There are generally two types of procedures you can come across in coding medical reports, diagnostic and therapeutic procedures. Being a medical coder, you can code many different types of procedures. Most of the times coders are not aware of these terms diagnostic and interventional (therapeutic) exams. So, we will just brush up our mind and clear all our confusion related to these procedures.
What is a Diagnostic exam in Medical Coding?
A patient when comes to a physician he or she just tells the physician about the signs and symptoms of the disorder. Then, physician goes ahead to perform a procedure which will help him to find out the disorder or disease-causing symptoms. So, whenever a physician performs a procedure to find out the final disorder or disease, it is termed as Diagnostic exam. Now, we will see the examples of diagnostic exam in medical coding.
As you would have seen, I have shared some sample charts of medical reports previously, which has few x-ray reports. In addition, I have posted how chest X-ray reports are coded. So, these x-rays reports just help us to find out the exact cause of the problems. For example, patient with chest pain comes to physician and the physician performs chest x-ray and found out Pleural effusion. Hence, here the diagnosis pleural effusion is responsible for causing chest pain.
Similarly, like X-ray, Biopsies are the perfect example of diagnostic exam. We have learned about thyroid biopsy, breast biopsy, lung biopsy etc. that will easily help you to know more about diagnostic procedures. In biopsy exam, a small piece of abnormal mass or lesion is collected and sends to pathology for further examination. Biopsies help us to find out any benign tumor or malignancy present in such abnormal growth.
This exam is also help us in diagnosing disorder like arthritis, osteoarthritis etc. Arthrogram is done specifically in the joints to diagnose any joint pain. A contrast is injected in the joint and series of pictures are taken to examine the joint thoroughly. I have complete guide for coding arthrogram procedure, which will really help you in coding.
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Therapeutic or Interventional Procedure
When a patient has diagnosis and the physician goes ahead to treat that diagnosis, then such exams are termed as therapeutic procedure. For example, a patient has a thrombus in right lower extremity, and the physician performs thrombectomy (removal of thrombus). Such procedures are called as therapeutic or interventional procedures. Below are few more examples of therapeutic procedures.
Angioplasty procedure helps to open narrow or block blood vessels for smooth supply of blood to extremities. It helps in removing any obstruction or deposits in the path of blood flow. We have already learnt about coding angioplasty in AV fistula, which is put more light on this topic.
A stent is a small, metal mesh tube that keeps the tube, capillary or artery open. Stent placement coding varies for both vascular and non-vascular procedures. A non-vascular stent like nephroureteral stent can be placed in ureter to prevent any obstruction of the urine flow from the kidney. In vascular exam, after angioplasty, stent are placed to keep the arteries open and allow smooth flow of blood in the artery.
Thrombectomy as the name suggest is done to remove the thrombus. Accumulation of thrombus in veins affect the blood flow in vein, hence thrombectomies are performed to remove any obstruction material present in the veins. I have already shared how the thrombectomy procedures are coded in AV fistula, which will help you to learn more about this procedure.
An atherectomy is a procedure that utilizes a catheter with a sharp blade on the end to remove plaque from a blood vessel. This procedure also helps in maintaining the proper blood flow in the blood vessel. For lower extremity procedure coding, atherectomy procedures are combined with stent and angioplasty.
Embolization procedure helps in treating the abnormal blood vessels in the brain or other parts of the body. In embolization procedure, they sometimes block the blood vessel to reduce the blood supply to tumor cells. For example, Uterine fibroid embolization (UFE) procedure performed to blocks blood flow to fibroids in the uterus.