Watch the recorded webinar below…


0:04 Hey, good morning, good afternoon to everybody.
0:07 Let’s do a quick audio check.
0:09 Start off our day, by making sure that you could hear me.
0:14 So, in the chat window, if you don’t mind, drop me a note, saying, Yes, you could hear me, or, I guess if you couldn’t, you wouldn’t hear this request.
0:25 All right, yes.
0:26 So it’s one of those things that it works for one, it works for all.
0:30 Um, So we’re going to go ahead and proceed. You probably have already noticed, I am not Janice, Janice will be out for a little bit. I’ll be presenting in her place today. OK, so welcome to roundtable 150.
0:47 And I thank you for taking your time to join us today. My name is Scott …, I’m the vice president of coding education and continuous improvement here at ….
0:57 And today, we’re going to be doing a third quarter Selective Coding Clinic review, we have a little bit under 42,000 people here.
1:06 And it’s a pleasure to have you guys all here.
1:10 It’s not 42,000.
1:11 It is, I think, over 2000 people registered.
1:13 So these are always a big draw. We always get these these peaks every quarter.
1:19 Where are attendance spikes like, these are like the beanie babies of coding clinic topics.
1:25 So, hopefully, hopefully I don’t disappoint you. I think there’s some cool things to talk about. Before we get there, some housekeeping, there’s no common numbers. The format is streaming only. We had to change this format in order to accommodate the large numbers of attendees that we have.
1:41 Today’s webinar will be available on demand after the live session, and will be accessible through a link that we’ll provide in our follow-up e-mail, which will be sent out this afternoon.
1:50 So, give us a couple of hours to turn that around.
1:54 All right, please make sure that you’re opted into our e-mails, there’s certain e-mail settings that sometimes can block the communications that we’re trying to send out.
2:04 The e-mail will come from coding roundtables at … dot com.
2:07 Please make sure that that’s in your Safe senders list and mapping data to chunk, the e-mail will contain a link to our CTU landing page, you have two weeks from today’s date to download that, we cannot issue CEUs after that point. During the webinar, you can download the handouts and enter any questions you have.
2:26 So, in the handouts, you should see 1, 1 file.
2:34 five slides.
2:35 And the reason that it’s kind of short, and in terms of slides, it’s because we’re actually gonna reference the coding clinic itself. So just copying and pasting stuff from that document into the PowerPoint just doesn’t make any sense. So go ahead and take a second and download that now.
2:52 Be sure to visit our Socks Health webinars resources page for updated roundtable information.
2:56 We just, we have quarter four up there at present. So you could see what we have on deck next month, in November, and December. Quick survey, at the end of the webinar, please take a minute to answer that. Very straightforward questions helps us gage if we’re hitting the mark.
3:11 It helps us understand if there’s anything that we could help your organization with. So, thanks again for your attention.
3:16 And let’s go ahead and get underway.
3:25 So, you know, as is the case with every coding clinic, there’s things that are exciting.
3:32 There’s things that are, no, not so exciting, and a lot of things that are somewhere in between.
3:37 I would say my overall impression from reviewing this one is that there’s really nothing nothing mind bending about the instructions in here. I think it’s all pretty, pretty straightforward.
3:50 I’m not going to I’m may get on my soapbox.
3:53 A couple of different times during nesters are certain Things I find interesting and maybe would have done differently, but that’s not to instill doubt. We have to kind of follow the guidance. Here. I get it. Sometimes I think that it’s some of that instruction is counter-intuitive. Alright.
4:12 So some of the things that caught my eye, that I think are worth discussing it. A little bit more detail.
4:20 There’s a couple of different articles or section’s vignettes, whatever you wanna call them inside the Coding Clinic that discuss complication the sequencing of complications associated with Neoplasm.
4:35 Related to that Moluccan pleural effusion.
4:37 There’s a couple, um, there’s two different coding clinics that talk about aortic aneurism procedures.
4:47 Kind of two different, um, objectives for each those discussions.
4:52 one is really to talk about the, the procedure coding and another is kinda set.
4:58 Provide an example of when we would code a stent. That isn’t actually a dilation. Diagnosis sequencing, post-partum cardiac conditions.
5:08 It’s hard to believe that it’s still an issue that goes way back to my my coding years.
5:15 Lymphoma and remission Witter, without Ned.
5:18 Ned stands for No Evidence of Disease, OK, monkeypox coding, and other fun stuff.
5:24 So consider this more of a, of a discussion than anything else. I went back and forth about, you know, what should I do? Or should I jump around according to the order of importance that I established here?
5:39 Should we just kinda flow through the Coding Clinic itself? I think just to minimize that back and forth. I’m going to pull the coding Clinic over. And we’re going to talk through those.
5:50 And there may be a couple of examples where I pull up a slide from the presentation itself, for some, for some additional context, all right? So, that is that.
6:08 All right, so, we’re going to talk about diagnosis secrets in complications associated with Neoplasm. When we get to the Coding Clinic, there’s the reference specifically desk.
6:19 Guideline and I’m going to read it out loud because I think the the specifics in the details actually are important.
6:26 So, this is from I C two, that’s an L, that should be a dot for First encounter for complications associated with Neoplasm when an encounter is for management of a complication associated with the neoplasm, such as dehydration.
6:40 And the treatment is only for the complication, and that’s my emphasis, not theirs, and the treatment is only for the complication.
6:47 Again, my emphasis, the complication is coded first, followed by the appropriate codes for the neoplasm. The exceptions to this guideline is anemia, and that’s a different story for a different day.
