Coding mid-term

Created by undercoverviking 

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Use both lists:

Alpha and tabular

Codes must be used tot he highest number of digits available

True

Never NOS

When there is a more specific code

Combination codes can be identified by:

with, due, to, in, associated with

Code____underlying condition

first

A code in brackets in the alpha-index

used only as secondary code for the specific condition

Influenza with pneumonia

487.0

Acute cholecystitis and choledocholithiasis

574.60

Diabetic Retinitis

250.50
362.01

Chondrocalcinosis of shoulder region due to calcium pyrophosphate

275.49
712.21

Arbovirus meningitis

066.9
3231.2

Rheumatoid arthritis with polyneuropathy

714.0
357.1

cataract due to chalcosis

360.24
366.34

Residuals of poliomyelitis

138

Sequela of old crush injury to left foot

906.4
E929.9

Cerebrovascular accident two years ago with residual hemiplegia of the dominant side

438.21

Contracture of hip following partial hip replacement one year ago

718.45
V43.64

Traumatic arthritis, right ankle, following fracture, right ankle

716.17
905.4
E887

Cicatricial contracture of left hand due to burn

709.2
906.6
E929.4

Brain damage following cerebral abscess seven months ago

348.9
326

Flaccid hemiplegia due to old cerebrovascular accident

438.20

Bilateral neural deafness resulting from childhood measles ten years ago

389.12
139.8

Mononeuritis, median nerve, resulting from previous crush injury to right arm

345.1
906.4
E929.9

Post-traumatic, painful arthritis, left hand

716.14

Locked -in state (paralytic syndrome) due to old cerebrovascular accident

438.50
344.81

Operative approach is considered:

to be an integral part of a procedure no code assigned except rarely

Canceled procedures use___codes

V

Principal procedure

performed for definitive treatment or one necessary to care for a complication

When conversion from a -scopic to an open approach becomes necessary

only the open procedure is coded

Arthrotomy of right knee with partial patellectomy

77.86

Resection of a brain tumor, right frontoparietal area

01.59

Laminectomy with excision of herniated lumbar disc

80.51

Exploratory laparotomy with partial resection of small intestine with end-to-end anastomosis

45.62

Exploratory laparotomy with appendectomy

47.09

Transurethral removal of ureteral calculus

56.0

Urethroscopy to control postperative hemorrhage, prostate

60.94

Cystoscopy with left retrograde ureteral pyelogram

87.74

Laparoscopic cholecystectomy

51.23

Cholecystectomy, open following attempt by laparosccopy

51.22
V64.41

V64.411

Laparoscopic surgical procedure converted to open procedure

Biopsy is:

taking tissue from a living person for the purpose of microscopic study

Biopsy code is not assigned:

when a lesion removed for therapeutic purposes is sent to the laboratory for examination.

closed biopsy

needle, brushm aspiration endoscopy.

open biopsy

by way of incision--incision is implicit in the biopsy code

When biopsy is incidental to removal of other tissue during a procedure

both the procedure and the biopsy are coded-more definitive procedure sequenced 1st.

Needle biopsy during and open procedure is coded:

closed biopsy

Biopsy performed immediately before a definitive procedure is begun

therapeutic code sequenced first

Frozen-section examination of open biopsy of left breast mass followed by left radical mastectomy

85.45 -- Unilateral radical mastectomy
85.12 -- Open biopsy of breast

Exploratory laparotomy with needle biopsy of pancreas.

54.11 -- Exploratory laparotomy
52.11 -- Closed [aspiration] [needle] [percutaneous] biopsy of pancreas

Open biopsy of nasal sinus

22.12 -- Open biopsy of nasal sinus

Needle biopsy of liver

50.11 -- Closed (percutaneous) [needle] biopsy of liver

Transurethral biopsy of bladder

57.33 -- Closed [transurethral] biopsy of bladder

Percutaneous biopsy of prostate

60.11 -- Closed [percutaneous] [needle] biopsy of prostate

V64

Persons encountering health services for specific procedures not carried out

Incomplete procedures:If incision only

code to incision of site

Incomplete procedures: if endoscipic approach is unable to reach site:

code endoscipy only

Incomplete procedures: If cavity or space was entered:

code to exploration of site

Shunt codes can be found in the index under the main terms:

Creation
formation
shunt

Revision of ventriculoperitoneal shunt:

must determine which portion of the shunt in involved

Coronary angioplasty is:

inherent in the placement of a coronary stent
code angioplasty00.66 or 36.03 stent insertion 39.90 or 00.55

Number of vessels treated with stents

00.40 - 00.43
coronary and periphery

Number of stents inserted

00.45 -- 00.48
coronary and periphery

00.44 -- Procedure on vessel bifurcation

Is used to identify the presence of a vessel bifurcation. It doesn't describe a specific bifurcation stent. maybe used only once per operative episode regardless of the number of vessel bifurcations.

