Hi. Today we're going to start the
chapter for the Digestive System. It's
very long, so there are two parts. What
I'm going to do differently in this
lecture is talk more about the anatomy
and some of the procedures and spend
less time in the actual code book. I
believe by now you should have learned
how to navigate the code book. You
realize that you just have to read the
code descriptions and don't stop reading
too soon. Be sure you've read far enough
that you know you're choosing the
correct code. Before I get started I
wanted to show you something in my code
book because I think sometimes students
are a little afraid to write in their
code books. I received some feedback
from a student recently and she told me
how helpful it was for her to see my
code book, with the notes and tabs and
the different things I had in there. So
what I decided to do is show you a
couple of pages from this section, the
Digestive System and how I've notated
some things and made sure that I could
see certain things. For example, these two
codes, the big difference is this is
the small intestine, this is a large
intestine but if you read it really
quickly, you might miss that. The other
thing I'm doing differently is I have
the body, the part of the body
system that we're talking about in this
case, the Intestines is in this column
and then this column, we have Meckel's
diverticulum and down at the bottom the
Appendix. Then the Appendix goes over,
continues into the next page for a
little bit and then the Colon and Rectum
starts. So this column would be the Colon and
Rectum but you see where I have
continued with my thought of circling a
family of codes and then highlighting
whatever is different between those two
codes. I make a point of, here's a single,
here's a multiple. That's a very easy
mistake to make so I'll usually write
somewhere beside the multiple or the
single, just to bring my eye to that
pretty quickly. This one the difference is
without a colostomy and with the
colostomy.
I wrote "with a colostomy". These two codes
are "back bench" which is cadaver
work, things that happen on the back
side. So I have this in here. That's the
main thing. I just wanted you to to see
how I write in my code book like here I
have single tumor or polyp, single tumor or polyp,
multiple polyps and the
techniques, you have to read the
description to get your techniques but
in finding your technique you might like
see hot biopsy forceps and just jump on
that code when in effect two polyps were
removed. So then you need to be selecting
this code with the multiple polyps with
a hot biopsy forceps. So just don't
be afraid to write in your book. I also
make a distinction. These codes are
"proctosigmoidoscopy", then over here when
I get to this column I'm starting this
"sigmoidoscopy" and I highlighted the
definition. That's all, I just wanted to
show you a little bit more about,
not to be afraid to write in that book.
Okay let's get started. Some facts to
remember. If you recall from some of our
previous podcasts, we use the FTR
acronym for "Facts to Remember". The parts
of the body that are covered under the
Digestive System are listed here and
they also would be those parts of the
body that are in a red font within the
Digestive System section (of the code book). You also would
see them on the Table of Contents. So
different ways just to remind yourself
what's in this section. What I think is
particularly interesting, you'll see
a question a little bit later. When we
get to the Abdomen, laparoscopic
aspiration of an ovarian cyst. Instead of
thinking of that as being in the Female Genital System, it falls in
the CPT book under the Abdomen (in the Digestive System chapter).
Another way to maybe even make a little
note, I think I will. I am thinking in my
Table of Contents for this section, I
will write "ovarian cysts" beside
Abdomen. Just to help us remember. Let
me show you that and you can see right
here where I've written "ovarian cyst"
here beside the Abdomen, Peritoneum and
Omentum. Okay, an endoscopy should always
be coded as far as the scope was passed
and that means when you are reading your
operative report, it's going to tell you,
the surgeon is going to dictate how far
he or she advanced the scope into the
Digestive System. There are upper and
lower endoscopies. You'll see those in
your code book. They're also
differentiated between whether or not
they were rigid or flexible and that's
referring to the scope itself and the
approach. How did the physician get the
scope into the body? An EGD is the short
abbreviation for
esophagogastroduodenoscopy. That is an
upper GI and it involves the examination
of the esophagus, the stomach and the
upper duodenum or the jejunum. EGDs
are completed, I've given some
reasons here why a physician might
perform that procedure. I also want
to bring to your attention there is no
alphabetical entry for EGD. If you go to the
index, you're not going to find EGD.
You have to know what EGD stands for,
esophagogastroduodenoscopy. I can't say
it quickly but I do know what it means.
If you think about what's happening
here, the scope is being advanced down
the esophagus through the stomach and to
the duodenum and it's a scope so
esophagogastroduodenoscopy.
I've given you here a few guidelines
around that.