6:56 So, that guideline itself kind of establishes the context for the next couple of discussions, So, allow me one second here, too, um, to switch my screens, and I’m going to pull the Coding Clinic up.
7:14 And, uh, we will get underway.
7:27 Already.
7:31 Alright, one more quick check. Can you guys see the decoding clinic? Alright?
7:39 Yes, OK. Thank you guys for the quick response. It really allows us to keep moving.
7:45 This is the only part we’re going to. we’re going to jump around, right. We’re going to start with the malignancy, and it’s over here on page 14. So, let’s get over to that.
7:58 There we go.
8:06 It’s added. It’s actually on page 10.
8:11 Alright, here we go.
8:14 So a patient with the past medical history of skinny melanoma and known metastasis to the brain and lung presents with lower facial droop a phasor and this …. The provider’s diagnostic statement with interest Ribeiro Hemorrhage of known Brain Metastasis in …, a DMA, likely causing the patient’s presenting symptoms. The patient improved with initiation of steroids.
8:36 What are the appropriate code assignments and sequencing of this admission?
8:41 So in this case, it’s really hard to introduce my opinion that is, in this case, the guidance is to code either The non traumatic interest, April hemorrhage, or the edema, right? Both of those are kind of established to be causal for the patient’s presenting symptoms and then decode additionally.
9:03 The malignant conditions, the secondaries, the primary melanoma, along with the, the complications associated with those conditions so the facial weakness aphasia, So we’re not going to get that.
9:15 This is really a question of what goes first, the malignancy, or the conditions that emergency cause that are causing the symptoms.
9:25 And in this case, the administration admission ministration of steroids, Gs.
9:31 Administration of steroids is really treating the edema, like steroids isn’t going to do anything to the inter cerebral hemorrhage, right. Steroids will knock down the edema, and the rationale here is that since the treatment that the patient was written was rendered to the patient does, not specifically addressed them, but we didn’t see but rather the consequence of malignancy that, that consequence as latency would go first.
9:58 OK, that the consequence of that and we’re going to see what go first, I think it’s kind of a and you know, a slippery slope. I get it.
10:07 Know, if there was a resection here from the met not to get ahead of ours of ourselves towards resection of the mad if they treated the met with radiation. Therapy. You know, maybe if they administered chemotherapy or something to that effect.
10:19 And I think we can make the case for the …
10:22 principle, but since the treatment that was rendered only addressed the complication of the malignancy, the edema that, then it’s telling us that we could put either one of those first. So either the intra cerebral hemorrhage or the cerebral.
10:39 Or the cerebral edema, OK. So that is the first.
10:44 What do we call these things?
10:45 So we call these coding clinics, I guess we’ll call them Coding Clinics, I think of that unit, the actual publication to be the Coding Clinic, but I guess, technically, this is a Coding clinic within a Coding Clinic. Alright.
10:56 So patient with No, moving over to page 10. A patient with known adenocarcinoma of the lower third of the esophagus was admitted with a tax year end double vision, so it’s kinda starting off.
11:09 Similarly to the previous case where there’s central, nervous, system involvement causing neurological symptoms, in this case, the patient underwent surgical resection in the metastatic brain lesion.
11:21 Alright, so now we have a very different clinical pathway, then the previous example, right? And you could kind of see what this is setting up. So this patient underwent surgical resection of the metastatic brain lesion and for that reason, what we’re doing is we’re coding that secondary malignant neoplasm as the principle.
11:42 We could code the consequence of that which is a non traumatic hemorrhage and then the other malignant neoplasm conditions.
11:50 Personally, I would dip further in this case to see how we know what the appropriate code would be for that esophageal cancer. Would it be a history or would it be, Would it be a current? In this case, there are some.
12:05 They’re doing it as current.
12:07 I think, given the context of a full record, we could probably maybe go either way depending on what’s happening.
12:15 So, in this case, we have surgical treatment directed towards the secondary neoplasm, sort of putting that first, coding the complications additionally, along with the, do your neurological complications and then any other neoclassic conditions that are present during this visit.
12:35 So that’s, hopefully, you guys, I know it’s not by accident, I did position those two right after each other.
12:42 Probably, strategic, and good job on them, for doing that.
12:46 Alright, patient with known left brands kit.
12:49 Breast cancer metastatic to the brain, presented it, ED with altered mental status.
12:54 Diagnostic imaging revealed stable, metastatic brain cancer, with increased, … cerebral edema. So it’s kinda starting off, Similar to that, that, first case case, 1 of 3.
13:05 At the time of discharge, the provider suspected that the progressive cerebral edema, around unknown metastatic brain lesions was contributing to the patient’s altered mental status, which improved with steroids therapy. So, I’m going to put this out there for the group, based on what we discussed for the first case.
13:23 What are your thoughts?
13:26 What are your thoughts on the Principal Diagnosis for this case?
13:49 Any thoughts?
13:55 Yeah. So I got a lot of people saying cerebral edema, saying, let us X coders on here, hi guys.
14:02 Yeah, right?
14:03 Edema right stairway, again very similar to the first case, Initiation of steroids to knocked down, Knock down the edema. And for that reason, the cerebral edema the principal diagnosis. OK I’m not making a fool of myself, we’re going to get the next page. And look at the answer.
14:23 G 3993.6 cerebral DMO’s Principal Diagnosis.
14:27 79.31 secondary malignant Neoplasm of Brain and then see 50.9 went to malignant Neoplasm, an unspecified site of left female breast.
