Coding an Operative Report Part II: Musculoskeletal System

[Music]

welcome to session two

in this presentation 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

on obama

followed by

miss carla

miss courtney

miss dolly miss vivian and miss melissa

and the goals of the presentation are to

review

integumentary

musculoskeletal

and respiratory scenarios

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 risk

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

let's move on to the next section

musculoskeletal system

and for the first scenario i would

invite miss code miss courtney onto the

floor miss courtney flores all yours

all right coders what cpt and icd-10 cm

codes are reported

a2800

modifier lt

m72.2 b28060

modifier lt m7 2.2

c28062 modifier lt

m72.2

d28008

modifier lt m72.2

pre-operative diagnosis plantar

fasciitis left foot post-operative

diagnosis same as preoperative diagnosis

procedures plantar fasciotomy left hill

for informed consent the more common

risks benefits and alternatives to the

procedure were thoroughly discussed with

the patient an appropriate consent form

was signed indicating the patient

understands the procedure and its

possible complications the 61 year old

male was brought to the operating room

and placed on the surgical table in a

supine position following anesthesia the

surgical site was prepped and draped in

the normal sterile fashion attention was

directed to the left heel where

utilizing a 61 blade a stab incision was

made taking care to identify and retract

all vital structures the incision was

deepened to the medial band insertion of

the fascia the fascia was then incised

and evolved from the calcaneus the

surgical site was flushed with saline

next one cc of depot medraw was injected

in the operative site the site was

dressed with a light compressive

dressing excellent capillary refill to

all of the digits was observed without

excessive bleeding noted hemostasis none

estimated blood loss minimal injectables

agent used for local anesthesia was 5.0

cc marcane 0.5 percent with epinephrine

pathology no specimen sent dressings

applied bacitracin ointment site was

dressed with a light compressive

dressing condition patient tolerated the

procedure and anesthesia well vital

signs were stable vascular status was

intact to all digits patient recovered

in the operating room alright coders

your time starts now

and coders i think that's time

and

what a flawless way to read the

unoperative scenario i'm sure i won't be

able to read

it operating report in such a manner

such a beautiful manner mr uh miss

courtney thank you thank you thanks a

lot

and coders i see like you didn't needed

two and a half minutes to solve this one

great to see that once again

so let's all the scenario

you know the drill the first step

highlighting the keywords

we have the pre-operative and

post-operative diagnosis same plan the

facilities of left foot

the procedure performed is a planned

aphasiotomy

left

heel the patient was placed in a supine

position

and anesthesia was given

the stab incision was made the incision

was deepened

the fascia

was then incised and ovals

from the calcaneus

next one cc of department role was

injected in the operative site

and as majority of you have said the

correct answer is option d

now let's move and solve the scenario

second step

before that okay what is plantar

fasciitis

uh this is one of the condition which i

see uh most commonly people coming up

with

so it is an inflammation of the fibrous

tissue

which is a plantar fascia along the

bottom of your feet that connects the

heel