One of the more substantial changes in CPT in 2017 involves the guidelines and reporting of administration of moderate sedation. CPT defines moderate sedation as the administration of medications to depress a patient’s consciousness during a procedure. Moderate sedation is also sometimes referred to as conscious sedation (these terms are synonymous so whether the medical records you are coding use the term moderate sedation or conscious sedation the guidelines outlined in this article will apply). Continue reading “Moderate Sedation”
Category: Article
Thyroidectomy Coding
If you are new to coding ENT procedures, the thyroidectomy section of the CPT manual can be daunting. There are several code options to choose from and all of the descriptions which are similar with minor variations between the descriptions can run together. To accurately code these procedures, you need to identify a few details from each operative report:
- Was the entire thyroid removed or only a portion?
- If less than the entire thyroid was removed, was only one lobe removed or were both lobes removed (in whole or in part)?
- Was any portion of the thyroid removed in a prior surgery?
- How did the surgeon reach the thyroid (e.g., through a neck incision or through an incision in the chest wall)?
Answering these four key questions will help you to select the correct CPT code. Let’s look at a couple of examples. Continue reading “Thyroidectomy Coding”
Incision & Drainage
An incision and drainage procedure as the name implies involves making an incision into the body and draining fluid from the body. This fluid drained can be an area of infection such as an abscess or it may be an area of hematoma or seroma.
At first glance, coding incision and drainage procedures looks pretty straightforward (there are just a handful of codes for incision and drainage in the integumentary section of the CPT manual). Not all incision and drainage procedures should be coded with these codes from the integumentary section though. There are incision and drainage codes throughout the surgery section of the CPT manual that are designed to represent deeper incision and drainage procedures for various locations throughout the body. Let’s start by looking at the incision and drainage procedure in the integumentary section of CPT. Continue reading “Incision & Drainage”
Become a Research Pro
The key to cooking any great meal begins by starting off with the right ingredients. We first locate a recipe (or for those of you more culinarily creative than myself, you may create your own). Next we need to schedule a trip to the grocery store to make sure we have all the required ingredients on hand. When it comes time to cook this fabulous meal, we have to measure the correct amount of each ingredient and follow the recipe step by step in a methodical manner to ensure the outcome is what we intended.
When it comes to medical coding, the step by step mechanism for coding accurately works much the same way, but so often, we don’t break down the process of accurately coding one step at a time. So many coders I have talked to feel like they should simply “know” the correct code the first time they attempt to code a new specialty or procedure, or they go searching for a resource that will give them the right code without developing the ability to discover the right code on their own. Continue reading “Become a Research Pro”