14:37 And again, we would know that we would have to refer to the, that, the full context of the record to figure out the specific site, neoplasm, determine whether it’s best coded using A History Code or A, or an active code, OK?
14:54 All right!
15:00 What did I want to talk about next?
15:04 Let’s go to.
15:07 I promised I wasn’t going to skip around.
15:09 But I am malignant Pleural Effusion. Let’s talk about the malignant pleural effusion. That’s actually, on page 14, so we’ll go back to that.
15:21 With that.
15:25 All right, so here we are, Bottom right-hand corner. Patient was admitted with recurrent malignant pleural effusion, and Thoreson thesis with placement of … Catheter was performed.
15:35 Pleural fluid cytology was positive for cancer cells. The patient has a past history of left Breast cancer at a time underwent a lumpectomy. More recently she was diagnosed with invasive ductal carcinoma, less breast … positive, HER two negative, and had a bilateral mastectomy.
15:51 Patient has known metastasis, metastasis to the cervical lymph nodes liver and bone, and on and is on adjuvant Tamoxifen. Therapy. All right, so that the question asked, would it be appropriate to assign J 91 millennium, pleural Effusion, as the principal diagnosis? And then goes on to cite the instructional note that says, Code first, the underlying neoplasm.
16:13 And so person was kind of like, I do what I want type of mood. But the If you look at the.
16:23 At the at the instructional note, which I’ll pull up here as Code first. That the underlying Neoplasm So we really don’t have an option here.
16:34 So we know that it’s not going to bleed in the Milligan pleural effusion as a principle. We could pull that along for the secondary.
16:41 But what we would need to do is go ahead and code first, the underlying neoplasm OK, now.
16:53 Here’s when you have a malignant pleural effusion.
16:58 And it’s really because you have pleural involvement.
17:02 That said, it’s never established here in the in this vignette that the patient as quote, unquote, …, I do not like the way that parole fusion might employ fusions are kind of index and ICD 10 CM.
17:17 Alright, that’s, That will be my hill to die, on, I guess. But, in this case, what we would code first is, it tells us to Code first.
17:27 The, the malignant Neoplasm of the unspecified site, the left female Breast, as Principal, and then Code the malignant pleural effusion. As secondary, and then we’re going to pull along the other metastatic sites that were established in the Vignette.
17:45 We could go to …, 17 point, zero for the ER positive, and then the Z 79.81, for the long term use of S E R. M S.
17:55 OK, so this kind of I don’t know.
18:00 I did It just just doesn’t It doesn’t seem right to me. I don’t really have a recourse other than follow the guidance.
18:06 The guidance tell us, too coded latency, first, encode the pleural effusion second.
18:13 I would definitely be looking it throughout the record to see if there’s documentation of, quote, unquote, plural myths.
18:23 Um, if that were the case, I would code that principle, then related pleural effusion. Second, and breast cancer, kinda third, or somewhere down the line. But here, again, we don’t have, we don’t have that documentation, so we’re left with malignant more pleural effusion, which is the occasion for the admission.
18:40 And an instructional note that’s telling us to code the, the underlying what we didn’t see first, OK, So that is that.
18:53 All right, this one is pretty interesting, the aortic aneurism repair, that’s up here in page five. Suddenly get back to that.
19:04 Course, it’s blocking me.
19:11 All right.
19:13 Patient underwent an open aortic aortic aneurism repair during the procedure, the aortic bifurcation was dissected free, down, to the illiac, bifurcation point. You’re going to do, I’m going to pull over my other presentation here. I’m just gonna read through this through the question.
19:28 I’m gonna pull that over to my other, my other screen, and I’m gonna pull up a slide that helps us understand the anatomy involved, OK, In this particular question.
19:46 All right.
19:49 Speaking of monkeypox, it’s like, all these things have gone.
19:53 I feel like I’m going to put a monkey interspace.
19:57 All right.
19:57 So, backing up a little bit patient, underwent open, aortic aneurysm repair, So therefore we got the procedure. We got the approach right out the gate. During the procedure, the aorta react dot bifurcation, was dissected free down to the illiac by … points.
20:15 Alright, let’s see if we could do a little drawing.
20:17 Here, try this, it’ll probably be messy or it. So the aortic aorta iliac, bifurcation, dissect, freed down to the Illiac bifurcation point. So they’re really talking about if, this is the Illiac bifurcation points, where it, bifurcation of the extra on illiac.
20:33 You’re talking about, you know, really like freeing up this area here.
20:42 All right, in this area here.
20:46 So, just trying to getting it nice and freezer. They could do what they need to do. Both company only extra noted to be densely calcified with a palpable stent. And the right common iliac Let’s establish that this is right.
20:58 And this is left.
20:59 You can also see that from the from that call out lines there.
21:04 All right.
21:05 So, palpable stent and the right common iliac.
21:09 Alright, so over here we got a stent going on.
21:17 OK, And an aneurysm and the left common iliac. So over here, we kinda got like some of this, this thing going on.
21:27 Aneurism.
21:30 All right.
21:31 So now we kind of understand what this patient’s vessel’s look like and what’s going on with them and we can move on. At the left, illiac, bifurcation, the external iliac, arteries were separately dissected freeze and now the dissection kind of comes down to this part. Everything is nice and free at this point.
21:49 There’s a lot of opportunity to do. Actually gotta have myself.
21:54 The Illiac, bifurcation, the extra and Internet parties were separate, dissected free. So that’s over here. Sorry, guys.
