1. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 20 RESPIRATORY SYSTEM

2. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Respiratory System Anatomic site arrangement –Nose –Larynx Further subdivided by procedure –Incision –Excision –Introduction –Removal of foreign body –Destruction –Endoscopy –Other procedures

3. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Endoscopy Endoscopy in all subheadings except Nose Each preceded by “Notes”

4. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Endoscopy Rule One Code full extent –Example: Procedure begins at mouth and ends at bronchial tube –Bronchial tube = full extent

5. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Endoscopy Rule Three Surgical always includes diagnostic –Example: Diagnostic bronchial endoscopy begins Identifies foreign body Removed (surgical endoscopy)

7. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 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 Medicare requires one line item with modifier -50

9. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Nose (30000-30999) (…Cont’d) When approach to nose: External approach, use Integumentary System codes Internal approaches, use Respiratory System codes

12. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Nose, Incision (30000, 30020) Bundled into Incision codes, drain or gauze insertion and removal Supplies reported separately

13. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 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 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

14. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Nasal Turbinates Figure: 20.4 Nasal turbinates Excision of turbinates are considered unilateral If performed bilaterally, use modifier -50

15. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 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 Figure: 20.5

16. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Nose, Removal of Foreign Body (30300-30320) Divided by whether removal at office or hospital (requires general anesthesia)

17. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 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

18. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 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 –External approach

19. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Nose, Destruction (30801, 30802) Use of ablation (removing by cutting) Used for removal of excess nasal mucosa or to reduce turbinate inflammation (Cont’d…)

20. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Nose, Destruction (30801, 30802) Based on intramural or superficial extent of destruction Intramural: Deeper mucosa Superficial: Outer layer of mucosa (Cont’d…)

21. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 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

22. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Accessory Sinuses, Incision, Excision, Endoscopy (31000-31299) 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Laryngoscopy Visual examination of the larynx Flexible lighted tube passed through mouth or nose into larynx

28. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Larynx, Introduction (31500, 31502) Endotracheal intubation is establishment of airway Numerous CCI edits Figure: 20.11

29. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Larynx, Repair (31580-31590) Several plastic procedures and fracture repairs Laryngoplasty procedures based on purpose

31. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Trachea and Bronchi, Incision (31600-31614) Most codes: Tracheostomy –Planned (ventilation support) –Emergency Divided by type: –Transtracheal or cricothyroid (Cont’d…)

32. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 Trachea and Bronchi, Incision Figure: 20.12 Figure: 20.13 (…Cont’d) Transtracheal approach and entry

33. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Trachea and Bronchi, Incision Figure: 20.14 Figure: 20.15 Cricothyroid approach and entry

34. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 Endoscopy (31615-31656) Bronchoscope inserted into nose or mouth Rigid endoscopy performed under general anesthesia Flexible endoscopy performed under local or conscious sedation

35. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 Trachea and Bronchi, Introduction (31715-31730) Injection Catheterization Aspiration Transtracheal introduction Some include inhaled gas as contrast material

36. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 Trachea and Bronchi, Excision, Repair (31750-31830) Plastic repairs of trachea and bronchi Excision of stenosis/tumors Suturing tracheal wounds Scar revision

37. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 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 –Total pneumonectomy: 1 lung

38. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 Lungs and Pleura, Incision (32035-32225) Thoracotomy: Surgical opening of chest to expose to view –Used for Biopsy Cyst Foreign body removal Cardiac massage

39. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 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

40. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 Lungs and Pleura, Removal (32421, 32422) Figure: 20.18 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…)

41. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 Lungs and Pleura, Removal (32421, 32422) Figure: 20.19 (…Cont’d) Chest tube may be inserted to drain fluid and is reported in addition to aspiration

42. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 42 Introduction (32550, 32551) Includes: –Insertion of tunneled indwelling pleural catheter –Tube thoracostomy Includes moderate sedation Removal (32552) Destruction (32560-32562) –Chemical pleurodesis or effusion For recurrent persistent pneumothorax or multiloculated effusion

43. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43 Thoracoscopy (32601-32674) Diagnostic and surgical lung procedures Surgical thoracoscopy always includes diagnostic thoracoscopy

44. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 44 Conclusion CHAPTER 20 RESPIRATORY SYSTEM