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CHAPTER 6

CHAPTER 6. RESPIRATORY SYSTEM. Respiratory System. Anatomic site arrangement Nose Larynx Further subdivided by procedure Incision Excision Introduction Removal of foreign body Destruction Endoscopy Other procedures. Endoscopy. Endoscopy in all subheadings except Nose

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CHAPTER 6

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  1. CHAPTER 6 RESPIRATORY SYSTEM

  2. Respiratory System • Anatomic site arrangement • Nose • Larynx • Further subdivided by procedure • Incision • Excision • Introduction • Removal of foreign body • Destruction • Endoscopy • Other procedures

  3. Endoscopy • Endoscopy in all subheadings except Nose • Each preceded by “Notes”

  4. Endoscopy Rule One • Code full extent • Example: Procedure begins at mouth and ends at bronchial tube • Bronchial tube = full extent

  5. Endoscopy Rule Two • Code correct approach • Example, for removal: • Interior lung lesion via endoscopy inserted through mouth • Exterior lung lesion via endoscopy inserted through skin • Incorrect approach = incorrect code = incorrect reimbursement

  6. Endoscopy Rule Three • Surgical always includes diagnostic • Example: • Diagnostic bronchial endoscopy begins • Identifies foreign body • Removed (surgical endoscopy)

  7. Multiple Procedures • Frequent in respiratory coding • Watch for bundled services • Medicare—reference the CCI edits • Sequence primary procedure first, no modifier • Sequence secondary procedures next, with -51

  8. Bilateral Procedures (…Cont’d) • Bilateral procedures often performed • Format for reporting chosen by payer • Example: Nasal lavage • 31000 x 2 • 31000 and 31000-50 • 31000-50 • 31000-RT and 31000-LT • Medicare requires one line item with modifier -50

  9. Laryngoscopic Procedures • Uses terms indirect and direct • Indirect: Tongue depressor with mirror used to view larynx • Direct: Endoscopy passed into larynx; physician directly views vocal cords

  10. Nose (30000-30999) • Used extensively by otorhinolaryngologists (ear, nose, and throat specialists ENT) • But also used by a wide variety of physicians (Cont’d…)

  11. Nose (30000-30999) (…Cont’d) • When approach to nose: • External approach, use IntegumentarySystemcodes • Internal approaches use Respiratory Systemcodes

  12. Nose, Incision (30000, 30020) • Bundled into Incision codes, drain or gauze insertion and removal • Supplies reported separately

  13. Nose, Excision (30100-30160) • Contains intranasal biopsy codes • Polyp excision, by complexity • “Simple” involves polyps that are easy to remove • “Extensive” involves sessile polyps (thick base) • More time consuming and requires a greater skill level (30115) • Excision includes any method of destruction, even laser • Use -50 (bilateral) for both sides • Reduction of turbinates, 30140-52 From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

  14. Nose, Introduction (30200-30220) • Common procedures • Example: Injections to shrink nasal turbinate tissue • Displacement therapy (saline flush) performed through nose to remove mucus • Insertion of nasal button

  15. Nose, Removal of Foreign Body (30300-30320) • Divided by whether removal at office or hospital (requires general anesthesia)

  16. Nose, Repair (30400-30630) • Many plastic surgery procedures, such as: • Rhinoplasty (reshaping nose, internal and/orexternal) • Stated as “revision” or “primary” • Rhinoplasty for nasal deformity secondary to congenital cleft lip/palate • Septoplasty (rearrangement of nasal septum) • Not included in a rhinoplasty

  17. Nose, Destruction (30801, 30802) • Use of cauterization or ablation(removing by cutting) • Used for removal of excess nasal mucosa or to reduce turbinate inflammation

  18. Nasal Hemorrhage (30901-30906) • Code based on: • Site of hemorrhage (anterior or posterior) • Control was simple or complex • If a posterior hemorrhage, was it the initial or a subsequent procedure?

  19. Nasal Turbinates Figure: 6.4 • Nasal turbinates • Excision of turbinates is considered unilateral • If performed bilaterally, use modifier -50

  20. Nasal Reconstruction • Codes for obtaining grafts for nasal reconstruction surgery are in Musculoskeletal subsection • Codes for other procedures on the nose are in Integumentary subsection

  21. Nose, Destruction (30801, 30802) • Based on intramural or superficial extent of destruction • Intramural: Deeper mucosa • Superficial: Outer layer of mucosa

  22. Nose, Other Procedures (30901-30999) • Control of nasal hemorrhage • Packing • Ligation • Cauterization • Anterior packing placed through nose • Posterior packing placed at very back of throat • Code 92511 (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same session (Cont’d…)