22:02 I’m sure they’d do the same on the other side anyway.
22:05 The infant renal abdominal aorta was dissected, free, Skeletonized, and circumscribed. The aneurism was opened a dacron bifurcation graph was sown end to end to the Infrared or abdominal aorta. Right. So here’s the the Renal Arteries, here’s the Infra, Renal abdominal aorta right here.
22:24 And they’re talking about putting, let me see if I could change this, to a highlighter, you’re talking about putting a graft on end to end. Alright? So.
22:38 We kinda got that going on.
22:41 Right? End to end And the reason that’s important is because it’s going to factor into the grid operation that we use. Next, the left common iliac bifurcation was endarterectomies to enable suture to the bifurcation.
22:54 Says it right? Limited Dacron graph is titled Anatomically beneath both theaters down to the right groin and so on and to decide.
23:01 I don’t think that they did a great job of explaining the kind of what’s going on in the left side. You kinda have to read between the lines a little bit here. But I’m going to read through that. That part says next to left common iliac, bifurcation, was endarterectomies to enable suture to the bifurcation so if we have to lend this graft.
23:21 All right, this Lamm right here.
23:26 Is?
23:30 Going there, it writes it a bifurcation.
23:36 So this limb is functionally taking a place of that common iliac artery. Alright?
23:41 So that’s kinda going right here.
23:45 The right limit, the …, was tunnel to amortize anatomically beneath both theaters so they get a why nothing all around down to the rake Ryan and so and so and so and so on. And decide to an arterial route to me in the comments from our arteries.
23:58 So this is the other limit, the graft, which we’re going to put in here, and it is going and to decide.
24:10 Right there, OK?
24:15 So now that we have this going on and the reason I’m taking the time with this is, I think this, this case, really?
24:21 This case, really, I think and exemplifies the intent of rude operations and how we always have to be cognizant of what the heck are they doing here.
24:31 There’s no codes these days, I’d say, a repair, right or that type of stuff.
24:37 We have to say, OK, well, what’s the nature of the repair or the replacing the the body part or are they, you know, bypassing the body part in this case. We have both.
24:49 All right. So in this case they’re replacing the abdominal aorta here. Alright, see that this graph is taking a place that aorta and they’re also replacing functionally the, the common iliac there, OK.
25:01 Notice that we’re not replacing the common Iliac here. On the, on the right hand side, we’re actually bypassing it.
25:07 We’re taking that that limb of the graft and we’re attaching it more digitally and decide that a common ephemeral, OK So there’s my, that’s the last of the drawings.
25:22 Let’s go back to the eight.
25:28 Let’s go back to this guy.
25:33 Right, so let’s tell us to do code replacement of abdominal aorta with synthetic synthetic substitute open approach.
25:40 OK, so we establish a approach right at the beginning.
25:43 And why is it a replacement its replacement because that graft is the upper portion of it is taking the place the abdominal aorta synthetic, because it’s graphed. Then the replacement of the left common iliac artery again, same thing, just a different vessel. Why is it a replacement?
25:57 Because that craft limb is functionally taking over that, the function of that vessel? And then the bypass.
26:04 Why is it a bypass, not a replacement, because it’s not functionally taking the place of the common iliac artery? It’s it’s actually just bypassing it in.
26:12 And where we’re scooting down here to the common femoral artery, OK.
26:17 So this is a this would be, like, really good coding exam question.
26:24 If I were getting a coder, see if they kind of see ICD 10 PCS, or what it is, and are able to kinda think through a case critically?
26:32 This would be a really good one. Alright. This would be a really good one.
26:38 All right.
26:42 So I think for the rest of these, to avoid the bouncing and bouncing around, since we’re kinda here at the beginning of the Coding Clinic, It’s just going to be kind of a stream of consciousness discussion about the things that I think are worth talking about. OK, someone asked me if I could provide a copy of the Coding Clinic.
26:58 I actually can’t, right, you would either have to subscribe to that yourself, or secure a copy through your, through your organization, OK.
27:10 Alright, a little bit about monkeypox, so some monkeypox questions hit the coding clinic.
27:17 Editor’s desk, and this past month, where’s my phone, top 27?
27:22 Someone asked, how do we follow the coding guidelines, just encoding guyanese, we did for …, for monkeypox, and the short answer was no.
27:33 The reason that we kind of mobilized and very quickly around covidien stood up some guidelines encode is because no caught, it came out of left field. There is no previous code for covert 19.
27:46 And initially, OK.
27:50 So, there was, there was basically one huge, one off, right, Monkeypox is actually that could have been around since ICD nine.
28:01 Alright, so number one, it’s different in kind of in that.
28:04 In the way that we have a code for monkeypox, whereas Covert it was kinda net new.
28:09 All right, so the short answer here is no don’t follow kovac guidelines.
28:12 I know that, you know, from what we hear on the News eight, that kind of sound to kind of presented somewhere like, it’s another viral infection, but the reality is, that monkey pox is not novel at all, it’s been around for quite some time, it’s just kind of rows back up to the surface.
28:30 There’s a couple of scenarios in asymptomatic. Patient comes in, say, Hey, I’ve been exposed.
28:35 We see that, see, 20.828, which was, was a code that we used initially for covert exposure, and before, we had zero point eight two two.
28:46 So, again, if we have a patient presenting with suspected exposure to a person, or after being exposed to someone at the act of monkeypox, then we had the Z 20.828. And then there’s another scenario where the patient comes after being treated. There’s no lesions, everything is a OK.
