Description of CPT code 96547 and 96548 Procedure codes 96547, 96548 describe hyperthermic intraperitoneal chemotherapy (HIPEC) procedure that includes intraoperative perfusion of a heated chemotherapy agent into the abdominal cavity through catheters. The HIPEC procedure is distinct from the primary procedure and may include chemotherapy agent selection, confirmation of perfusion equipment settings for chemotherapy agent delivery, additional incision(s) for catheter and temperature probe placement, perfusion supervision and manual agitation of the heated chemotherapy agent in the abdominal cavity during chemotherapy agent dwell time, irrigation of the chemotherapy agent, closure of…
Read MoreCPT code 31242 and 31243 : Coding guidelines for coders
Description of code 31242 and 31243 CPT code 31242 and 31243 are established from 2024 for reporting endoscopic energy-based neurolysis of the posterior nasal nerve. Below is the description of the new cpt codes. 30117 Excision or destruction (eg, laser), intranasal lesion; internal approach 30118 external approach (lateral rhinotomy) 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) 31242 with destruction by radiofrequency ablation, posterior nasal nerve 31243 with destruction by cryoablation, posterior nasal nerve CPT codes 31242 and 31243 have been established to report nasal/sinus endoscopic destruction…
Read MoreED (Emergency Department) Sample Coded charts
Sample Coded chart 1 General Chief Complaint: Altered Mental Status Time Seen by Provider: 12/07/23 19:12 History Source: Patient Mode Of Arrival: EMS Presenting Limitation(s): No Limitations – History of Present Illness HPI narrative: This is a 76-year-old male patient who presents to the emergency department tonight by ambulance for evaluation of altered mental status that was witnessed by nursing home staff. According to EMS patient was supposedly lying in bed on his knees and hands. Patient at time of physical exam is alert and oriented x4. He denies any…
Read MoreCPT code 43770-43775 Unique Coding tips for coders
Basics of Bariatric Surgery CPT codes 43770-43775 Bariatric Surgery codes 43770-43775 also report procedures performed for gastric restrictive procedures that are accomplished by placing a restrictive device around the stomach to decrease its functional size. Code 43770 reports “placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components)” . The band is adjustable because the band is hollow and contains a tube that can be inflated with fluid. After surgery, fluid is gradually inserted into the tube through a subcutaneous port (just beneath the skin) with a…
Read MoreCPT code 43290 and 43291 Coding tips
Basics of CPT code 43290 and 43291 Currently, several CPT codes describe procedures to induce weight loss, such as codes 43644 and 43645 (laparoscopic gastric bypass), codes 43770-43775 (laparoscopic gastric banding and laparoscopic sleeve gastrectomy), code 43845 (open biliopancreatic diversion), and code 43846 (open gastric bypass). These are invasive procedures that permanently alter the gastrointestinal (GI) tract. From 2023, to report EGD performed to assist with weight loss, new codes have been established for the deployment (43290) and removal (43291) of an intragastric balloon via a flexible transoral endoscope. Esophagogastroduodenoscopy…
Read MoreHow to code Patients receiving preoperative evaluations only
For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation. Usually, a surgeon will want a preoperative clearance performed by the patient’s primary care provider, often due to a chronic or preexisting condition. When the primary care provider reports the diagnosis for this visit, the first-listed diagnosis will be the appropriate Z…
Read MoreHow to code Patients receiving therapeutic services only
For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is…
Read MoreNursing facility services CPT coding guidelines
Introduction Nursing facility services A nursing facility is not a hospital but does have inpatient beds and a professional health care staff that provides health care to persons who do not require the level of service provided in an acute care facility. A skilled nursing facility (SNF) is one that has a professional staff that often includes physicians and nurses. The patients of a skilled nursing facility require less care than that given in an acute care hospital, but more care than that provided in a nursing home. Skilled nursing…
Read MoreHow to code Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign,…
Read MoreWhat are First-listed diagnosis in ICD-10 CM?
Selection of first-listed condition in ICD-10 CM In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin…
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