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CHAPTER 6. RESPIRATORY SYSTEM. Respiratory System. Anatomic site arrangement Nose Larynx Further subdivided by procedure Incision Excision Introduction Removal of foreign body Destruction Endoscopy Other procedures. Endoscopy. Endoscopy in all subheadings except Nose

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chapter 6

CHAPTER 6

RESPIRATORY SYSTEM

respiratory system
Respiratory System
  • Anatomic site arrangement
    • Nose
    • Larynx
  • Further subdivided by procedure
    • Incision
    • Excision
    • Introduction
    • Removal of foreign body
    • Destruction
    • Endoscopy
    • Other procedures
endoscopy
Endoscopy
  • Endoscopy in all subheadings except Nose
  • Each preceded by “Notes”
endoscopy rule one
Endoscopy Rule One
  • Code full extent
    • Example: Procedure begins at mouth and ends at bronchial tube
    • Bronchial tube = full extent
endoscopy rule two
Endoscopy Rule Two
  • Code correct approach
  • Example, for removal:
    • Interior lung lesion via endoscopy inserted through mouth
    • Exterior lung lesion via endoscopy inserted through skin
  • Incorrect approach = incorrect code = incorrect reimbursement
endoscopy rule three
Endoscopy Rule Three
  • Surgical always includes diagnostic
    • Example:
      • Diagnostic bronchial endoscopy begins
      • Identifies foreign body
      • Removed (surgical endoscopy)
multiple procedures
Multiple Procedures
  • Frequent in respiratory coding
    • Watch for bundled services
    • Medicare—reference the CCI edits
  • Sequence primary procedure first, no modifier
  • Sequence secondary procedures next, with -51
bilateral procedures
Bilateral Procedures

(…Cont’d)

  • Bilateral procedures often performed
  • Format for reporting chosen by payer
    • Example: Nasal lavage
      • 31000 x 2
      • 31000 and 31000-50
      • 31000-50
      • 31000-RT and 31000-LT
  • Medicare requires one line item with modifier -50
laryngoscopic procedures
Laryngoscopic Procedures
  • Uses terms indirect and direct
  • Indirect: Tongue depressor with mirror used to view larynx
  • Direct: Endoscopy passed into larynx; physician directly views vocal cords
nose 30000 30999
Nose (30000-30999)
  • Used extensively by otorhinolaryngologists (ear, nose, and throat specialists ENT)
  • But also used by a wide variety of physicians

(Cont’d…)

nose 30000 309991
Nose (30000-30999)

(…Cont’d)

  • When approach to nose:
  • External approach, use IntegumentarySystemcodes
  • Internal approaches use Respiratory Systemcodes
nose incision 30000 30020
Nose, Incision (30000, 30020)
  • Bundled into Incision codes, drain or gauze insertion and removal
  • Supplies reported separately
nose excision 30100 30160
Nose, Excision (30100-30160)
  • Contains intranasal biopsy codes
  • Polyp excision, by complexity
  • “Simple” involves polyps that are easy to remove
  • “Extensive” involves sessile polyps (thick base)
    • More time consuming and requires a greater skill level (30115)
  • Excision includes any method of destruction, even laser
  • Use -50 (bilateral) for both sides
  • Reduction of turbinates, 30140-52

From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

nose introduction 30200 30220
Nose, Introduction (30200-30220)
  • Common procedures
  • Example: Injections to shrink nasal turbinate tissue
  • Displacement therapy (saline flush) performed through nose to remove mucus
  • Insertion of nasal button
nose removal of foreign body 30300 30320
Nose, Removal of Foreign Body (30300-30320)
  • Divided by whether removal at office or hospital (requires general anesthesia)
nose repair 30400 30630
Nose, Repair (30400-30630)
  • Many plastic surgery procedures, such as:
    • Rhinoplasty (reshaping nose, internal and/orexternal)
    • Stated as “revision” or “primary”
    • Rhinoplasty for nasal deformity secondary to congenital cleft lip/palate
    • Septoplasty (rearrangement of nasal septum)
      • Not included in a rhinoplasty
nose destruction 30801 30802
Nose, Destruction (30801, 30802)
  • Use of cauterization or ablation(removing by cutting)
  • Used for removal of excess nasal mucosa or to reduce turbinate inflammation
nasal hemorrhage 30901 30906
Nasal Hemorrhage (30901-30906)
  • 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 procedure?
nasal turbinates
Nasal Turbinates

Figure: 6.4

  • Nasal turbinates
  • Excision of turbinates is considered unilateral
  • If performed bilaterally, use modifier -50
nasal reconstruction
Nasal Reconstruction
  • Codes for obtaining grafts for nasal reconstruction surgery are in Musculoskeletal subsection
  • Codes for other procedures on the nose are in Integumentary subsection
nose destruction 30801 308021
Nose, Destruction (30801, 30802)
  • Based on intramural or superficial extent of destruction
  • Intramural: Deeper mucosa
  • Superficial: Outer layer of mucosa
nose other procedures 30901 30999
Nose, Other Procedures (30901-30999)
  • Control of nasal hemorrhage
    • Packing
    • Ligation
    • Cauterization
  • Anterior packing placed through nose
  • Posterior packing placed at very back of throat
  • Code 92511 (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same session

(Cont’d…)

nose other procedures
Nose, Other Procedures

(…Cont’d)

