The Elephant in the Tense Room: Trust

As the 73rd AHIMA House of Delegates (HoD) meeting approached, I remembered the passionate discourse of last year’s meeting. Well, it appears I wasn’t alone. Last year’s meeting was the talk of this year’s meeting, especially since there were some new action items that could potentially foster the same level of discussion.

To prepare for the HoD 2019 meeting, Robert Rules of Order was provided and discussed, a parliamentarian was included in the meeting and AHIMA’s General Counsel was in attendance. As a result of these efforts, we had a very orderly meeting, discussion and voting process. People were able to ask questions, get answers and clarification without being insulted and belittled. The vote was a standing vote and each person standing, either for or against the issue, was counted.
 
Even with all the preparation to ensure an orderly discourse, there was still an elephant in the room that had to be discussed- trust.
 

AHIMA leadership talked about trust, the lack of confidence and lack of belief in the organization and its leadership. It is important that even during debate and discussion, everyone should feel appreciated and at a minimum heard. 

As a member of AHIMA and OHIMA, we have a responsibility to vote, engage, trust the process and articulate our value in a respectful manner. As AHIMA pivots into the new transition, we must prepare ourselves by staying updated to information and announcements regarding changes, sharing our voice and advocating for our profession. We must remember to trust the process as we navigate the upcoming years of change and beyond.

 

About the Author

Clarice Warner, RHIA, CCS-P, CPC, CHC is the Corporate Director of Corporate Responsibility for the Mercy Health Corporate Office in Cincinnati, Ohio.  She is also the Founder and Education Director for the Professional Reimbursement Network.  Clarice serves as a 1st-year Director and Delegate on the OHIMA FY 2018-19 Board of Directors, overseeing the Public Good strategy and Advocacy Committee.   

Cystoscopy and Ureteroscopy Procedures

Cystoscopy and ureteroscopy procedures will be discussed in this episode of “Spotlight on CPT”.  These procedures are similar as they both begin with the insertion of a scope through the urethra and into the bladder.  

When coding procedures that involve the urinary system, terminology is vital.  Organs have similar names and it is important for accurate coding that we differentiate between the terms correctly.  So let’s start this discussion with an overview of the urinary system beginning externally.
 
    1 Urethra
    Leads to
    1 Bladder
    Leads to
    2 Ureters
    Leads to
    2 Kidneys 


And the Urinary System looks like this:

Source: https://www.yourdictionary.com/urinary-system

When a cystoscopy or cystourethroscopy is performed, the catheter is inserted in the urethra and then into the bladder.  Inspection occurs there.  This is often done for patients that have bladder neoplasms.  Biopsies can be taken or fulguration/resection which can destroy/remove abnormal tissue.  These destruction or removal codes are based on the location and size of the lesion.  Biopsies taken from the same area that is being destroyed, in the same encounter, are not separately coded.  However, it the biopsy comes from a different area of the bladder, it can be coded with an appropriate modifier.

Ureteroscopy procedures may include a pyeloscopy as well.  A code from this section could be assigned for a ureteroscopy with lithotripsy and double-J stent insertion with a combination code of 52356.

If one is not careful, it would be easy to be in the wrong section of the CPT manual when assigning codes.  This could result in code 52204 cystourethroscopy with biopsy being assigned instead of 52354 for cystourethroscopy with ureteroscopy with biopsy. 

Now, light has been shed on coding cystoscopy and ureteroscopy procedures.

 

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

CSA Leadership Conference - Listening Session on AHIMA Election

During the 2019 CSA Leadership Symposium there were many options in regards to breakout sessions.  One of the many options was, “Listening Session-AHIMA Election”.  I attended this session out of curiosity.   This session was facilitated by Dr. Valerie Watzlaf, Shawn Wells and Ralph Morrison.  The purpose of this session was to discuss concerns from the CSAs represented in regards to the rationale for having only one (1) candidate for President of AHIMA on the 2019 ballot.  

When entering the meeting I was expecting the facilitators to just explain why there was only one candidate on the ballot and that would be the end of it.  That is not what happened.  The facilitators allowed the audience to drive the meeting.  The biggest area of contention was the fact that of some of those present felt as though they were being forced to select a president.
 
Every year the Nominating Committee are tasked with going through all submissions for those that are to appear on the ballot.  This year was a rather difficult year as the committee did not feel as though they had more than viable, well-qualified candidate for President.  The committee felt there was only one candidate that was exemplary in comparison to all other applicants.  The committee went to the AHIMA Board and asked for a change in the policy.  The policy calls for more than one candidate to be on the ballot.  The board agreed.  When Shawn Wells was asked if the board could do things over would they make the same decision?  He responded that they would not have made the same decision if given the opportunity do over. 

