal catheters are inserted into the abdomen (peritoneal cavity) for the purposes of drainage. The choice of catheter depends on the purpose for which the catheter is being placed and the physician’s preference.


Reports often refer to the catheters by brand name, such as Tenkhoff, Foley, and Swan neck. Catheters are inserted on either a permanent or a temporary basis. The approach for placement can be closed (percutaneous) or open. The closed placement requires a puncture wound made on the abdomen with the catheter threaded through the incision and into the abdominal cavity. During an open procedure, the surgeon may place a drain, securing the catheter in place outside of the abdomen. The drain placement is bundled into the procedure and not reported separately.



From the Trenchesimage


“The keys [to long term success in the medical coding field] are flexibility and a lust for knowledge. This field is ever evolving and growing, and for one to remain relevant you must embrace that change.”


THOMAS



CASE 7-6   7-6A Operative Report


CASE 7-6



7-6A  Operative report


LOCATION: Inpatient, Hospital


PATIENT: Gladys Hanson


SURGEON: Gary Sanchez, MD


PREOPERATIVE DIAGNOSIS: End-stage renal disease


POSTOPERATIVE DIAGNOSIS: End-stage renal disease


PROCEDURE PERFORMED: Placement of a tunneled peritoneal dialysis catheter


INDICATION: This 23-year-old female has end-stage renal disease and is going to need permanent dialysis. She elected peritoneal dialysis. Please see clinic consultation for further details of the discussion of procedure and risks involved.


PROCEDURE: The patient was brought to the operating theater and placed in the supine position on the operating room table. After receiving a general anesthetic, she was prepped and draped in a sterile fashion. An incision line that was infraumbilical and vertical was infiltrated with 0.5% Marcaine. An incision was then made and carried down through the subcutaneous tissues down to the anterior fascia. The anterior fascia was grasped and divided sharply. The peritoneum was also divided sharply. The peritoneal cavity was entered. A peritoneal dialysis catheter was then inserted using a Bozeman catheter into the pelvis. The patient had been placed in a Trendelenburg position. We then were able to place the catheter with ease. We placed a 2-0 Vicryl in a pursestring fashion through the peritoneum. This was also attached to the cuff in adjacent spots. This was then secured. Interrupted sutures of 2-0 Vicryl were then used to close the fascia. The sutures in the cuff were also placed through the cuff to help secure this in place. It was then tunneled out to the left side. The cuff was buried in the subcutaneous tissues. The subcutaneous tissues and vertical midline incision were closed with interrupted sutures of 3-0 Vicryl around and over the catheter. The skin was closed with 4-0 Vicryl in a running subcuticular fashion. Steri-Strips and a sterile dressing were applied. The catheter-retaining device was used at the exit site to help secure it in place. We had also flushed this intermittently with heparinized saline during the procedure at various steps and then let the drain back out at all times as well as at the end of the procedure. This flushed well and irrigated well. The patient tolerated the procedure well and went to the recovery room in stable condition. No family was present to meet with postoperatively to discuss the results.




Endoscopy procedures


Procedures are often performed by means of an endoscope and laparoscopy. The surgical approach determines the code. For example, if the patient has a lesion on the outside of the intestine, the physician would open the abdomen (open procedure) or use a laparoscopy (tube inserted through the abdominal wall) to excise the lesion. Codes for the open procedure are located in the Intestine, Excision category (44100-44160). Codes for the laparoscopic approach are located in the Intestine, Laparoscopy category. If the lesion was inside the intestine and the surgeon used an endoscope inserted through the anus to remove the lesion, you would report the service with a code from Intestine, Endoscopy (44360-44397). There are endoscopic, laparoscopic, and open approaches in many of the subheadings of the Digestive System subsection.



The endoscopic procedure uses an existing orifice (opening), a laparoscopic procedure uses a small incision, and an open procedure uses a larger incision.


There are endoscopic and laparoscopic codes for the gastrointestinal tract, such as the esophagus, stomach, intestines, and anus as well as abdomen, peritoneum, and omentum.