  23. Nose, Other Procedures (…Cont’d) • Anterior packing • When surgery is performed solely to improve the patient’s appearance (no signs/symptoms), it is cosmetic • Non-covered under the Medicare program (diagnosis code V50.1) Figure: 6.5 (Cont’d…)

  24. Nose, Other Procedures (…Cont’d) • A balloon may be inserted to further control bleeding • Posterior hemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packing • Simple packing with gauze or anterior packing suggests a simple procedure Figure: 6.6

  25. Accessory Sinuses, Incision, Excision, Endoscopy (31000-31294) • Codes for lavage(washing) of sinuses • Cannula (hollow tube) placed into sinus, saline solution flushed through • Use -50 (bilateral) for both sides • Sinusectomy: All sinus contents including mucous membranes are removed • Antrostomy: Making an opening into the sinus • An “antrotomy” means cutting into the sinus

  26. Larynx, Excision (31300-31420) • Laryngotomy: open surgical procedure to expose larynx • For removal procedure (e.g., tumor) • Sometimes confused with Trachea/Bronchi codes for tracheostomy • Used to establish airflow

  27. Larynx, Introduction (31500, 31502) • Endotracheal intubation is establishment of airway • Numerous CCI edits Figure: 6.8

  28. Larynx, Repair (31580-31590) • Several plastic procedures and fracture repairs • Laryngoplasty procedures based on purpose

  29. Trachea and Bronchi, Incision (31600-31614) • Most codes: Tracheostomy • Planned (ventilation support) • Emergency • Divided by type: • Transtracheal or cricothyroid (Cont’d…)

  30. Figure: 6.9 Figure: 6.10 Trachea and Bronchi, Incision (…Cont’d) • Transtracheal approach and entry

  31. Figure: 6.11 Figure: 6.12 Trachea and Bronchi, Incision (…Cont’d) • Cricothyroid approach and entry

  32. Endoscopy (31615-31656) • Bronchoscope inserted into nose or mouth • Rigid endoscopy performed under general anesthesia • Flexible endoscopy performed under local or conscious sedation

  33. Trachea and Bronchi, Introduction (31715-31730) • Catheterization • Instillation • Injection • Aspiration • Trachea tube placement • Some include inhaled gas as contrast material

  34. Intubation • Endotracheal intubation involves a tube placed through the nose or mouth, through the pharynx and larynx, and into the trachea to establish an airway

  35. Laryngoscopy • Visual examination of the larynx • Flexible lighted tube passed through mouth or nose into larynx

  36. Trachea and Bronchi, Excision, Repair (31750-31830) • Plastic repairs of tracheoplasty and bronchoplasty

  37. Lungs and Pleura, Removal (32421, 32422) Thoracentesis: needle or catheter inserted into pleural space for aspiration(withdrawal) of fluid or air for analysis, to drain pleural effusions, or to re-expand a collapsed lung (Cont’d…) Figure: 6.14

  38. Mediastinoscopy • Visual examination of mediastinum • Procedure usually done in operating room with local or general anesthesia • Suprasternal (above the breastbone) incision is made • Procedure to remove biopsy samples of lymph nodes, tumors, or tuberculosis

  39. Lungs and Pleura, Removal (32421, 32422) • (Cont’d…) • Chest tube may be inserted to drain fluid and is reported in addition to aspiration • (Cont’d…) Figure: 6.15

  40. Lungs and Pleura, Incision (32035-32225) (…Cont’d) • Thoracotomy: Surgical opening of chest to expose to view • Used for • Biopsy • Cyst • Foreign body removal • Cardiac massage

  41. Lungs and Pleura, Excision (32310-32405) • Biopsy codes in Excision and Incision categories • Excisional biopsy done with percutaneousneedle • Incisional biopsy done with chest open

  42. Lungs and Pleura, Excision/Incision • Biopsy codes in Excision and Incision categories • Excisional biopsy with percutaneous needle • Incisional biopsy with chest open • Includes pneumocentesis and lung removal • Segmentectomy:1 segment • Lobectomy: 1 lobe • Bilobectomy: 2 lobes • Total pneumonectomy:1 lung

  43. Introduction (32550, 32551) • Includes: • Insertion of tunneled indwelling pleural catheter • Tube thoracostomy • Destruction (32560) • Chemical pleurodesis • For recurrent persistent pneumothorax

  44. Thoracoscopy (32601-32665) • Diagnostic and surgical lung procedures • Surgical thoracoscopy always includes diagnostic thoracoscopy

  45. ConclusionCHAPTER 6 RESPIRATORY SYSTEM

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