It is appropriate to list multiple
codes if your surgical report supports
that. Also remember that if a
physician is doing multiple procedures
at the same time at the same session,
it's appropriate to link a modifier -51.
While I'm thinking of that, let me show
you something else in the code book that
came to my attention recently and that
is students are getting a little bit
confused about the difference between
these modifiers and these modifiers.
These modifiers (left side) are for physician services.
These (right side)are for facility services and it says
"Hospital Outpatient Use" but we need to
remember this one (on the left). In fact, why don't we
write "MD" for physician to help us
remember that. Ok, esophageal
dilation- there's two methods for
dilation. An endoscopic where the
physician is inserting a balloon or a
plastic dilator over a guide wire to
stretch the esophagus. That's one code or
a Manipulation that isn't using a scope
and the surgeon is just passing a tapered
dilating instrument through the mouth
into the esophagus to dilate the
esophagus. Bougies are types of
instruments that you might use and
here's two pictures that you can see. I
found these. You know how I'm a big fan
of Google Images. I found these two on
Google images that shows you the Maloney
and the Hurst. They are common as
far as bougies that are used in
esophageal dilation. ERCP or an endoscopic
retrograde cholangiopancreatography. What
I've done here is to just talk about the
parts of the body that this is affecting,
what they do and why we're doing this
procedure. The liver makes the bile. The
gallbladder stores the bile until it's
needed. The bile ducts carry the bile
from the liver to the gallbladder and
the small intestine.
Then there's a pancreas that is
producing chemicals that help with
digestion and it also produces insulin.
So this is the parts of the Digestive
System that we are studying right now.
Here is an anatomy lesson that you can
see the stomach, the gallbladder, how it
hooks into the stomach there. What
you're seeing coming down, that dark,
that's the actual scope showing you how
it might come down to do this procedure.
You see the pancreatic duct there.
The jejunum is the beginning of the
small intestine along with the duodenum.
The duodenum comes first, then the jejunum.
You've got the liver in the background,
back behind the gallbladder. It's a good
little diagram. I looked at some
actual photographs on Google images but
honestly, when I'm looking inside a body,
I can't easily tell what I'm looking at.
So I'm just going to, let's just say I'm
not a surgeon, so I'm just going to use a
diagram like this because to me
this makes more sense. Here is another
diagram that talks about ERCP. It's
combining the use of x-rays and a scope
so the physician can then see the inside
of the stomach and the small intestine,
inject dyes into those ducts that we
were just looking at so those ducts can
be seen on x-ray. So let's do a problem.
It's Exercise 4.24 #4. This is
from your textbook. Okay so let's do
Exercise 4.24 #4 for ERCP with
removal of bile duct stones. You can try
to do that one now. I will give you the answer
on the next slide. There you go. Your
main term is endoscopy, because that's
the first the word in ERCP. The "E" is
endoscopy or endoscopic. You are
scoping the bile duct for the purpose of
removing a stone. A stone is also known as
a calculus (plural form is calculi). Two codes are given in the
index and when I read the code
descriptions. 43264 was correct.
Alright, let's talk for a bit about lower
GIs. Now we're talking about procedures
it says performed through a natural orifice.
This is going to be the rectum or the anus and the reason why it
makes that distinction is because there
are codes for performing these
procedures through a stoma. A stoma would
be an artificial opening the surgeon
has created. So here I've got how that
exam follows and this is words taken
from the codebook. Here's an anatomy
lesson where you can see the different
parts of the colon, where they lie in
relation to the stomach, the liver and
then you see the colonoscope
would be coming in from the anus coming
in, up through the sigmoid and it would just
keep going. Here is another diagram.
It just shows the colon, where the scope
would come up through the rectum, through
the sigmoid, up through the descending to
a splenic flexure, transverse colon,
hepatic flexure, ascending colon so a
colonoscopy goes a lot further than a
sigmoidoscopy or a proctosigmoidoscopy.
Sigmoidoscopy indications for a lower GI:
got a couple of things there This is
just another diagram that I pulled
showing the colonoscope which is the
dark piece going up through the bowel. The
nice thing about this particular diagram
it shows what the surgeon might find
during a colonoscopy. He might see
diverticulitis, she might see cancer or
polyp, a flat polyp or lesion, adhesions
which would be there from previous
surgeries and just how the body healed.
