1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 20 RESPIRATORY SYSTEM

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

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endoscopy Endoscopy in all subheadings except Nose Each preceded by “Notes”

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

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endoscopy Rule Two 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 = incorrect ____________ approach reimbursement

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

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Bilateral Procedures 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 ________ requires one line item with modifier -50 Medicare

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

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

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

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nose, Incision (30000, 30020) Bundled into Incision codes, drain or gauze insertion and removal Supplies reported separately

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

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nasal Turbinates Figure: 20.4 Nasal turbinates Excision of turbinates are considered unilateral If performed bilaterally, use modifier -50

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nose, Introduction (30200-30220) saline flush nasal Common procedures Example: Injections to shrink nasal turbinate tissue Displacement therapy (_________) performed through nose to remove mucus Insertion of _____ button Figure: 20.5

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nose, Removal of Foreign Body (30300-30320) Divided by whether removal at office or hospital (requires ______ anesthesia) general

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

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

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

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

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nasal Hemorrhage (30901-30906) Code based on: –___ of hemorrhage (anterior or posterior) –______ was simple or complex If a posterior hemorrhage, was it the initial or a subsequent procedure Site Control

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nose, Other Procedures (30901-30999) Control of nasal hemorrhage –Packing –Ligation –_____________ Anterior packing placed through nose _______ packing placed at very back of throat Code 92511 (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same session Posterior (Cont’d … ) Cauterization

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nose, Other Procedures 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 V50.1) Figure: 20.6 (…Cont’d) (Cont’d…)

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nose, Other Procedures 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 Figure: 20.7 (…Cont’d)

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

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Laryngoscopy Visual examination of the larynx Flexible lighted tube passed through mouth or nose into larynx

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Larynx, Introduction (31500, 31502) Endotracheal intubation is establishment of airway Numerous CCI edits Figure: 20.11

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

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Larynx, Repair (31580-31590) Several plastic procedures and fracture repairs Laryngoplasty procedures based on purpose

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

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Trachea and Bronchi, Incision Figure: 20.12 Figure: 20.13 (…Cont’d) Transtracheal approach and entry

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Trachea and Bronchi, Incision Figure: 20.14 Figure: 20.15 Cricothyroid approach and entry

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

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

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

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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 –_____________: 1 segment –_________ : 1 lobe –__________ : 2 lobes –__________________ : 1 lung Segmentectomy Lobectomy Bilobectomy Total pneumonectomy

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

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

40. Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Lungs and Pleura, Removal (32554-32557) Figure: 20.18 Thoracentesis: needle or catheter inserted into pleural space for ________ (withdrawal) of fluid or air for analysis, to drain pleural effusions, or to re- expand a collapsed lung aspiration (Cont’d…)

41. Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Lungs and Pleura, Removal (32556, 32557) Figure: 20.19 (…Cont’d) Chest tube may be inserted to drain fluid or a syringe may be used to aspirate fluid

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

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

44. Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 20 RESPIRATORY SYSTEM