CHAPTER 20 RESPIRATORY SYSTEM Copyright 2014 by Saunders

Respiratory System • Anatomic ____ site arrangement – Nose – Larynx procedure • Further subdivided by ____ – Incision – Excision – Introduction – Removal of foreign body – Destruction – Endoscopy – Other procedures Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 2

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

Endoscopy Rule One • Code full extent _____ – Example: Procedure begins at mouth and ends at bronchial tube – Bronchial tube = full extent Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 4

Endoscopy Rule Two approach • Code correct ____ • Example, for removal: – Interior lung lesion via endoscopy inserted through mouth – Exterior lung lesion via endoscopy inserted through skin • Incorrect approach = incorrect code = reimbursement incorrect ______ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 5

Endoscopy Rule Three • Surgical always includes diagnostic – Example: • Diagnostic bronchial endoscopy begins • Identifies foreign body • Removed (surgical endoscopy) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 6

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, -51 with ___ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 7

Bilateral Procedures • Bilateral procedures often performed • Format for reporting chosen by payer – Example: Nasal lavage • 31000 x 2 • 31000 and 31000 -50 • 31000 -RT and 31000 -LT Medicare requires one line item with modifier -50 • ____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 8

Laryngoscopic Procedures indirect and direct • Uses terms ______ • Indirect: Tongue depressor with mirror used to view larynx • Direct: Endoscopy passed into larynx, physician directly views vocal cords Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 9

Nose (30000 -30999) otorhinolaryngologists • Used extensively by _________ (ear, nose, and throat specialists ENT) • But also used by a wide variety of physicians (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 10

Nose (30000 -30999) (…Cont’d) • When approach to nose: Integumentary • External approach, use ______ System codes • Internal approaches, use Respiratory _____ System codes Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 11

Nose, Incision (30000, 30020) • Bundled into Incision codes, drain or gauze insertion and

Nose, Excision (30100 -30160) • Contains intranasal biopsy codes complexity • Polyp excision, by _____ • “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 From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby. -50 (bilateral) for both sides • Use ___ • Reduction of turbinates, 30140 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 13

Nasal Turbinates Figure: 20. 4 • Nasal turbinates • Excision of turbinates are considered unilateral • If performed bilaterally, use modifier -50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 14

Nose, Introduction (30200 -30220) Figure: 20. 5 • Common procedures • Example: Injections to shrink nasal turbinate tissue • Displacement therapy saline flush performed (_____) through nose to remove mucus • Insertion of nasal _____ button Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 15

Nose, Removal of Foreign Body (30300 -30320) • Divided by whether removal at office

Nose, Repair (30400 -30630) • Many plastic _____ surgery procedures, such as: – Rhinoplasty _____ (reshaping nose, internal and/or external) – Stated as “revision” or “primary” – Rhinoplasty for nasal deformity secondary to congenital cleft lip/palate – Septoplasty _____ (rearrangement of nasal septum) • Included in a rhinoplasty Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 17

Nasal Reconstruction • Codes for obtaining grafts for nasal reconstruction surgery are in Musculoskeletal _______ System subsection • Codes for other procedures on the nose are in Integumentary ______ subsection – External approach Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 18

Nose, Destruction (30801, 30802 _____) ablation (removing by cutting) • Use of _______ • Used for removal of excess nasal mucosa or to reduce turbinate inflammation (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 19

Nose, Destruction (30801, 30802) (Cont’d…) intramural or superficial extent of • Based on ____ destruction • Intramural: Deeper ______ mucosa layer of mucosa • Superficial: Outer _____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 20

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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 21

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…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 22

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 (DX V 50. 1) (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 20. 6 Slide 23

Nose, Other Procedures (…Cont’d) • A balloon may be inserted to further control bleeding • Hemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packing • Simple packing with gauze or anterior packing suggests a simple procedure Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 20. 7 Slide 24

Accessory Sinuses, Incision, Excision, Endoscopy (31000 -31299) lavage (washing) of sinuses • Codes for ______ – _______ 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 25

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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 26

Laryngoscopy • Visual examination of the larynx • Flexible lighted tube passed through mouth

Larynx, Introduction (31500, 31502) • Endotracheal intubation is establishment of airway • Numerous CCI

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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 29

$Larynx, Repair (31580 -31590) • Several plastic procedures and fracture repairs • Laryngoplasty procedures$

Trachea and Bronchi, Incision (31600 -31614) • Most codes: Tracheostomy – _______ Planned (ventilation support) – _____ Emergency • Divided by type: – Transtracheal ______ or _____ cricothyroid (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 31

Trachea and Bronchi, Incision (…Cont’d) Figure: 20. 12 Figure: 20. 13 • Transtracheal approach

Trachea and Bronchi, Incision Figure: 20. 14 Figure: 20. 15 • Cricothyroid approach and

Endoscopy (31615 -31661) • Bronchoscope inserted into nose or mouth Rigid endoscopy performed under general • ____ anesthesia • Flexible ______ endoscopy performed under local or conscious sedation Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 34

Trachea and Bronchi, Introduction (31717 -31730) • Catheterization with bronchial brush biopsy • Aspiration for airway clearance • Nasotracheal catheter • Tracheobronchial fiberscope • Transtracheal introduction Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 35

Trachea and Bronchi, Excision, Repair (31750 -31830) • Plastic repairs of trachea and bronchi • Excision of stenosis/tumors • Suturing tracheal wounds • Scar revision Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 36

Lungs and Pleura, Incision/Excision • Biopsy codes in Incision and Excision 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 pneumonectomy: 1 lung – Total _________ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 37

Lungs and Pleura, Incision (32035 -32225) • Thoracotomy _____: Surgical opening of chest to expose to view – Used for • Biopsy • Cyst • Foreign body removal • Cardiac massage Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 38

Lungs and Pleura, Excision (32310 -_____) 32405 • Biopsy codes in Excision and Incision categories – Excisional ____ biopsy performed with percutaneous needle Incisional biopsy performed with chest open – ____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 39

Lungs and Pleura, Removal (32554 -32557) • Thoracentesis: needle or catheter inserted into aspiration pleural space for ____ (withdrawal) of fluid or air for analysis, to drain pleural effusions, or to re-expand a collapsed lung (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 20. 18 Slide 40

Lungs and Pleura, Removal (32556, 32557) (…Cont’d) • Chest tube may be inserted to drain fluid or a syringe may be used to aspirate fluid Figure: 20. 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 41

Introduction (32550, 32551) • Includes: – Insertion of tunneled indwelling pleural catheter – Tube thoracostomy moderate sedation • Includes ____ • Removal (32552) • Destruction (32560 -32562) – Chemical pleurodesis or effusion • For recurrent persistent pneumothorax or multiloculated effusion Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 42

Thoracoscopy (32601 -32701) • Diagnostic and surgical lung procedures • Surgical thoracoscopy always includes diagnostic thoracoscopy • 32701 reports stereotactic radiation therapy Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 43