About the Author 

Tonya L. Bates, RHIA is the currently Board President of the OHIMA FY 2020-21 Board of Directors.  She can be reached at tla511j2@att.net.

Coding Hernia Repairs in ICD-10-PCS

The previous installment of “In the kNOW”  presented information on hernia diagnosis coding.  Now our attention is going to turn to appropriately hernia repairs.  Let’s start with a basic piece of information which has been provided in Coding Clinic which states that when a hernia is manually reduced it is not separately reported.  So no code assigned for a manual hernia reduction.   

Hiatal hernias can be repaired either through an open or percutaneous endoscopic approach.  Additionally, a determination will have to be made on the correct root operation to assign.  Was it a repair only, in which case the root operation is Repair, or was it with the use of mesh or other augmentative agent, in which case the root operation would be Supplement.

Hiatal hernias repaired through a percutaneous endoscopic approach with mesh = 0BUT4JZ

Hiatal hernias repaired through a percutaneous endoscopic approach without supplement = 0BQT4ZZ

Inguinal hernia repairs have similar determinations that must be made:  Open or Percutaneous endoscopic approach; Repair or Supplement root operation.  If it is a Supplement, what type of material: autologous, non-autologous, or synthetic substitute?  A coding professional will also have to distinguish whether the procedure was done on the left side, right side, or bilaterally.

Inguinal hernia repaired via an open approach with mesh = 0YU60JZ

Inguinal hernia repaired via an open approach without supplement = 0YQ60ZZ

Parastomal hernias are a type of incisional hernia occurring at the site of an ostomy.  These can be repaired either with an open or laparoscopic approach.

Parastomal hernia repair with an open approach = 0WQF0ZZ

Internal hernias are seen in patients who have undergone bariatric surgery.  Those who have bariatric procedures performed laparoscopically have a greater incidence of internal hernias often located in Petersen’s space.  That is an area between the mesentery and the transverse colon.  The primary consideration regarding this type of hernia repair is whether it was done with an open or laparoscopic approach.  It is important to keep in mind that the hernia defect is in the mesentery so that is the correct body part that should be coded.

Internal hernia repair done laparoscopically = 0DQV4ZZ

In ICD-10-PCS, incisional, ventral, and umbilical hernia repairs are all coded to repair of the abdominal wall.  Approach and root operation determinations are critical to assigning the correct code for these repairs as with the others we have already discussed.

Repair, abdominal wall, open approach = 0WQF0ZZ

Occasionally, for patients who have already had an incisional hernia repair, a second repair becomes necessary.  A surgeon may perform an abdominal component release.  This procedure separates the layers of the abdomen (components) in order to primarily close the hernia.  This is done with what are called relaxing incisions, which effectively free the abdominal muscle making that the body part for the root operation Release.  It is not uncommon to see the use of mesh in this procedure as the now single layer abdominal area will be weakened. 

Right abdominal component separation = 0KNK0ZZ

Ventral hernia repairs may require an abdominoplasty along with plication.  If dermal and fat layers are removed, coding professionals should be sure to code the root operation Excision for the abdominal subcutaneous tissue and fascia taken out, in addition to the root operation Repair for the plication of the abdominal wall.

Questions have arisen regarding the appropriateness of assigning an additional code(s) for lysis of adhesions during hernia surgery.  The official advice provided indicates that should the lysis of adhesions go beyond what must be done to get to the operative site then the lysis can be separately coded.  Apply the root operation Release and assign the code(s) for the body part that is freed. 

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

August Adversities

by Dianna Foley, RHIA, CHPS, CCS 


Test your ICD-10-CM seventh character for injury/external cause coding skills with this short scenario.

August has brought some interesting adversities to the Klutz children.  See for yourself.

Last winter, little Dana suffered superficial frostbite to both her hands.  She is now experiencing numbness from that injury and her pediatrician is looking into Botox injections as a potential treatment.

Meanwhile, it appears that Raymond has a nonunion of his distal tibial fracture, which occurred when he fell out of a tree last fall.  He is going to have to have surgery to correct the initially closed fracture.

Janine is continuing to go to rehab for the bilateral biceps strain she developed as a result of scrubbing floors during spring cleaning.  Janine continues to suffer from the strains caused by the repetitive circular movements she used for scrubbing.

Egon has developed a keloid scar on his palm from a laceration he got last year when he accidentally cut his right palm with a bread knife.

