Health Information Management

Coding case studies: You make the call

HIM-HIPAA Insider, April 13, 2004

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Use the clinical documentation below to determine the CPT codes and
modifiers to use for these two case studies.

Case study one:

Preoperative diagnosis: Morbid obesity

Procedure: Cancellation of gastric bypass, secondary to skin infection

Complications: As above

Indications: A 30-year-old female with a long history of morbid obesity,
recently underwent silastic gastric banding, and due to reflux disease,
subsequently required a procedure to loosen the band. Most recently she has
experienced significant reflux disease, and presents for removal of her band
and open Roux-en - Y gastric bypass.

Description of procedure: The patient was brought to the operating room and
placed in the supine position. General endotracheal anesthesia was
administered. The patient's gown was removed for prepping, at which point
clinicians noticed there were small, acnelike lesions over the anterior
surface of her abdomen, her intriginous areas, and on her legs. Several of
the lesions fell on the incision line.

Additionally, there was a large midline abdominal wall defect, which was
assumed to represent an abdominal wall hernia, and most likely will require
a mesh repair. For these two reasons the case was canceled after general
anesthesia was administered. The patient was awakened from anesthesia and
taken to the recovery room.

There were no immediate complications evident, with the exception of
cancellation of the case after general anesthesia.

CPT codes(s) and modifiers:

Case study two:

Clinical diagnosis: Obstructive sleep apnea

Operation: Aborted uvulopalatopharyncoplasty

Postoperative diagnosis: Same

Description of procedure: After obtaining informed consent, the patient was
taken to the operating room and placed in a supine position. The patient was
properly identified, and the anesthesia service performed bilateral superior
laryngeal nerve blocks and applied topical anesthesia to the oropharynx.
Attempts were made to orally intubate the patient, using a fiberoptic scope.

The patient exhibited significant coughing and gagging with the procedure.
It was extremely difficult to visualize the larynx. After multiple
unsuccessful attempts, the procedure was aborted. We decided to take the
patient to the recovery room and discuss further treatments of his
obstructive sleep apnea, including tracheostomy. The patient was taken to
the recovery room in stable condition. There were no complications
associated with the procedure.

Summary of findings: Aborted uvulopalatopharyncoplasty, secondary to
difficulty with fiberoptic oral intubation.

CPT codes and modifiers:

Click here to find out the answers.

This week's excerpt is adapted from the book, "The Modifier Clinic: A guide
to hospital outpatient issues,"
by Lolita M. Jones, RHIA, CCS.


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