Coding an Operative Report Part II: Pathology and Laboratory

[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 pathology

and laboratory 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 intro

cars 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 we

are having oh

pathology and laboratory section yes

said goodbye to the Radiology section

and for this scenario we are having Miss

melis I think Miss Melissa

he is not here with us

so Miss Eva Miss Eva can you read the

scenario for me

foreign

I'll take it from you right now

actually hold on

because I was not ready just give me one

second

okay I'm gonna take it from you Mr

Sandeep thank you miss you you're

welcome

okay coders so for the next oh hold on

one sec

is it this one Mr Sandeep

that's a scenario

okay sorry coders

um what are the CPT in icd-10-cm code is

reported a

88104 e 10 22 and 18.6 z 99.2

b88108 e 10.22 and 18.6 z 99.2

c 88125 e 10.22 and 18.6 z 99.2 and d a

eight one zero six e 10.22 and 18.6 Z

99.2 requested by R Simon MD cytology

report collected 126 present year

received 127 present year pathology is

performing the service is an employee of

the lab specimen source a peritoneal

fluid

specimen description a hundred

milliliters of yellow fluid cyto

preparation to CCF

pertinent clinical data and clinical

diagnosis 26 year old female with

end-stage renal disease due to type 1

diabetes presents for elective kidney

transplant cytologic impression

peritoneal dialysis joint fluid no

cytologically malignant cells are

identified common 100 milliliters yellow

fluid is received from which two Papua

Nicolaus stain

cytocentrifuge slides are being slides

contain mesothelial cells with a

spectrum of reactive changes and

histocytes no malignant cells are

identified what are the CPT and

icd-10-cm codes reported coders you have

two minutes

whole cake orders and at least the time

and how are you feeling about coding the

pathology and laboratory scenarios

what do you think how it is how it's

going

I'm not creating this one of the

responses I got I know these are a bit

of dry chapter but as we do the churning

that will be that will uh that will help

us to save the time

so let's solve the scenario the cytology

is a procedure which is uh performed in

the uh it is received by pathologist is

one who's performed and he is an

employee of the lab

and the specimen is collected from the

peritoneal fluid

patient is having end stage uh renal uh

DC csrt and that is due to type 1

diabetes mellitus

and the two property I'm sorry I I don't

know how well Miss Eva read it with such

fluency

centrifuge slides were made so

centrification was a technique which was

used

I'm not going to read that again

okay the correct answer will be option b

let's see how we arrived into option b

these are the procedures performed

versus inventory we are having

cytopathology on the peritoneal fluid

and the technique which is used was

centrifugation and the diagnosis

inventory we are having end-stage renal

disease which is due to type 1

diabetical disc the procedure performed

was a cytopathology studied it is a

study of cellular changes in disease

states that uh happens in the disease

such as cancer infection or inflammation

so that was a study which was performed

in the scenario

let's look into option C

88125 which is coding for cytopathology

forensic example sperm so eight eight

one two five what the lab analyst uh

analyst it performs is that uh it is

done uh for any specific uh specimen for

the forensic analysis purpose such as

any crime scenes or any something uh

that is related to forensic

so uh it was not in our scenario we had

a cytopathology of a peritoneal fluid

which was performed that's why option C

is a wrong one

yeah centrifugation means a

concentration

option C is wrong let's look into option

A that will be

88104 which is calling for cytopathology

fluids which is performed by a washing