QUESTION: A physician admits a 30-year-old male with lower abdominal pain. A CT scan showed consistency with perforated appendicitis. However, the patient had an appendectomy 10 months prior. The physician documents "appendiceal stump syndrome." How should I code this case?
QUESTION: I have a question regarding the coding of a computer-assisted fluoroscopy. Consider the following documentation: Use and interpretation of intraoperative fluoroscopy. After positioning the patient, the posterior lumbar area was prepped and draped in the standard sterile fashion. The prior incision was marked with a marking pen. C-arm fluoroscopy was used to map an incision extending from the tip of the spinous process of L2 to that of L5. After performing a time-out, this incision was infiltrated with local anesthetic and incised with a 10-blade scalpel. Dissection proceeded through the subcutaneous fat using Bovie monopolar cautery. Self-retaining retractors were applied. Dissection then proceeded in the midline through the avascular plane through the lumbodorsal fascia and musculature using the Bovie. Self-retaining retractors were deepened. Would you assign a procedure code for the fluoroscopy for this inpatient procedure or would it just be inclusive in the procedure? There seems to be confusion when comparing this procedure in an inpatient setting vs. an outpatient setting.
Coders tell a patient’s story with a principal diagnosis and additional diagnoses, some of which are CCs or MCCs. William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, and Cheryl Ericson, MS, RN, CCDS, CDIP, explain the value of educating physicians and coders about CCs and MCCs.
Coders may struggle to differentiate the ICD-10-PCS root operations excision and resection. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, explain why excision is the root operation of choice for excisional debridement and sebaceous cyst removal.