What do you need to know about the case to start the coding process?
Complete a Power Point to address the following questions and 2 case studies.
Title Slide (1 slide)
Explain the steps involved in CPT coding (2-4 slides)
What are modifiers and when are they used, provide example (2 slides)
What are add-ons and when are they used, provide example (2 slides)
Explain each type of patient (3-5 slides)
For each case study, complete the 3 steps of CPT coding providing rational for your choice of answer and provide the correct CPT code. (3-4 slides per case study, do not include case study in PowerPoint).
Slide 1: Summary the case: What do you need to know about the case to start the coding process?
Slide 2: State the procedure to be completed and where the procedure is taking place (hospital or surgery center). What is the CPT code at this point?
Slide 3: Is there is a need for a modifier or add on for the case? If so explain why and state the updated code
The following websites provide free code look up: https://www.aapc.com/code/, https://www.findacode.com/search/search.php, https://www.supercoder.com/
These websites do offer a free trial and somethings you can find codes without signing up.
Case study one:
Preoperative diagnosis: Morbid obesity
Procedure: Cancellation of gastric bypass, secondary to skin infection
Complications: As above
Indications: A 30-year-old female with a long history of morbid obesity, recently underwent silastic gastric banding, and due to reflux disease, subsequently required a procedure to loosen the band. Most recently she has experienced significant reflux disease, and presents for removal of her band and open Roux-en -Y gastric bypass.
Description of procedure: The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was administered. The patient’s gown was removed for prepping, at which point clinicians noticed there were small, acne like lesions over the anterior surface of her abdomen, her intriginous areas, and on her legs. Several of
the lesions fell on the incision line.
Additionally, there was a large midline abdominal wall defect, which was assumed to represent an abdominal wall hernia, and most likely will require a mesh repair. For these two reasons the case was canceled after general anesthesia was administered. The patient was awakened from anesthesia and taken to the recovery room.
There were no immediate complications evident, with the exception of cancellation of the case after general anesthesia.
Case study two:
Clinical diagnosis: Obstructive sleep apnea
Operation: Aborted uvulopalatopharyncoplasty
Postoperative diagnosis: Same
Description of procedure: After obtaining informed consent, the patient was taken to the operating room and placed in a supine position. The patient was properly identified, and the anesthesia service performed bilateral superior laryngeal nerve blocks and applied topical anesthesia to the oropharynx. Attempts were made to orally intubate the patient, using a fiberoptic scope.
The patient exhibited significant coughing and gagging with the procedure. It was extremely difficult to visualize the larynx. After multiple unsuccessful attempts, the procedure was aborted. We decided to take the patient to the recovery room and discuss further treatments of his obstructive sleep apnea, including tracheostomy. The patient was taken to the recovery room in stable condition. There were no complications associated with the procedure.
Summary of findings: Aborted uvulopalatopharyncoplasty, secondary to difficulty with fiberoptic oral intubation
16 – 22 slides
Use the tips at http://www.garrreynolds.com/preso-tips/design/ to create the slideshow. Because good PowerPoints have very few words, submit a script that describes the content of each slide – about 50 words per slide (placed in the Notes Pages).
Title and reference slides are required