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

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

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

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

5. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Endoscopy Rule Two Code correct approachCode correct approach Example, for removal:Example, for removal: –Interior lung lesion via endoscopy inserted through mouth –Exterior lung lesion via endoscopy inserted through skin Incorrect approach = incorrect code = incorrect reimbursementIncorrect approach = incorrect code = incorrect reimbursement

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

7. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Multiple Procedures Frequent in respiratory codingFrequent in respiratory coding –Watch for bundled services –Medicare—reference the CCI edits Sequence primary procedure first, no modifierSequence primary procedure first, no modifier Sequence secondary procedures next, with -51Sequence secondary procedures next, with -51

8. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Bilateral Procedures Bilateral procedures often performedBilateral procedures often performed Format for reporting chosen by payerFormat for reporting chosen by payer –Example: Nasal lavage 31000 x 231000 x 2 31000 and 31000-5031000 and 31000-50 31000-5031000-50 31000-RT and 31000-LT31000-RT and 31000-LT Medicare requires one line item with modifier -50Medicare requires one line item with modifier -50

9. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Laryngoscopic Procedures Laryngoscopic Procedures Uses terms indirect and directUses terms indirect and direct Indirect: Tongue depressor with mirror used to view larynxIndirect: Tongue depressor with mirror used to view larynx Direct: Endoscopy passed into larynx, physician directly views vocal cordsDirect: Endoscopy passed into larynx, physician directly views vocal cords

10. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Nose (30000-30999) Nose (30000-30999) Used extensively by otorhinolaryngologists (ear, nose, and throat specialists ENT)Used extensively by otorhinolaryngologists (ear, nose, and throat specialists ENT) But also used by a wide variety of physiciansBut also used by a wide variety of physicians(Cont’d…)

11. Copyright © 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:When approach to nose: External approach, use Integumentary System codesExternal approach, use Integumentary System codes Internal approaches, use Respiratory System codesInternal approaches, use Respiratory System codes

12. Copyright © 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 removalBundled into Incision codes, drain or gauze insertion and removal Supplies reported separatelySupplies reported separately

13. Copyright © 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 codesContains intranasal biopsy codes Polyp excision, by complexityPolyp excision, by complexity “Simple” involves polyps that are easy to remove“Simple” involves polyps that are easy to remove “Extensive” involves sessile polyps (thick base)“Extensive” involves sessile polyps (thick base) – More time consuming and requires a greater skill level (30115) Excision includes any method of destruction, even laserExcision includes any method of destruction, even laser Use -50 (bilateral) for both sidesUse -50 (bilateral) for both sides Reduction of turbinates, 30140Reduction of turbinates, 30140

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

15. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Nose, Introduction (30200-30220) Common proceduresCommon procedures Example: Injections to shrink nasal turbinate tissueExample: Injections to shrink nasal turbinate tissue Displacement therapy (saline flush) performed through nose to remove mucusDisplacement therapy (saline flush) performed through nose to remove mucus Insertion of nasal buttonInsertion of nasal button Figure: 20.5

16. Copyright © 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)Divided by whether removal at office or hospital (requires general anesthesia)

17. Copyright © 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: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 Included in a rhinoplasty

18. Copyright © 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 subsectionCodes for obtaining grafts for nasal reconstruction surgery are in Musculoskeletal subsection Codes for other procedures on the nose are in Integumentary subsectionCodes for other procedures on the nose are in Integumentary subsection –External approach

19. Copyright © 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)Use of ablation (removing by cutting) Used for removal of excess nasal mucosa or to reduce turbinate inflammationUsed for removal of excess nasal mucosa or to reduce turbinate inflammation

20. Copyright © 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 destructionBased on intramural or superficial extent of destruction Intramural: Deeper mucosaIntramural: Deeper mucosa Superficial: Outer layer of mucosaSuperficial: Outer layer of mucosa

21. Copyright © 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: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 procedureIf a posterior hemorrhage, was it the initial or a subsequent procedure