Peter rounds out the children’s’ issues as he is going to the wound clinic this week to get a dressing change for the second degree burn he got by reaching across the steam from a boiling tea kettle to reach for the cookie jar.  That resulted in his right wrist burn.

That’s all the lingering issues for the Klutz children…at this time!

 
Click HERE for the answers.

AHIMA's Transformation: Change Isn't Linear

Hello my name is Ms. Shelia Robertson and I’m your OHIMA 1st year Delegate.  I had the extreme pleasure of attending my first Leadership Conference earlier this month and where do I begin!  The Leadership Conference was more than I ever imagined. The energy and excitement of the presenters was electrifying.
 

AHIMA’s Transformation Story: Mission, Vision & Strategy presented by Valerie Watzlaf and Wylecia Wiggs-Harris was insightful and inspiring!  Their dedication and commitment are very encouraging to me.  One of the things I took away from their session was that, “change can happen quickly however transformation isn’t linear.”
 

They discussed being a Transformational Leader and likened it to petrified wood which in time becomes rock (solid).  The message was to “be centered” and support others through the change.

 

There were so many dynamic sessions and I wanted to attend them all but that was impossible.  I had a great experience in Chicago and ate some of the best food the city had to offer.  Until next time, remember in regards to leadership, “failure is an event to learn from.”  

About the Author 

Shelia Robertson, RHIA is the currently a 1st Year Delegate on the OHIMA FY 2020-21 Board of Directors.  Shelia is a Supervisor in the Release of Information department at University Hospitals in Cleveland, Ohio.

Coding Hernia Repairs

This edition of “Spotlight on CPT” presents information on coding hernia repairs.  Correctly assigning hernia repair codes requires coders to first determine what type of hernia is being repaired.  A coder must identify if the hernia is inguinal, femoral, incisional, umbilical, ventral, hiatal, etc.  Based on the type of hernia being repaired other factors may need to be considered such as:

• Initial vs. recurrent
• Reducible vs. incarcerated/strangulated/obstructed
• Unilateral vs. bilateral
• Laparoscopic vs. open
• Age
• Mesh usage
• Sliding

To begin, let’s take a deeper look at inguinal hernias.  Determine the approach (open or laparoscopic) of the repair first.  Next, the age of the patient is an important consideration.  There are four age groups that a patient could fall into as noted here:

• Preterm infant (<37 weeks at birth up to 50 weeks postconception age)
• Full term infant (< 6 months of age) or preterm infant (> 50 weeks postconception age but younger than 6 months)
• 6 months to < 5 years
• 5 years and older   

Let’s take just a minute to look at calculating the weeks for preterm infants.  Imagine that an infant was born at 35 weeks of gestational age.  Two months later he is coming in for an inguinal hernia repair.  You would take the 35 weeks and add 8 weeks (two months) to arrive at 43 weeks of postconception age.  This means the codes for this repair will be either 49491 for a reducible hernia or 49492 for an incarcerated hernia.  Now if the same preterm infant was coming in four months after birth you would take the 35 weeks of gestational age at birth and add 16 weeks (4 months) to arrive at 51 weeks postconception age.  The correct category of codes would be 49495-49596 again based on reducibility. 

Once a coding professional knows the correct age group to focus on, a determination must be made as to whether this is the first repair of the hernia or if it is a recurrent repair.  Finally, coders need to identify from the provider documentation if the repair was performed on a reducible or incarcerated hernia.    

A final consideration regarding inguinal hernia repairs is to know if it was considered sliding or not.  A sliding hernia is one that has a retroperitoneal organ protruding into the sac.  When sliding inguinal hernias are repaired, no matter what the age, the code to be assigned is 49525.  If a sliding hernia is described as incarcerated, coders are directed to use the codes for incarcerated hernia repair.

Coders can apply the previous method for coding other hernias as well.  Determine approach, identify initial or recurrent, and consider the reducibility of the hernia in order to assign the appropriate code. Open umbilical hernias are the only other hernia type besides open inguinal where age is a factor. 

An important reminder when coding hernia repairs is that the use of mesh is considered integral to these procedures unless the hernia is incisional or ventral.  When incisional or ventral hernias are repaired with an open method using mesh, assign two codes; one for the hernia repair itself and a second (49568) which is an add-on code for the insertion of the mesh.  However, coding professionals should recognize that if an incisional hernia is repaired laparoscopically, the use of mesh is included in the code (49654 or 49655) and the add-on code should not be reported. 

Now, light has been shed on coding hernia repairs.
 

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.