Remember to code to the full extent of the procedure, which is the point at which the procedure terminates. For example, if the procedure begins with an endoscope being placed into the mouth, through the esophagus, and terminating in the stomach, the full extent is the stomach. Although the operative report will state the procedure performed in the identifiers of the report, such as “Procedure Performed,” you must always read the full operative report to ensure the full extent is reported. For example, the Procedure Performed identifier may state esophagogastroscopy (full extent is the stomach), but upon reading the report, you may find that the duodenum was referenced, making the procedure an esophagogastroduodenoscopy (full extent is the duodenum).


Use the correct approach and code to the fullest extent of the procedure.





Hernia


Hernias of the groin are the most common type of hernia, accounting for 80% of all hernias. There are two major types of inguinal hernias (K40.9-/550.–): indirect (oblique) and direct. Indirect inguinal hernias result when the intestines emerge through the abdominal wall in an indirect fashion through the inguinal canal. Direct inguinal hernias penetrate through the abdominal wall in a direct fashion. Femoral hernias occur at the femoral ring where the femoral vessels enter the thigh.


ICD-9-CM: In both inguinal and femoral hernia classifications, there is a fifth digit to indicate unilateral or unspecified (0); unilateral or unspecified, recurrent (1); bilateral (2); and bilateral, recurrent (3). Classification of hernias is based on the location of the hernia and whether there is obstruction and/or gangrene present. If the documentation indicates incarcerated or strangulated, the hernia is classified as obstructed.


A common type of hernia is a hiatal or esophageal hernia, also referred to as a sliding hernia or diaphragmatic hernia.


When the diaphragmatic hernia is mentioned with obstruction, report the diagnosis with K44.0/552.3; when it is without obstruction, report the diagnosis with K44.9/553.3.



CASE 7-7   7-7A Operative Report, Esophagogastroduodenoscopy


CASE 7-7



7-7A  Operative report, esophagogastroduodenoscopy


LOCATION: Outpatient, Hospital


PATIENT: David Amron


PHYSICIAN: Larry Friendly, MD


PREOPERATIVE DIAGNOSIS: Upper gastrointestinal bleeding


POSTOPERATIVE DIAGNOSIS: Mild gastritis, mild duodenitis, a 5-mm (millimeter) gastric ulcer, not actively bleeding; biopsies obtained for Helicobacter pylori; also hiatal hernia


INDICATION: A 70-year-old white man who has chronic renal failure secondary to amyloidosis presents with 1 week of coffee-ground emesis. He smokes two to three packs per day and has two to three melenic stools per day. We do not have any results of laboratory tests. He was just admitted. We suspect upper gastrointestinal bleeding. He has not been on any NSAIDs (nonsteroidal antiinflammatory drugs). He has never had an ulcer. He has no other gastrointestinal symptoms.


PROCEDURE PERFORMED: Esophagogastroduodenoscopy


PREOPERATIVE MEDICATION: Demerol 50 mg (milligram) IV (intravenous); Versed 4 mg IV


FINDINGS: The flexible Pentax video pediatric endoscope was passed without difficulty into the oropharynx. The gastroesophageal junction was seen at 40 cm (centimeter). Inspection of the esophagus revealed no erythema, ulceration, exudate, friability, or other mucosal abnormalities. From 40 to 43 cm, there was a 3-cm hiatal hernia. Along the lower border of the hernia sac, there was a 5 × 2-mm ulceration. It was not actively bleeding. Photograph was obtained. The stomach proper was entered. Coffee-ground material was present, but no fresh blood. Endoscope was advanced to the second duodenum. Inspection of the second duodenum revealed no abnormalities. The first duodenum and duodenal bulb revealed some mild patchy erythema and no ulceration. The antrum revealed patchy erythema but no ulceration. Retroflexion revealed the previously described minimal ulcer and hiatal hernia. Nothing was seen in the fundus or cardia. Biopsies were obtained of the antrum to rule out H. pylori. The patient tolerated the procedure well.