  • Anterior packing
  • When surgery is performed solely to improve the patient’s appearance (no signs/symptoms), it is cosmetic
  • Non-covered under the Medicare program (diagnosis code V50.1)

Figure: 6.5

(Cont’d…)

nose other procedures1
Nose, Other Procedures

(…Cont’d)

  • A balloon may be inserted to further control bleeding
  • Posterior hemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packing
  • Simple packing with gauze or anterior packing suggests a simple procedure

Figure: 6.6

accessory sinuses incision excision endoscopy 31000 31294
Accessory Sinuses, Incision, Excision, Endoscopy (31000-31294)
  • Codes for lavage(washing) of sinuses
    • Cannula (hollow tube) placed into sinus, saline solution flushed through
  • Use -50 (bilateral) for both sides
  • Sinusectomy: All sinus contents including mucous membranes are removed
  • Antrostomy: Making an opening into the sinus
  • An “antrotomy” means cutting into the sinus
larynx excision 31300 31420
Larynx, Excision (31300-31420)
  • Laryngotomy: open surgical procedure to expose larynx
    • For removal procedure (e.g., tumor)
  • Sometimes confused with Trachea/Bronchi codes for tracheostomy
    • Used to establish airflow
larynx introduction 31500 31502
Larynx, Introduction (31500, 31502)
  • Endotracheal intubation is establishment of airway
  • Numerous CCI edits

Figure: 6.8

larynx repair 31580 31590
Larynx, Repair (31580-31590)
  • Several plastic procedures and fracture repairs
  • Laryngoplasty procedures based on purpose
trachea and bronchi incision 31600 31614
Trachea and Bronchi, Incision (31600-31614)
  • Most codes: Tracheostomy
    • Planned (ventilation support)
    • Emergency
  • Divided by type:
    • Transtracheal or cricothyroid

(Cont’d…)

trachea and bronchi incision

Figure: 6.9

Figure: 6.10

Trachea and Bronchi, Incision

(…Cont’d)

  • Transtracheal approach and entry
trachea and bronchi incision1

Figure: 6.11

Figure: 6.12

Trachea and Bronchi, Incision

(…Cont’d)

  • Cricothyroid approach and entry
endoscopy 31615 31656
Endoscopy (31615-31656)
  • Bronchoscope inserted into nose or mouth
  • Rigid endoscopy performed under general anesthesia
  • Flexible endoscopy performed under local or conscious sedation
trachea and bronchi introduction 31715 31730
Trachea and Bronchi, Introduction (31715-31730)
  • Catheterization
  • Instillation
  • Injection
  • Aspiration
  • Trachea tube placement
  • Some include inhaled gas as contrast material
intubation
Intubation
  • Endotracheal intubation involves a tube placed through the nose or mouth, through the pharynx and larynx, and into the trachea to establish an airway
laryngoscopy
Laryngoscopy
  • Visual examination of the larynx
  • Flexible lighted tube passed through mouth or nose into larynx
trachea and bronchi excision repair 31750 31830
Trachea and Bronchi, Excision, Repair (31750-31830)
  • Plastic repairs of tracheoplasty and bronchoplasty
lungs and pleura removal 32421 32422
Lungs and Pleura, Removal (32421, 32422)

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…)

Figure: 6.14

mediastinoscopy
Mediastinoscopy
  • Visual examination of mediastinum
  • Procedure usually done in operating room with local or general anesthesia
  • Suprasternal (above the breastbone) incision is made
  • Procedure to remove biopsy samples of lymph nodes, tumors, or tuberculosis
lungs and pleura removal 32421 324221
Lungs and Pleura, Removal (32421, 32422)
  • (Cont’d…)
  • Chest tube may be inserted to drain fluid and is reported in addition to aspiration
  • (Cont’d…)

Figure: 6.15

lungs and pleura incision 32035 32225
Lungs and Pleura, Incision (32035-32225)

(…Cont’d)

  • Thoracotomy: Surgical opening of chest to expose to view
    • Used for
      • Biopsy
      • Cyst
      • Foreign body removal
      • Cardiac massage
lungs and pleura excision 32310 32405
Lungs and Pleura, Excision (32310-32405)
  • Biopsy codes in Excision and Incision categories
    • Excisional biopsy done with percutaneousneedle
    • Incisional biopsy done with chest open
lungs and pleura excision incision
Lungs and Pleura, Excision/Incision
  • Biopsy codes in Excision and Incision categories
    • Excisional biopsy with percutaneous needle
    • Incisional biopsy with chest open
  • Includes pneumocentesis and lung removal
    • Segmentectomy:1 segment
    • Lobectomy: 1 lobe
    • Bilobectomy: 2 lobes
    • Total pneumonectomy:1 lung
introduction 32550 32551
Introduction (32550, 32551)
  • Includes:
    • Insertion of tunneled indwelling pleural catheter
    • Tube thoracostomy
  • Destruction (32560)
    • Chemical pleurodesis
      • For recurrent persistent pneumothorax
thoracoscopy 32601 32665
Thoracoscopy (32601-32665)
  • Diagnostic and surgical lung procedures
  • Surgical thoracoscopy always includes diagnostic thoracoscopy
conclusion chapter 6

ConclusionCHAPTER 6

RESPIRATORY SYSTEM