Medical Coding Guide - Page 6 of 91

When to use Lab code 83880 Natriuretic Peptide Testing

January 23, 2024April 29, 2024 Jitendra M.Sc CPC

Introduction of CPT code 83880 B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in the left ventricle. It is secreted in response to ventricular volume expansion and pressure overload, factors often found in congestive heart failure (CHF). BNP is increased in congestive heart failure, left ventricular hypertrophy, acute myocardial infarction, coronary angioplasty, and hypertension. Elevations are also observed in pulmonary hypertension (indicating right ventricular dysfunction), acute lung injury, hypervolemic states, chronic renal failure and cirrhosis. Decreasing levels indicate therapeutic response to anti-hypertensive therapy. CPT lab code 83880 is used…

Sample Coded report for Rotator Cuff repair CPT code

January 22, 2024January 20, 2024 Jitendra M.Sc CPC

PREOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear. Right shoulder SLAP tear. Right shoulder impingement. Right shoulder AC DJD. POSTOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear. Right shoulder SLAP tear. Right shoulder impingement. Right shoulder AC DJD. Right shoulder biceps tear INDICATION FOR PROCEDURE: Brief History: A 76 y.o. -year-old male has had persistent shoulder pain and functional limitation despite conservative management. MRI showed above-mentioned findings. Operative and non-operative options were discussed and time was allowed for questions. Risks of surgery were discussed. Signed consent was obtained, and patient was scheduled for above-mentioned procedure. PROCEDURE PERFORMED: Right shoulder arthroscopic rotator cuff repair. Right shoulder arthroscopic…

Screening Abdominal Aortic Aneurysm (AAA) CPT code for all payers

January 21, 2024April 29, 2024 Jitendra M.Sc CPC

Aorta is one of the main organs of abdominal region. It is the main artery from where all the small arteries arise. Arteries arising from the Aorta form Vascular Families. Vascular Families help us in Selective and Non-Selective catheterization coding. Ultrasound Procedure coding is very straight in radiology. We have already learned how to code abdominal ultrasound complete and limited in my previous post. But, in this article we will learn how to code single organ ultrasound separately with different payers. We will learn how to code Screening Abdominal Aortic…

Sample Coded report Humerus Fracture CPT code

January 20, 2024 Jitendra M.Sc CPC

Pre-op Diagnosis: Closed fracture of distal left humerus Post-op Diagnosis: Same as Pre-op Procedure(s): Left – OPEN REDUCTION INTERNAL FIXATION DISTAL HUMERUS VIA OLECRANON OSTEOTOMY- Wound Class: Clean Proc. Description(s) & CPT Code(s): OPEN REDUCTION INTERNAL FIXATION DISTAL HUMERUS: Anesthesia: General Complications: none Findings: complex fx Technique: The patient was taken to the OR and given general anesthesia. A foley catheter was placed. A time out was done. Prophylactic IV antibiotics were given. He was placed in the lateral position on the beanbag with all bony prominences padded. The patient and site were identified. The left upper extremity was prepped and draped in the usual…

CPT code 85730 (Partial thromboplastin time PTT) Coding Guide

January 17, 2024April 13, 2024 Jitendra M.Sc CPC

Code Description of CPT code 85730 ((Partial thromboplastin time PTT) 85730 – Thromboplastin time, partial (PTT); plasma or whole blood This exam may be ordered as a partial thromboplastin time or PTT, or as an activated partial thromboplastin time or APTT. The specimen is plasma. The method is automated coagulation instrument. The partial thromboplastin time is prolonged when deficiencies of coagulation factors VIII, IX, XI, and XII are present. This test is used to monitor the effectiveness of the anticoagulant drug heparin, which is prescribed for patients who have had…

Difference Between ICD 10 Status codes and Personal History codes

January 16, 2024April 30, 2024 Jitendra M.Sc CPC

ICD 10 coding guidelines are very important to following in diagnosis coding. Same rule has to be followed for coding procedure codes. Many coders are still have confusion in coding multiple ICD 10 codes in a medical chart because they do not the coding guidelines. In ICD 10, coder have confusion in coding Aftercare and followup codes, ruleout or fall ICD codes, suspected diagnosis codes etc. Yes, all these ICD 10 codes have created lot of confusion in coders mind. Even Z codes have specific coding guidelines. But, many codes…

Sample Coded report for Closed Fracture CPT code

January 15, 2024January 14, 2024 Jitendra M.Sc CPC

PREOPERATIVE DIAGNOSIS: 1. Closed Left Tibial Plateau Fracture POSTOPERATIVE DIAGNOSIS: 1. Same PROCEDURES PERFORMED: 1. Closed Reduction with placement of external fixator: Left tibial plateau ANESTHESIA: General endotracheal ESTIMATED BLOOD LOSS: Minimal COMPLICATIONS: None. DRAINS: None. SPECIMENS: None. TOURNIQUET: None. HPI & INDICATIONS FOR PROCEDURE: The patient is a who presented to the emergency department s/p motor vehicle collision. He was a restrained driver whose operatively in a vehicle that struck a pole at a high rate of speed. Presented to the ED with complaints of left knee pain. Imaging revealed a…

When to use ICD 10 Status Z codes as Secondary diagnosis

January 14, 2024April 30, 2024 Jitendra M.Sc CPC

We have now almost became familiar with the ICD 10 codes. We all are now familiar with the difference between the ICD 9 and ICD 10 codes. The new diagnosis codes are huge in numbers. The ICD 10 codes are more specific compared to ICD 9 codes. Also, the new terms like Excludes 1 and Excludes 2 helps in coding correct diagnosis codes. In ICD 10 codes, the most of the errors happens in sequencing the ICD 10 codes. If their are multiple diagnosis codes in a medical report, then…

Best coding tips for Burns in ICD 10

January 14, 2024April 29, 2024 Jitendra M.Sc CPC

Definition and degree of Burn Burn is an injury caused by exposure to heat or flame. Burn are classified into different degree to code the most specific ICD 10 code. Tissue injury or death caused by heat, flame, chemical, electricity, or radiation; the depth of a burn is measured by degree. To know more specific about degree of burns, let us check them in more detail. First Degree Damage from first-degree burns is limited to the outer layer of the epidermis, with erythema and increased tenderness. First-degree burns have good capillary…

How to choose Primary diagnosis in Medical coding

January 14, 2024April 29, 2024 Jitendra M.Sc CPC

In all medical coding facility, ICD codes play a very important role. The sequencing of diagnosis codes should be correct for proper payment of the Procedure. As a medical coder, I have seen how coders struggle to code the ICD 10 diagnosis codes. Today, I am just here to share my knowledge on coding the primary diagnosis. When there are multiple diagnosis codes in a medical report, medical coders struggle to choose primary diagnosis and secondary diagnosis. Sometimes even the coders have confusion in coding admit diagnosis, Reason for Visit(ROS)…