IMPRESSION: Some old blood present, no active bleeding. A 5-mm gastric ulcer along the inferior border of the 3-mm hiatal hernia, not bleeding. Mild gastritis and mild duodenitis are present. Biopsies obtained for Helicobacter pylori.


PLAN: Will observe patient for 24 hours and possibly discharge, follow hemoglobins. At this point, it does not appear that the patient has amyloid of the gastrointestinal tract.




Rectal procedures


Rectal endoscopic procedures are:



The codes are divided based on the extent and the purpose of the procedure. Note that the stand-alone codes 45300, 45330, and 45378 each have a list of indented codes based on the purpose (such as biopsy, foreign body removal, ablation, control of bleeding, etc.).


If the patient is fully prepared for the endoscopic procedure, and the procedure has begun but is not completed due to extenuating circumstances, use modifier -53, Discontinued Procedure, with the endoscopic code. Some payers, such as Medicare, require the coder to report -53 (Discontinued Procedure) to report a procedure that could not be completed. These extenuating circumstances could be that the patient has become unstable, the bowel preparation for the surgery was not sufficient to continue the procedure, or an equipment failure has occurred. Remember, in order to report modifier -53, the procedure must have been started and then terminated for extenuating circumstances. An additional code Z53.09/V64.1 should be reported for surgical or other procedure not carried out because of contraindication.



Polyps


A polyp is a growth on a pedicle (stem) that bleeds easily and may become malignant. In the Index, the codes for a diagnosis of polyp(s) are located under the main term “Polyp, polypus” subtermed by location, such as nose (J33.9/471.9), labia (N84.3/624.6), and gum (K06.8/523.8). These codes are then referenced in the Tabular for further information regarding code assignment. A polyp is not a neoplasm; rather, it is an abnormal growth of normal cells. Sometimes the term “hyperplastic” is used in the pathology report of a polyp specimen. The term means that there is an increase in the number of normal cells.



CASE 7-8   7-8A Operative Report, Colon Polypectomy 7-8B Pathology Report


CASE 7-8



CASE 7-8A  operative report, colon polypectomy


Report the services for the following case. When reporting the diagnosis for the operative procedure, reference the pathology report located in 7-8B.


LOCATION: Outpatient, Hospital


PATIENT: Jatin Al-Assad


SURGEON: Larry Friendly, MD


SCOPE USED: Pentax video colonoscope


MEDICATIONS GIVEN: Fentanyl 75 μg (microgram) and Versed 3 mg (milligram) IV (intravenous) prior to the procedure


PREOPERATIVE DIAGNOSIS: Polyp on sigmoidoscopy


POSTOPERATIVE DIAGNOSIS: Colon polyps


PROCEDURE PERFORMED: Colonoscopy with removal of polyps


INDICATION: The patient is a 48-year-old male who presented for screening sigmoidoscopy on January 15. He was found to have several adenomatous polyps in the sigmoid colon and rectum. This procedure is being done to remove those polyps and any other polyps in the more proximal colon.


FINDINGS: About five polyps were seen, three pedunculated and two sessile. These were snared. The remainder of the colon and rectum were normal.


DESCRIPTION OF TECHNIQUE: After informed consent was obtained, the patient was prepared for colonoscopy. He was placed in the left lateral decubitus position. A digital rectal examination was performed and was unremarkable. The lubricated Pentax video colonoscope was then guided digitally into the rectum and advanced to the cecum. The scope was withdrawn and the mucosa inspected. The cecum, ascending colon, transverse colon, and descending colon were normal. Through the sigmoid colon and rectum, five polyps were seen. The largest measured about 1 cm (centimeter) in diameter. Three were pedunculated. These were snared. Two others were smaller and sessile. The distal rectum was normal. The scope was withdrawn. The patient tolerated the procedure well and was discharged ambulatory with a driver.


RECOMMENDATIONS: Follow-up colonoscopy in 2 years due to the relatively large number of polyps seen on this examination in a relatively young man.


Pathology Report Later Indicated: See Report 7-8B.


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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Digestive system, hemic/lymphatic system, and mediastinum/diaphragm

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