Coding an Operative Report Part II: Radiology

[Music]

foreign

we will discuss steps to solving a

medical coding exam case study but first

I want to introduce you to the team

first up Mr Sandeep

Mr Sandeep coming to you live from Abu

Dhabi he is an AMCI co-lead instructor

next up Miss Eva

coming to you live from the state of

Florida she's also a co-lead instructor

and the intern coordinator and finally

myself Mrs J I'm the curriculum director

at AMCI

now

let's meet the AMCI interns we have Miss

anubama

followed by

Miss Carla

Miss Courtney

Miss Dolly Miss Vivian and Miss Melissa

goals of the presentation we will

extract the correct codes from Radiology

documentation

now let's talk about how to solve a

multiple choice case study scenario the

AMCI way for the board exam this is how

we do it we teach you to highlight your

key terms and this key on the right

tells you the colors that you should use

and for what a yellow highlighter should

be used for diagnoses all diagnoses

signs and symptoms

the green will be for procedures so if

you have a green highlighter the green

will be used to highlight only

procedures and pink these are inclusive

or bundled items all right

once you've done your highlighting

you're going to have to document your

inventory that's your procedures

diagnoses and select a primary code

which diagnosis is primary which

procedure is primary then you're going

to review all pertinent guidelines

and finally the code that best matches

your inventory list is often the correct

code or a code that is pertinent to a

guideline that will be your best code

all right so here are some do Nots when

you're highlighting you can kind of get

discombobulated so we've compiled some

things that you don't even have to

highlight

number one don't highlight things

observed by The Physician because you

cannot code for them

number two

don't highlight closures if a provider

or surgeon is closing up a surgical site

there's no need to highlight it however

if it involves a skin procedure or skin

defect closure you may definitely have

to code that so if it's closing a

surgical site other than skin defects or

wounds or lesions

you do not code it or highlight it also

you don't highlight bleed control

hemostasis because that's pretty

customary and it's bundled into the

procedure code you don't highlight

drains irrigation of the surgical site

nope and you don't highlight

installation and removal of clamps and

trocars because that these are used to

open up or maintain the surgical or

operative site so the physician can view

what they're doing particularly if it's

an open procedure

also you don't highlight dressings and

finally you do not highlight surgical

wrists now that we've gotten that out of

the way I think you're ready to get

started and I'm going to hand it over to

Mr Sandeep all right Mr Sandeep take it

away

next chapter would be Radiology

and let me invite Miss Kala to read out

the first scenario for the Radiology

okay

can you hear me

can you hear me Mr Sandy yes Miss Carla

it's very clear

all right

what are the CPT and ICD-10 CM codes

reported answer a

76770 modifier 26 z48

8.816 and 13.70

and 28.81 and 27.0 answer B

51798 modifier 26

z48.816 and 13.0.70

in

28.81 and 27.0 answer C

76700 modify 26

z48.816 and 13.70

in 28.81 and 27.0 and answer D

76775 modifier 26 z48.816

and

13.70 and

28.81 and in 27.0

location Regional Hospital study

ultrasound urinary tract

indications status

utero

reimplantation to evaluate for continued

this vessel cultural

vasocoruterol reflux

length kidney left kidney length 7.0

centimeter prior length 7.4 centimeter

paracetime

parents chimna

cortical scarring pelvic dilation normal

callous Hill dilation normal

Hydro info OSIS

grade normal right kidney length 6.6

centimeters prior left length 6.4

centimeter

parenting Chima

cortical scarring pelvic dilation normal

calcium dilation normal

hydrophone

grade normal

interval hydro and ferosis

change none uterus normal bladder almost

empty and difficult to evaluate

impression number one in inter interval

right renal enlargement without hydro

and

fibrosis

two stable

asymmetric small left renal size likely

to represent the fuse

represent the fuse cortical scarring all

right coders you have two and a half

minutes let's get it let's go and your

time starts now

I'm sorry

I cross two and a half minutes

okay I was just looking into the chats

for this one I can see a lot of option A

um so this is going to be a teachable

moment I think

no I'm sorry this is the correct one I

think okay let's read the high uh

keywords

location is a regional hospital the

study performed as an ultrasound of

urinary tract

and the indication was status uh

urethral implantation to evaluate the

continued ways equal eurater reflex

organs which was examined is one is left

kidney they have done the examination of

the parenchyma pelvic dilation calcium

dilation hydronephrosis as well and the

right kidney also examined they have

done a pelvic a parenchyma examination

pelvic dilation

dilation hydronephrosis as well for that

and urethral ureters was also examined

the bladder was also examined

the final they came to the impression of

right renal enlargement stable

asymmetric small uh left renal size

as everyone said the correct answer is

going to be

option A

how do we come to option A

first let's have a procedure inventory

procedure performed was ultra sound of

kitten return platter the diagnosis we

are having Aftercare following the

gender urinary system right renal

enlargement and small left renal size

let's have a look into option C first

76770 which is coding for ultrasound of

an abdomen

are we doing an abdominal ultrasound

here we had kidney we have ureters and

we have a bladder which was examined

nope nope yes no as you said we are not

doing an ultrasound of an abdominal so

option C is wrong one let's look into

option b five one seven nine eight which

is coding for measurement of

post-woiding residual urine at or

bladder capacity by ultrasound

non-imaging

so was the measurement was a ultrasound

performed uh to measure the post voidal