Medical Coding 1 CH 6-Notes/General & Endoscopy

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The respiratory system subsection is arranged how?

By anatomic site, then by procedure (incision, excision).

How are endoscopy codes listed?

Throughout the subsection, according to anatomic site.

Procedures performed on the throat and mouth are listed where?

Digestive System subsection

Why is it important to note the extent of the cosmetic repair in the medical record?

So you do not report the same service more than once & unbundle a code. Be sure to report the service with the code that describes the furthest extent of the service provided.

How are endoscopic procedures performed?

Scope is placed through an existing body orifice or a small incision is made into a cavity for scope placement. Most sinus endoscopies are listed as unilateral, unless description indicates bilateral. Some codes include multiple sinus procedures commonly performed in the same operative session.

When coding endoscopic procedures, what is it important to remember?

May start at one site and follow through to another site. Choose the code that most appropriately reflects the farthest extent of the procedure (furthest anatomical site). Only code when an endoscope is used in the procedure.

Why is it important to code the correct approach for the procedure?

The same surgical procedure may be performed using different approaches.

Multiple endoscopic procedures may be performed through the scope during the same operative session, how would this be coded?

With modifier -51 placed on subsequent and lower priced (least resource-intensive) procedures. Not necessary when the CPT manual offers a code for which the description includes all separate elements of the procedure in one code.

Would you code a diagnostic endoscopy separately from a surgical endoscopy?

No-diagnostic endoscopy is always bundled into a surgical endoscopy if performed in the same space. If diagnostic sinus endoscopy is performed on the right maxillary sinus and surgical endoscopy is done on the left, both are reportable with LT and RT modifiers.

What is the difference in indirect and direct approach when coding laryngoscopic procedures?

INDIRECT-physician uses a tongue depressor to hold the tongue down and view the epiglottis. DIRECT-endoscope is passed into the larynx & physician can look directly at the larynx through the endoscope. Operative note will indicate either direct or indirect.

Finding endoscopy codes in the CPT index

Under ENDOSCOPY, then under ANATOMIC SUBTERM of the site. Also, by the ANATOMIC ENDOSCOPY TITLE (bronchial biopsy using endoscopy is listed under Bronchoscopy then under subterm biopsy.

Segmental resection is what type of procedure

Surgical, removal of part of an organ or structure. Segmental-removal of part of lobe of lung

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