29:06 And then we, you know, we basically would follow the same guidelines that we would it for, follow up visit after any other viral condition, or 0 9, encounter for follow up examination, other than malignant neoplasm right, and then Z 86.19 personal history of other infectious and parasitic diseases.
29:26 We’re going to hear a lot about monkeypox over the past couple of days.
29:29 Hopefully, that’s in the rear view and hopefully cove it isn’t a rear view and never have to see him again. Alright. So there’s the.
29:37 There’s D the aorta Oh, erotic aneurysm repair there, that we spent some time on. Thank you for allowing me to do that.
29:45 There’s a patient coming in as getting A a bariatric surgery for a morbid morbid obesity, that’s due to metabolic syndrome.
29:54 And then the question goes, hey, where do I put first? I put the metabolic syndrome, where do the morbid obesity? I think the, kinda the chain of reasoning here behind the question is that really treating the metabolic syndrome, right?
30:09 They’re actually treating the manifestation, which is the morbid obesity, so can we put that first? And the answer there is no, and the reason the answer is no, is because of the instructional note.
30:22 It tells us that we need to put the, the E 88.81 first seems weird.
30:29 Again, I try not to let my opinion kind of get into this, But there it is, right, my, my gut instinct, my gut instinct, which is got me in trouble many times. So why would we not put morbid obesity, but we have this instructional note. And the key thing there is that we follow those.
30:48 Interesting case.
30:50 Top of page eight right-hand side. We have a 38 year old female.
30:53 She is already status post bilateral mastectomy, so her breast are surgically absent.
30:59 But she’s coming and for a hyper echoing foci adjacent to the implant.
31:04 In the in the area, it’s now known to be palpable and thickening, even though it’s also known to be benign and stable.
31:12 So the question is, like, how do we document or how do we code a lump or mass and abreast of the patient? No longer has pressed if they’ve been surgically removed.
31:22 And the answer here is to code are 22.2 localized flung mass and bump and trunk.
31:32 If we’re splitting hairs, technically, the vignette doesn’t mention that. It says presser.
31:38 OK, whatever, And also Code Z, 90.13, which explains that the patient status post mastectomy and Z, 98.82.
31:48 Um, the, uh, the fact that the patient has A.
31:56 Breast implants and site two, OK.
32:00 Alright. Patient developed a partially obstructing blood clot and the right main bronchus that was successfully removed during bronchoscopy with this because as a pulmonary embolism. I’m going to put this one out to the group.
32:11 Now that I could see everybody’s questions are recording this one as a pulmonary embolism.
32:23 Someone says they just lost audio.
32:28 Um, Put it in the question box.
32:35 All right, thank you, Kenny.
32:38 Anybody else?
32:40 Penny on the island here is Penny, the only one that’s not coding this the pulmonary embolism, Bridget.
32:45 I need two more.
32:49 OK, so the consensus here is no right and why a pulmonary embolism is.
32:59 An embolism or a clot that isn’t your pulmonary artery.
33:02 All right. It’s a It’s a clot. In the pulmonary artery, a couple.
33:07 I’m trying to, no, what should I do one page at a time?
33:11 Quick, quick question, then, should I do one page at a time, or two pages at a time?
33:21 Is your chance? This is your chance to effect change on my presentation style.
33:25 You guys are powerful.
33:28 All right, one page or 2. 1 page. Alright, let me see if I can do that here.
33:38 No, it’s not any better view.
33:44 Let’s do.
33:47 Fit Height.
33:49 How about fit width?
33:57 Zoom, fit width, All right.
34:04 Now I gotta get the next page.
34:13 OK, so, um, We’re down here, we’re moving onto that. Why is it not coded as a pulmonary embolism? It’s because it’s not right, it’s just a clot that happens to be in the bronchus. It’s actually in the respiratory tree not endear, not in the arterial treat along.
34:27 So that’s why we would not coded as a, as an embolism.
34:33 OK, All right, so, we already talked about these.
34:37 one of the things that Janice always says, That cracks me up, I’m not going to talk about this.
34:42 I’m not gonna talk about this but then she goes on to talk about it.
34:45 So, I catch myself channeling Janissaries, alright, so, here we go, we already talked about that so, I truly am not going to talk about it because I already did.
34:57 All right, we talked about the …
35:00 one and how that one is a little bit different because they’re taking the, they are taking the brain met out. Then we had that follow on.
35:11 Um, this next example, we’re not gonna go into it in great detail, one point I wanted to make here is that shouldn’t say ah steel, integrated should say arceo as you integrate it.
35:24 So, if you want to google what in us, ICO integrated implant is you actually have to transpose that T there for an S So it’s really just an alternative to those those socket type implants.
35:38 If you want to think of a patient that has an above knee amputation, sometimes you see those like fiberglass shells that that wrap, um, around that.
35:48 They’re an amputation site, it’s kinda like a socket construction type deal.
35:53 The ICO integrated implants, it’s actually a no a rod that’s integrated into it will be a femur in this case.
36:03 Mucho my horror, OK.
36:05 So, has anybody seen osho integrated implants, anybody coated those?
36:11 Recently, put that in the question window or the chat window, just curious how, um, how prevalent these are and in the actual, in the world.
36:25 Alright, so, anyway, this patient comes in, there’s a lot of, kind of soft tissue issues around the implant It sounds like that, it sounds like, things are just kinda like flapping around there.
36:37 So they what they go ahead and do is they, kind of tighten things up and X two different ways of doing that.
