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Coding mid-term

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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