Also ulcerative colitis which is a very
painful condition and
appendicitis you might see because of
the little appendix that's there at the
end of where the scope is going. It is
not unusual to have polyps on a normal
scope so the surgeons just watch them. I don't
know anyone who hasn't had something on
their colonoscopy report so it's just
something that the doctor watches
when he's in there. It also has in
the middle here of our diagram Crohn's
disease, which is another disease. He
would see the inflammation in the
ulceration of the walls of the intestine.
This diagram shows us the difference
between a colonoscopy and a
sigmoidoscopy where the blue is a
colonoscopy. You see it goes much further
than the green which is the
sigmoidoscopy. Here on the very end
going into the body is the endoscope.
Questions a coder
might ask before assigning a code for an
endoscopy: Was the diagnostic endoscopy
performed as part of the
surgical (endoscopy) and if so, only surgical (endoscopy) is
coded. What was its purpose and what
approach was used? Your codes
around that are going to be
differentiated by your answers to these
questions. Removing tumors or polyps-
there are several ways and the four that
our codes talk about are hot biopsy
forceps, bipolar cautery (cauterizing)
the snare and a laser. When a laser is
used, the coder is going to code Ablation,
not amenable to removal by the other
three things. If a colonoscopy is
incomplete and that might happen if the
doctor gets in there with the scope and
it's got too much stool still in it, it
wasn't a good preparation or there's a
disease that's obstructing the
advancement of the scope or the patient
just can't tolerate it something's going
on that he or she can't tolerate
the procedure, then you're going to be
looking at some modifiers.
I made a distinction here so you
could see what might happen, the
difference between a "reduced" service
meaning the scope started in but it
could not go as far as it should have
gone for a colonoscopy. That would be a
reduced service. A "discontinued" procedure
might be when the physician is doing the
procedure but the patient's just not
tolerating it and it just needs to stop.
That would be (modifier) -53 and then the facility,
in order to explain to the insurance
company the charges, is going to show a
modifier -73 if it's discontinued prior
to anesthesia and a modifier -74 if it's
discontinued after anesthesia. So be
really careful when you look at those
two groups of modifiers on the inside
front cover of your codebook to be sure
you're choosing the correct one. I have
some information here about screening
colonoscopies. If you are working in a
doctor's office or an ambulatory surgery
center and you're working a lot with
Medicare patients, you will know how to
build these as well as having software
in your practice that's going to take
away the 45378 CPT code and then give
it a G code but you still need to know
that that's going to happen so that you
can get paid for that if it's a Medicare
patient. Then I have some information
about Coding Guidelines for biopsies and
lesion removals. This is telling us
when a biopsy is taken and the remaining
portion of the same lesion is excised, in
other words, you take the biopsy of this
lesion and then (the surgeon) goes back in, in the
same session and says, you know what, I'm
just going to take that whole lesion off. You(the coder) is going to assign the code for the
excision only; you're not going to assign
the biopsy. This language, you would
get that from reading the operative
report and the pathology report that the
doctor and the hospital is going to give
you or the facility is going to give you.
Likewise, if one lesion is biopsied and a
different lesion is excised, you're going
to assign both the biopsy and the code for
the excision. Now this is applicable
unless the CPT code description includes
the phrase "with or without biopsy." You
really have to read your code
descriptions to be sure you're choosing
the right one. If it says that ,if it says
"with or without biopsy" you're only going
to code the excision. It would be
appropriate to append the biopsy code
with a modifier -59 to show that you've
got two different procedures in the same
operative session where you've got one
lesion biopsied and a different lesion
excised. That's a modifier -59. The coder
is going to get this information from
the operative report and the pathology
report. Also you'll notice when you're
reading your CPT codes it will say "with
biopsy, single or multiple" when you have
that code description you're only going
to use that code once regardless of how
many biopsies are taken. Your
code description says "single or multiple".
An example I've chosen there is 45331
for a sigmoidoscopy with biopsy,
single or multiple. No matter how many
biopsies are taken, you would use that
code once. So now let's look at an
example. This is from your
textbook, Exercise 4.25 is Operative
Report #2: A colonoscopy with a
biopsy of polyps removed with hot biopsy
forceps. Here's your answer. It would
be colonoscopy, flexible, removal, polyp.
Another example 4.24 #2 a
proctosigmoidoscopy with removal of polyps.
You notice there's two polyps here and when
you look at these codes, you really have
to watch because one says "single polyp"
and another says "multiple polyps" and
because there were two polyps from your
operative report, you would use the
code for "multiple polyps" and it's 45315.
That's the end of
Chapter 4 Part 1. I'll be recording the
next one very soon. Thank you.