36:44 They take one of the muscles and they kind of just stretch it over to our side and take it down there another one to do the other side And then there’s actually a fascia cutaneous graft.
36:54 That’s part of the.
36:57 That’s part of the procedure as well. Alright, so it says to go ahead and code it as a complication, which I don’t think is.
37:06 which I think is fairly obvious.
37:07 In this case then it goes ahead and describes the surgical technique that I just summarize that taking the muscles and kind of taking them over to the other side and doing this fascia, cutaneous flap and removing some skin along the way.
37:24 All right?
37:25 So we have to reposition codes where the two of the muscles you can read up into coding clinic or there is … and biceps purist of techno musculature and there’s the fascia: cutaneous graph there. And then there’s one more. To wrap it up that talks about the excision of the skin and subcutaneous tissue. There’s also some redundant tissue there, and it goes on. Give you the rationale.
37:47 Um.
37:50 Kind of a gender reassignment surgery very complicated. There was a P now in version vaginoplasty here.
37:56 We’re not going to go over this one only because I don’t think it’s super common, but there’s kind of repetitive procedures that are done there to address it.
38:07 It’s just, again, really, just a matter of time here, trying to make sure that we put the attention, where it’s needed. Most. We talked about our pleural effusion case.
38:20 All right, patient has been diagnosed with my senior gravis, and the patient also has ESRD due to …, and first we need to understand what this …, and so two words, prefix and suffix, so that prefix mio muscle, steamier weakness.
38:36 Alright so we have weakness of the muscle in my senior could be due to a number of different things that I think that when it comes to mind first is my Senior gravis which is an autoimmune condition where the neuromuscular junction is attached and.
38:51 No, it’s just problems from from that point on. There’s other, there’s also a congenital … which is much more rare.
38:58 And then they talk about diabetic mild trophy which is kinda just wasting on the muscles due to diabetic complications. And the question is: Do we code?
39:09 Should we code this minus any gravis as a complication of diabetes? And so, I’m going to put that one out there for consideration.
39:17 Um, What do you guys think? She’ll be code, the, technically, it is patient, it has my senior gravis in a station that has diabetes. What do we do here in this case?
39:34 Any suggestions?
39:38 All right. Well, the answer is, do not code.
39:41 Do not code them.
39:45 Direct, link them. Alright. So, we just have are based on a diagnostic statement we ever diabetes, with their end stage renal disease. We’ve also established that. The patient is on dialysis.
39:55 We got our Zip code there, and the Maya senior gravitas, separate and distinct, separate and distinct, and the patient was coming in with that, so that would be worsening up, I believe. They said That would be the reason that we do as Principal.
40:10 OK.
40:13 Carrie Partum codes, this used to get, I remember these getting denied, I remember the Patient Accounting Office yelling at us because it was like a 45 year old patient that was getting some type of.
40:29 G is what we were doing back then left ventricular assist devices.
40:33 And they were getting denied, because we’re coding them as post-partum cardiomyopathy.
40:37 Sorry, they were hitting an edit, saying that the patient is, know, too old to be considered post-partum. So there’s always had to be kind of worked out behind the scenes. So anyway, in this case, this patient coming in, for heart transplantation surgery, due to end stage heart failure due to Perry Partum cardiomyopathy. So, we have … cardiomyopathy, causing end stage heart failure for which this patient is coming in.
41:01 To get a heart transplant, Alright, asked us kind of, Hey, what do we do here?
41:09 All right, and let’s get the Principal Diagnosis aside, it has this coding I 50.8 for end stage heart failure. Has this coating the sequela of a complication of pregnancy O 94 and in this case, assigning, oh, nine zero point three …
41:26 cardiomyopathy as an additional diagnosis, alright, as an additional diagnosis.
41:31 So, it makes a lot of sense. All, right, I think this makes a lot of sense.
41:37 There is another case, which I believe is the next one.
41:39 Similar, little bit of a plot twist, I’d never heard of this condition, um, but we’ll read through it real quick, So, 42 year old female transferred to our facility for Statement of Treatment of End stage ischemic cardiomyopathy, so, end stage ischemic cardiomyopathy. Alright, so this is cardiomyopathy.
42:00 That’s on the basis of ischemia, some type of, um, lack of flow to the myocardium, said it’s a little bit different than that.
42:09 Tear apart Perry part I’m cardiomyopathy or post-partum cardiomyopathy, which is not on the data schema, so we have a different type of cardiomyopathy. And this, due to Perry, pardon spontaneous coronary artery dissection sounds terrible.
42:22 That occurred more than 10 years ago.
42:24 So here’s a 43 year old that had this She status Bo’s Cabbage, they don’t ECMO and as they’re an …, as a bridge to transportation, as a bridge to transplantation for 12 years. Now, assuming that this is kind of a current case, the provider document that this schema cardiomyopathy due to scad.
42:48 What do we do here?
42:50 And the answer is, in this case, the patient had a period party, I’m Terry Partum Scad, which led to ischemic cardiomyopathy, just not have piri piri partum cardiomyopathy.
43:01 So that guidance from this point on is the same as the previous one. With the exception of we’re not coding Pericardium cardiomyopathy, because it’s ischemic cardiomyopathy.
43:10 That’s going first.
43:13 And then, we’re doing the O 94 for sequela of complication of pregnancy, childbirth. There’s other codes that I’m sure you could put near status, post cabbage, and so on and so forth.