22. Copyright © 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 hemorrhageControl of nasal hemorrhage –Packing –Ligation –Cauterization Anterior packing placed through noseAnterior packing placed through nose Posterior packing placed at very back of throatPosterior packing placed at very back of throat Code 92511 (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same sessionCode 92511 (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same session (Cont’d … )

23. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Nose, Other Procedures Anterior packingAnterior packing When surgery is performed solely to improve the patient’s appearance (no signs/symptoms), it is cosmeticWhen 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)Non-covered under the Medicare program (DX V50.1) Figure: 20.6 (…Cont’d) (Cont’d…)

24. Copyright © 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 bleedingA balloon may be inserted to further control bleeding Hemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packingHemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packing Simple packing with gauze or anterior packing suggests a simple procedureSimple packing with gauze or anterior packing suggests a simple procedure Figure: 20.7 (…Cont’d)

25. Copyright © 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 sinusesCodes for lavage (washing) of sinuses –Cannula (hollow tube) placed into sinus, saline solution flushed through Use -50 (bilateral) for both sidesUse -50 (bilateral) for both sides Sinusectomy: All sinus contents including mucous membranes are removedSinusectomy: All sinus contents including mucous membranes are removed Antrostomy: Making an opening into the sinusAntrostomy: Making an opening into the sinus An “antrotomy” means cutting into the sinusAn “antrotomy” means cutting into the sinus

26. Copyright © 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 larynxLaryngotomy: open surgical procedure to expose larynx –For removal procedure (e.g., tumor) Sometimes confused with Trachea/Bronchi codes for tracheostomySometimes confused with Trachea/Bronchi codes for tracheostomy –Used to establish airflow

27. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Laryngoscopy Visual examination of the larynxVisual examination of the larynx Flexible lighted tube passed through mouth or nose into larynxFlexible lighted tube passed through mouth or nose into larynx

28. Copyright © 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 airwayEndotracheal intubation is establishment of airway Numerous CCI editsNumerous CCI edits Figure: 20.11

29. Copyright © 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 airwayEndotracheal 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 © 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 repairsSeveral plastic procedures and fracture repairs Laryngoplasty procedures based on purposeLaryngoplasty procedures based on purpose

31. Copyright © 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: TracheostomyMost codes: Tracheostomy –Planned (ventilation support) –Emergency Divided by type:Divided by type: –Transtracheal or cricothyroid (Cont’d…)

32. Copyright © 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 entryTranstracheal approach and entry

33. Copyright © 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 entryCricothyroid approach and entry

34. Copyright © 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 mouthBronchoscope inserted into nose or mouth Rigid endoscopy performed under general anesthesiaRigid endoscopy performed under general anesthesia Flexible endoscopy performed under local or conscious sedationFlexible endoscopy performed under local or conscious sedation

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

36. Copyright © 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 bronchiPlastic repairs of trachea and bronchi Excision of stenosis/tumorsExcision of stenosis/tumors Suturing tracheal woundsSuturing tracheal wounds Scar revisionScar revision

37. Copyright © 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 categoriesBiopsy codes in Incision and Excision categories –Excisional biopsy with percutaneous needle –Incisional biopsy with chest open Includes pneumocentesis and lung removalIncludes pneumocentesis and lung removal –Segmentectomy: 1 segment –Lobectomy: 1 lobe –Bilobectomy: 2 lobes –Total pneumonectomy: 1 lung

38. Copyright © 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 viewThoracotomy: Surgical opening of chest to expose to view –Used for BiopsyBiopsy CystCyst Foreign body removalForeign body removal Cardiac massageCardiac massage

39. Copyright © 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 categoriesBiopsy codes in Excision and Incision categories –Excisional biopsy performed with percutaneous needle –Incisional biopsy performed with chest open

40. Copyright © 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 © 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 aspirationChest tube may be inserted to drain fluid and is reported in addition to aspiration

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

43. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43 Thoracoscopy (32601-32665) Diagnostic and surgical lung proceduresDiagnostic and surgical lung procedures Surgical thoracoscopy always includes diagnostic thoracoscopySurgical thoracoscopy always includes diagnostic thoracoscopy

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