Other immobilization, pressure, and attention to wound

93.59 Assigned for placement of a headframe fro steriotactic radiosurgery

CAS

00.3 -- Computer assisted surgery [CAS]

Robotic assisted surgery

Code primary surgical procedure
Code robotic assistance code

Revision of peritoneal portion of the ventriculoperitoneal shunt

54.95 -- Incision of peritoneum

Arthrotomy of right knee with excision of right medial meniscus and patellar shaving

80.6 excision of meniscus
77.66 shaving of patella

Right frontal craniotomy with resection of osteoma of frontal bone

01.6 -- Excision of lesion of skull

Dilation and curettage, uterus
Cervical biopsies, punch
Multiple vulvar biopsies

69.09 -- Other dilation and curettage
67.12 -- Other cervical biopsy
Punch biopsy of cervix NOS
71.11 -- Biopsy of vulva

Atherectomy of iliac artery with injection of thrombolytic agent and stent insertion

39.50 -- Angioplasty or atherectomy of other non-coronary vessel(s)
99.10 -- Injection or infusion of thrombolytic agent
39.90 -- Insertion of non-drug-eluting peripheral vessel stent(s)
00.40 Procedure on a single vessel
00.45 Insertion of one vascular stent

Esophagoscopy with biopsy of esophagus

42.24

Submucous septectomy, nasal, and nasal septoplasty

21.5

Exploratoy laparotomy
Cholecystectomy
Incidental appendectomy
Intraoperative cholangiogram
Common bile duct exploration with dilation of sphincter of Oddi

(omit code-operative approach)
51.22 -- Cholecystectomy
47.19 -- Other incidental appendectomy
87.53 -- Intraoperative cholangiogram
51.81 Dilation of sphincter of Oddi
51.51Exploration of common duct

Laparoscopic appendectomy

47.01

Reclosure of operative wound of abdominal wall

54.61

Partial laparoscopic cholecystectomy

51.24

Craniotomy (omit code-operative approach)
with plastic repair of encephalocele
cranioplasty

02.12

Single vessel percutaneous coronary angioplasty with use of thrombolytic agent and insertion of stent

00.66 Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy
99.10 Injection or infusion of thrombolytic agent
36.06 Insertion of non-drug-eluting coronary artery stent(s)
00.45 Insertion of one vascular stent
00.40 Procedure on a single vessel

Endoscopic insertion of stent in pancreatic duct

52.93
00.45 (Okay, but 00.45 not needed with 52.93)

Removal of acoustic neuroma
via Stereotactic Cobalt-60 radio surgery

92.32
Placement of head frame
93.59
Computerized axial tomography of brain
87.03

V codes

admission
examination
history
observation aftercare
problem
status

Tab list for V codes located:

immediately after the final chapter of the main classification in vol.1

Table of drugs and chemicals

E codes for poisoning and adverse effects of therapeutic drugs

V codes as first listed diagnosis

specific aftercare like removal of orthopedic pins
sole purpose of special therapy IE radiotherapy, chemotherapy, or dialysis
Person not ill, but organ donor, receives prophylactic care, or counseling
Birth status of newborn

V code after care is not assigned when:

treatment is directed at a current acute disease or injury

V code exception for aftercare:

Dialysis V56x
chemotherapy v48.11
immunotherapy V58.12

Fracture codes

only for active treatment

Fracture subsequent encounters

orthopedic after care code

After care variety

surg for Neoplasms V58.42
injury and trauma V58.43
surg. to spec body systems V58.71-V58.78

After care listed first

True

epixtaxis

784.7Chronic epistaxis, severe, recurrent
Anterior and posterior nasal packing 21.02

Follow up examination

V67

Chronic epistaxis, severe, recurrent
Anterior and posterior nasal packing

784.7
21.02

Severe epistaxis due to hypertension
Nasal packing

784.7 401.9
21.01

Hereditary epistaxis

448.0

Chronic fatigue syndrome

780.71

v58.6

Long-term (current) drug use

V71 - always primary diagnosis

Observation and evaluation for suspected conditions not found

V71.5

Observation following alleged rape or seduction

Rape is not a medical diagnosis:

but a matter of jurisprudence. Do not assign V71.5 is rape is confirmed

V66.7 palliative care

can be used in any healthcare setting

V72.8

Other specified preoperative examination

V72

rarely for inpatient coding; never assigned as additional codes

V73-V82

screen exams fro early detection. Performed on well individuals

status V codes

indicate that a patient is a carrier of a disease, hs the sequelae or residual of a past disease or condition, or has another factor influencing health status.

V codes indicating status are redundant

when the diagnosis code itself indicates that the status exists.

History codes:

indicate that the problem no longer exists

Status codes

indicate that the condition is present

V84

genetic susceptibility to disease

carrier

is an individual who is able to pass it on to an offspring

genetic susceptibility

a genetic predisposition fro contracting a disease

Sign

objective evidence of disease observed by the examining physician

Symptom

subjective observation reported by the patient

Bacteremia 790.7

presence of bacteria in the blood stream after trauma or infection

Septicemia

systemic disease associated with the presence of path. micro org. or toxins in the blood

SIRS

systemic inflammatory response syndrome
Bodies response to systemic infection etc.

sepis

refers to SIRS due to infection

severe sepsis

associated acute organ dysfunction

urosepis

1 sepis
2 UTI

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