43:23 So, that wasn’t really the crux of the questions, that I kind of glossed over this um not super exciting here, this is they’re asking how do we code impingement of the joint to be … code This as impingement syndrome coding Clinic is holding us to the letter of the law and saying, no, it’s not called syndrome. So we’re not coding it as a syndrome.
43:46 Alright, and I go on to just basically say that in using quite a few more words.
43:55 Patient comes in with a gunshot wound, active chest hemorrhage, right Side the chest opened. So we have a thorough academy on the right hand side.
44:03 Aorta is cross clamped, so they can try to get a handle on where the bleeding is coming from, do the same on the left-hand side.
44:12 Basically find that there’s bleating coming from everywhere.
44:16 It’s beyond control.
44:17 So they they cease resuscitated efforts.
44:21 The question here is do we code the the aortic cross clamping? That was done as part of the lab, or automate, and the … Academy?
44:34 Um, the answer is no, is that that’s part of the exploratory procedure, getting things under control tickets to what’s happening.
44:40 It’s not a therapeutic occlusion.
44:45 That’s not the intent of that component of this procedure. It’s actually part and parcel of the of the exploration. So, the answer is no, I have a feeling that would really take your DRG for a ride. If you decided to code it that way, so don’t do it.
45:05 All right.
45:07 When we got here, dominate Nordic Aneurism, real renal artery Stenosis, peripheral artery Disease, certainly performed an open areas and repaired by forget a graph and the inferential aorta to the common iliac arteries.
45:20 After completion of stenosis, or right, illiac graft, and asked, most of us discover, so, first and foremost, we don’t have enough detail on the, on the repair of the aneurisms, too, code that out with any degree of certainty.
45:38 We think back to the previous example, we knew that it was going and decide side re-order.
45:43 We knew that it was basically going and, I’m sorry. End to end. Abdominal aorta is basically going, end to end, the bifurcation on that left-hand side. So we knew that that was going to be a replacement and we knew that it was side to end. The comments are more recent and we knew that was a bypass.
46:00 Again, not the crux of the question, here.
46:02 Um.
46:05 So we don’t have enough information. Your case you’re wondering what the, what the codes would be for that. Would they would happen during this procedure?
46:12 Among other things is that they put a stent in the proximal, aortic and asked them Moses to secure any at thermometers. I think that’s how you say that Debris.
46:24 So, that was the intent to keep that the crusty stuff to the side.
46:28 It wasn’t to address stenosis of the abdominal aortic. Of the abdominal aorta, right?
46:39 It was just to get that the at the, at aromatase debris opposed to the side, all right, Because if it ends up in your RTO, circulation, you’ll end up with thrombosis, NF.
46:52 And obviously, that would not be a good deal. So, you’re just trying to get that debris opposed to decide. Alright.
46:59 So it’s not dilate. It’s not dilated with the attempt to increase the size of the lumen.
47:05 Alright, so, that’s the, Again, there.
47:08 Their guidance, sir.
47:11 Next case is A is a patient that’s coming in that gets a cap selected to be performed because there are capsule contractors’ around a tissue expanders, and I had, I was like, googling this last day.
47:27 I’m like, this doesn’t, it doesn’t sound clinically realistic. Tissue expanders are usually put in there for weeks and months. Not in there very long when I’ve seen capsule or contracture It’s It’s been around implants that have been in there for years.
47:42 So, suspension of disbelief, let’s just assume that this could happen or it has happened and maybe I don’t know what I’m talking about, but this patient has …
47:50 around the tissue expander it says, What do we do about those? They did it a CAHPS elect me. And the answer is, we don’t do anything about them. Capsule ectomy is considered part.
48:05 It’s considered part of that procedure, it’s part of the removal of the expanders.
48:12 Of course, we would read on through this procedure note to see if, if the patient had implants put in and so on and so forth, flare hawk, if I’m the flare hawk, representative of kind of, not too happy that coding clinic was spitting flames at my, at my device. So, this patient comes in with the L four, L five, lumbar, spinal fusion. The procedure that flare hawk, watch a video on us, it’s really cool.
48:40 Uh, is used to put the first one in.
48:46 It breaks, they put a second one in brakes, and then they end up putting it and titanium inter body cage in. All right so what do we do for that so that the flare Hawk I’m getting, I’m getting the feeling the need to do a drawing.
49:02 So if this is.
49:06 L four and this is L five.
49:13 They bring this flare hawk device and it kinda looks like.
49:18 Like this, I’ve it’s just not to scale.
49:22 It looks like kind of like a optimus prime. And they get this guy here.
49:29 And they put it in here, and there’s that there’s an end on this device that when they manipulate it, it expands this device both vertically.
49:39 So this thing is actually getting larger in that plane, and it expands it horizontally.
49:46 So it’s getting larger and that plain and all that is occurring here in the inter for table space.
49:52 So the first two times they tried to put that in it broke, um, and then they ended up going ahead and putting a titanium inter body cage in.
50:00 So, um, the question was: how do we code that?
50:07 Can we get rid of that?
50:09 And the answer was I want to make sure we have it timed.
50:15 I think I missed any of the good stuff here.
50:18 My?
50:22 Can’t get my pencil to turn off here.
50:26 Purple.
50:29 OK, because this is, what do we do here, fusion of lumbar join with Antibody Fusion Device Posterior approach Interior column.
50:35 Basically.
50:36 I think the question is, you know, what did we do about these devices that were broken, is like, basically, just ignore that it happened.
50:41 So really, there’s, there’s, there’s no way, kind of procedure code wise, too.
50:47 Describe that kind of mechanical complication of those devices because it all occurred during that setting.
