Sample coded Medical coding reports for Coders

Jitendra M.Sc CPC
Sample Medical coding reports for Coders for 2019

Sample Medical Coding Report 1   PREOPERATIVE DIAGNOSIS:   Right trimalleolar ankle fracture. POSTOPERATIVE DIAGNOSIS:   Right ankle fracture in light of osteoporosis and subacute presentation. PROCEDURE:   Open reduction and internal fixation of right trimalleolar ankle fracture.   ANESTHESIA PERFORMED: General with 20 cc of 0.25% Marcaine ANTIBIOTICS:   Cefazolin 2 g IV. ESTIMATED BLOOD LOSS:  Less than 50 cc. TOURNIQUET: None. COMPLICATIONS:   Significant osteopenia requiring quad cortical fixation. IMPLANTS:   Arthrex locking and nonlocking plate through the lateral malleolus with 2.4 and 3.5 cortical screws and Arthrex 2.4 titanium T-plate and Arthrex 5th metatarsal hook…

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Coding for Simple Repair Procedures in Emergency Department

Jitendra M.Sc CPC
Coding for Simple Repair Procedures in Emergency Department

In Emergency Department, we have seen the importance of procedures or exams performed on the patients. Missing these procedures seriously affects the payment or reimbursement. Many immature coders are not aware of the documentation of these exam in emergency department report and missed to code them. Previously we have seen how we can report a short leg splint in a emergency department report and the supporting documentation required for it. Today we will checkout the coding of simple repair with emergency department cpt codes. The repair procedures are performed generally…

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CPT code 92081, 92082 & 92083 : Coding guide

Jitendra M.Sc CPC

Basics of CPT code 92081, 92081 and 92083 As medical coders we have to know about each procedure code because mainly billing is dependent on CPT codes. Even a single change in digit of CPT code will change the dollar value of that procedure code hence medical coders should accurately report the CPT codes. Today, we will discuss about the CPT code 92081, 92081 and 92083 used for visual field examination. These three CPT codes are based on limited, intermediate and extended examination of visual field. Read also : Coding…

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Percutaneous Lung Biopsy Cpt code : Perfect Coding guide

Jitendra M.Sc CPC
Learn how to code Percutaneous Lung Biopsy Cpt code

Basics of Percutaneous Lung Biopsy Cpt code In interventional radiology, we have many CPT codes for Biopsy procedures. Breast biopsy has the most number of CPT codes to code in Percutaneous surgery. Now, as we know biopsy procedure are done to take sample of particular organ and study it to find any abnormal finding in them. Like breast biopsy, we examine breast mass or lesion to see whether it is malignant or benign for breast cancer, similarly lung biopsy is done to examine the abnormal lung mass or nodule present in…

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Schizophrenia ICD 10 CM Coding Strategies ; A guide for coders

Jitendra M.Sc CPC

Basics of Schizophrenia ICD 10 CM Schizophrenia is a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling. F20.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. F20.9 – Schizophrenia, unspecified Related Synonyms of Schizophrenia ICD 10 CM Chronic schizophrenia Schizophrenia Schizophrenia in remission Schizophrenia, chronic Schizophrenia, subchronic Schizophrenia, subchronic with acute episode Subchronic schizophrenia Subchronic schizophrenia with acute…

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Top ICD 10 coding tips for HIV

Jitendra M.Sc CPC
Top ICD 10 coding tips for HIV

Coding guidelines for HIV B20 reports human immunodeficiency virus diseases and includes AIDS (acquired immune deficiency syndrome), which is caused by HIV (human immunodeficiency virus). HIV affects certain white blood cells (T-4 lymphocytes) and destroys the ability of the cells to fight infections, making patients susceptible to a host of infectious diseases (e.g., Pneumocystis carinii pneumonia [PCP], Kaposi’s sarcoma, and lymphoma). AIDS-related complex (ARC) is an outdated term for lesser infections associated with HIV. Additional code(s) are reported to identify all the manifestations of AIDS. It is extremely important that…

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Joint replacement (Wrist, Ankle & Elbow) Coding guide

Jitendra M.Sc CPC

Basics of Joint replacement procedures Joint replacement procedure are very common in old age patient. With growing age the bone density decreases and hence joint problems increases. In most of the case joint replacement procedure help in treatment problems like arthritis, osteoarthritis etc. Medical coders has lot of confusion in coding joint replacement or arthroplasty procedure.  To code the arthroplasty procedures, coders have to check the below things in the medical report. Procedure objective (replacement or revision of joint) Joint invovled with laterality Surface of joint being treated (acetabular, femoral,…

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Thrombocytopenia ICD-10 CM Coding Guide

Jitendra M.Sc CPC

Basics of ICD-10 CM codes of Thrombocytopenia Thrombocytopenia occurs when your bone marrow doesn’t make enough platelets. Platelets form blood clots to help stop bleeding. D69.6 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Clinical Information A condition in which there is a lower-than-normal number of platelets in the blood. It may result in easy bruising and excessive bleeding from wounds or bleeding in mucous membranes and other tissues. A condition in which there is an abnormally small number of platelets in…

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Mastering CPT Code 97116: Tips and Tricks for Accurate Billing

Jitendra M.Sc CPC

Basics of CPT code 97116 The provider instructs the patient in the proper ways of practicing various exercises, including climbing stairs, focusing on one or more areas, that assist them in walking comfortably and without strain for a period of 15 minutes. Below is the code description for CPT code 97116. 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) The qualified health care provider trains the patient in specific activities that will facilitate ambulation and stair climbing with or without an assistive device.…

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Unlocking the Secrets of 90686 CPT Code: A Majestic Guide for Coders

Jitendra M.Sc CPC

Basics of 90686 CPT code The provider administers into a muscle of a patient, a preservative–free, four–strain influenza virus vaccine, in a 0.5 mL dose to provide immunity to four forms of influenza, a severe and infectious respiratory disease. Below is the description of 90686 CPT code. 90686 Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use Influenza also known as the flu, is a contagious respiratory illness which is caused by influenza viruses and can cause mild…

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