Transcript 2006 Panel on Coding Diagnostic Coding and Documentation David R. Vandersteen, MD Children’s Hospitals of Minnesota Mayo Graduate School of Medicine.

2006 Panel on Coding
Diagnostic Coding and Documentation
David R. Vandersteen, MD
Children’s Hospitals of Minnesota
Mayo Graduate School of Medicine
Coding and Documentation Tips
“Code Pairing”
– List appropriate diagnoses to match the
procedures performed
Example: If doing a circumcision, use the
redundant prepuce ICD-9 diagnostic code.
If Code Pairing not possible
– Document what you do
– Document why you did it!
– Be specific!
General coding tips
Describe details of the procedure to justify the
“unpaired” codes
Example:
– 14040 Adjacent tissue transfer or rearrangement,
forehead, cheeks, chin, mouth, neck, axillae,
genitalia, hands and/or feet; defect 10 sq cm or less
– Dictate “Dorsal preputial rotational flaps were
mobilized on a vascular pedicle, rotated ventrally, and
used to resurface a 1 sq cm surface of deficient
ventral penile skin.”
Case #1:
6 month old male with distal (1 cm)
hypospadias with moderate chordee and
tethering of the scrotum to the ventral
penis.
Case #1:
Diagnoses and ICD-9 codes
– Hypospadias
752.61 Hypospadias
– Chordee
752.63 Congenital chordee
– Penoscrotal tethering
752.81 Scrotal transposition
– Preputial redundancy/asymmetry
605 Redundant prepuce and phimosis
Case #1:
Diagnosis and Procedural “Code Pairing”
– Hypospadias
752.61 Hypospadias
54324 One stage distal hypospadias repair (with or without
chordee or circumcision); with urethroplasty by local skin
flaps (eg, flip-flap, prepucial flap)
– Chordee
752.63 Congenital chordee
54300 Plastic operation of penis for straightening of chordee
(eg, hypospadias), with or without mobilization of urethra
Case #1:
Diagnosis and Procedural code “pairing”
– Penoscrotal tethering
752.81 Scrotal transposition
55175 Scrotoplasty; simple
– Excessive/asymmetric prepuce
605 Redundant prepuce and phimosis
54161 Circumcision, surgical excision other than clamp,
device or dorsal slit; except newborn
Case #2:
6 month old male with buried or concealed
penis along with penoscrotal web.
Case #2:
Diagnoses and ICD-9 codes
– Buried penis
752.65 Hidden penis
– Penoscrotal web
752.81 Scrotal transposition
752.63 Congenital chordee
– Preputial redundancy/asymmetry
605 Redundant prepuce and phimosis
Case #2:
Diagnosis and Procedural “code pairing”
– Buried penis
752.65 Hidden penis
???? CPT code
– Chordee
752.63 Congenital chordee
54300 Plastic operation of penis for straightening
of chordee (eg, hypospadias), with or without
mobilization of urethra
Case #2:
Diagnosis and Procedural code “pairing”
– Penoscrotal tethering
752.81 Scrotal transposition
55175 Scrotoplasty; simple
– Excessive/asymmetric prepuce
605 Redundant prepuce and phimosis
54161 Circumcision, surgical excision other than
clamp, device or dorsal slit; except newborn
Case #3:
6 month old male with chordee without
hypospadias.
Case #3:
Diagnoses and ICD-9 codes
– Chordee
752.63 Congenital chordee
– Preputial redundancy/asymmetry
605 Redundant prepuce and phimosis
Case #3:
Diagnosis and Procedural “code pairing”
– Chordee
752.63 Congenital chordee
54300 Plastic operation of penis for straightening
of chordee (eg, hypospadias), with or without
mobilization of urethra
– Excessive/asymmetric prepuce
605 Redundant prepuce and phimosis
54161 Circumcision, surgical excision other than
clamp, device or dorsal slit; except newborn
Case #4:
1 year old with high testis at level of
internal ring.
– Intra-op findings of large patent processus
vaginalis/ hernia
Case #4:
Diagnoses and ICD-9 codes
Undescended testis
– (752.51) Undescended testis
Case #4:
Diagnoses and ICD-9 codes
Inguinal hernia
– (550.9) Inguinal hernia, without mention of obstruction or
gangrene
550.90 unilateral or unspecified (not specified as
recurrent)
550.91 unilateral or unspecified, recurrent
Congenital hydrocele
– (778.6) Congenital hydrocele
Congenital hydrocele of tunica vaginalis
Case #5:
6 year old boy presents with a reducible
communicating hydrocele.
Case #5:
Diagnoses and ICD-9 codes
– Inguinal hernia?
(550.9) Inguinal hernia, without mention of
obstruction or gangrene
– 550.90 unilateral or unspecified (not specified as
recurrent)
Case #5:
Diagnoses and ICD-9 codes
– Hydrocele
(778.6) Congenital hydrocele
– Congenital hydrocele of tunica vaginalis
(603) Hydrocele
Includes hydrocele of spermatic cord, testis, or tunica
vaginalis
Excludes congenital hydrocele ( 778.6 )
– 603.8 Other specified types of hydrocele
– 603.9 Hydrocele, unspecified
General coding tips
Utilize auacodingtoday.com!
Free to all AUA members
Easily access and search of both CPT and ICD-9 codes
Bundling info/ cross check
Updated Edits
Access Medicare RVUs and Medicare fees for procedural
codes
Match ICD-9 codes to CPT codes
– i.e. Match diagnosis with procedure
Document!