50:54 Patient coming in and getting it intubated.
50:58 With the video assistant laryngoscope the question was to be code declaring a scope or laryngoscopy Dancer is no.
51:06 Answer is no, because it’s really was just used to facilitate the insertion of the endo tracheal tube that wasn’t, you know, diagnostic.
51:16 That said, it’s not to say that you could not have a diagnostic laryngoscopy, along with an end to tracheal intubation. So, I would know, kinda look at that note and see if it’s just really to facilitate placement.
51:29 Make sure it’s in a good spot, or if there’s some type of, um, or if there’s some type of pathology path that was this going on there. Interesting, device called three Cardia, This is used for patients that have acute de compensated heart failure.
51:49 What happens here, and I don’t have enough time for drawings, we’re going to finish in the next couple of minutes.
51:55 So the device is used to kind of reduce Venus congestion in the heart for patients that are in acute. Dies at dump di di compensator heart failure. So they come into your juggler vein.
52:09 Then they come into your vena Cava and they inflate this. They inflate this balloon, Right?
52:15 So this balloon is up there in your superior vena Cava, and it’s basically putting the brakes on the venous flow, um.
52:25 Into your heart. Right?
52:26 It’s kinda just that that cyclic inflation of of the of this balloon is, again, pumping a brake so to speak, of the blood that’s flowing back into your heart, remember, it’s kinda coming into your heart to the venous system and and so on.
52:43 And so it’s kinda just cyclically.
52:46 Slowing that down, And, uh, the advice here.
52:52 I’m doing that emoji teeth, where it kind of the grand thing, or it’s just showing our teeth assistance with cardiac output using balloon pump.
53:00 Intermittent is the advice.
53:02 To me, this is begging for a new technology code because I don’t think it’s really assisting with cardiac output.
53:11 It’s just kind of, To me, it’s, there’s a different kind of therapy involved here, but nonetheless, keep an eye out for pre cardia, if you see it done, follow this guidance. And, and you’ll be on your way.
53:21 So watch a couple of videos on it when you think about the intra aortic balloon pump, which is kind of what they’re comparing us to.
53:33 That’s different.
53:34 You’re actually facilitating slow, you’re actually trying to assist it, and that’s when you’re actually trying to slow it down.
53:44 Entry arctic bloom pumps are, are, are really. There’s a lot of cool videos on those, as well. I’m sure we’ve all had the occasion of code as a discipline.
53:52 So, patients coming in, they have an entity called backwards, then pump, they do avow salvo maneuver, um, where there’s a pair of catheters, cerebral spinal fluid, Bleak, Tara catheter, so it’s not actually the catheter itself that’s leaking. It’s just kind of the the part where the catheter is going in.
54:12 Through the dura OK, and so at saint don’t coded as a complication, because it’s not a catheter issue. It’s just leaking around a catheter.
54:21 Um, again, withholding judgement.
54:26 And so what they do is they go ahead, they create their repossession it.
54:30 Um, they do some suturing around a catheter soft tissue and so on and so forth. And so, they’re basically addressing the area around where the catheter goes in.
54:40 They make some recommendations about the procedure itself.
54:45 So, you have repositioning of kinda the business end of the catheter and then you got some other stuff there.
54:54 What else do we have?
54:55 We have five minutes see if there’s any other good ones that we should.
55:05 We can get to here. Actually, we’re on page 26 might just go through here.
55:11 Sharp code deform yet, that’s a really, really technical coding clinic.
55:15 Feel free to read over that one out in your own time. Involves external …
55:22 pretty kind of pretty complicated example there, too much to go over. Alright. So history of lymphoma is we have We’ve had that, right? We don’t have really a history of lymphoma code.
55:37 Or, I’m sorry, we do, but for if it’s described as in remission?
55:40 So, we have to diagnostic statements, such as history of lymphoma, status, post radiation, and chemotherapy in remission, that we don’t have a unique codes that are describing.
55:52 I’m lymphoma. That’s in remission. What do we do? And the answer here is Z 85.72.
56:04 It’d be nice to have a, uh.
56:08 It’s not essential modifiers put in there, maybe adjust the alphabetic index to allow for that to be a little bit more clear.
56:17 First time I ever saw Ned was added cancer Center in Philadelphia and no idea what it meant.
56:23 I had asked someone, that’s coding next to me, back in 99. So, history of non Hodgkin’s lymphoma and remission with no evidence disease. How do we code that Z 85.72 kind of? Alternatively stated.
56:39 You know parallels that the previous one Nelly retired had an opportunity to meet Nelly and talk to nellie and she was very kind of one of those champions of coding guidance.
56:50 So congratulations on her on um, whatever, next steps are her. She certainly putting a lot of legwork for us. She really nice person too. So.
57:03 Yeah, that’s it, I’m gonna get you guys out on time, it is 12 57.
57:07 I tried to take a look at the, at the questions.
57:13 CEUs, CEUs, you go out to our download page and download the CEU, Again, gave us a couple of hours to get that up there, but do not attach it to the presentation. I still am trying to figure out a better way to do CEUs. It is like the bane of my existence. self.
57:35 Someone said, Can we get a webinar with your judgement? Man, I’d probably, I think the Coding Clinic Police would come arrest me.
57:42 So, from now, you’re just gonna get some of my judgement. Alright, so cool. Thank you, guys. Keep doing a great job.
57:52 As a recovering coder, but you guys are doing is important. It’s difficult. And tell your friends and family that cheerleader.