Medical coding field has lot of different facilities. Medical coders who took medical coding as their career will not be aware of so many facilities before. However, with time we all will know how difficult job it is to be a medical coder. If there is slight mistake in a single numerical digit in CPT code, the whole dollar value will change. This will majorly effect the payment. So, preparing and clearing CPC exam or CCS exam is only a single step in the field of medical coding. There are different medical coding certification exams, which you will know when you start coding for different facilities. For example, coders who coded Interventional Radiology facility can go for CIRCC (Certified Interventional Radiology Cardiovascular Coder) exam. We are here just to focus on Surgery facility and how we can improve your skills to be perfect with surgery coding.
Ambulatory or Same Day Surgery
Ambulatory surgeries are same day surgeries like arthrogram, arthrocentesis, And Lumbar puncture etc. These procedures are majorly diagnostic procedures. These diagnostic procedures required supervision and interpretation (S&I) codes or guidance codes. For example, if a lung biopsy is performed using ultrasound guidance we have to assign lung biopsy CPT code followed by Ultrasound guidance code 76942. These are minimal invasive procedures or percutaneous (through the skin) procedures. Whenever a catheter is inserted into the body, it is guided with the help of guidance like ultrasound, fluoroscopic, CT etc. Hence, to be perfect with the Ambulatory surgery coding, one has to know when to use guidance or S&I codes with surgery procedure codes.
Interventional Radiology or Therapeutic Percutaneous Surgery
Interventional procedures are also called as therapeutic procedures. These are also minimal invasive or percutaneous procedures. Therapeutic procedures like stent placement, angioplasty, embolization etc. are coded in interventional radiology. Vascular procedures is the little difficult to understand. I have tried to explain the selective and non-selective catheterization, which is very important for coding vascular procedures. In addition, you can check how a stent placement is coded in AV fistula, which will help you in coding a therapeutic procedure. Therapeutic procedures are coded separately in AV fistula while for Lower extremity we have combined codes. For example, if an angioplasty and stent is placed is AV fistula we have to code both separately but for lower extremity vascular procedure, we have combined codes for angioplasty and stent placement.
Open surgeries are made by directly making an incision into the body and hence there is no need of guidance here. As we know these are also little complicated procedures to code. The orthopedic procedure are little tricky to code in this section. For few procedures like carpel tunnel syndrome and Total hip arthroplasty, I have explained in my previous blog posts. These procedures can also be done using arthroscope in which a small scope is introduced inside the body. There are separate codes for diagnostic and surgical arthroscopy. Surgical Arthroscopy always includes diagnostic arthroscopy. You can learn more about when you will read arthroscopy knee repair procedures. Always do read the notes below CPT codes, which will help you in finding inclusive CPT codes as well as add-on code.