Coding surgeries

Sandy Stevens

Santa Fe, TN
Best answers
Ok. Just some background. I have been a documentation specialist (title) of E/M Services for 13 of my 27 year career on the non-clinical side of the healthcare industry. I am a CPC and CPMA. I don't know how I accomplished that, perhaps, barely. I managed to maintain a 4.0 in a year-long medical coding program in a community college, which included CPT (not coding op notes, only how to look up a CPT), A&P, pharmacology and medical terminology. However, I honestly don't know how to use the rest of the CPT book. Of course, I can read the chapter specific guidelines, but I don't know how to abstract information from an operative note. I'm not looking, necessarily, for a particular specialty, though that would be nice. I'm talking about learning how to read an op note and coding it. I have been a contracted coder of HCCs and DRGs, since my E/M gig at the beginning of 2013 - and really I just learned that through a little research.

Can anyone suggest how I can accomplish this; how to abstract info to code operations? Are there courses I can take short of another certification? Any advice would be greatly appreciated.



Clarence, NY
Best answers
I am a Surgical coder and I think the Coder's Desk Reference is a great help. It gives a brief description of every CPT code. My second suggestion is that highlighters are your friend! :D

An op note gives you a lot of hints on where to start looking and what to look for. It tells you what the planned procedure is, so there is your starting point. (Just so you know, the procedure performed may not end up being what was planned but it is a good jumping off point)

Next, I look for the incision. If it's laparoscopic they will make incisions for the ports and if it's open they will just say they "began by making an incision...". So now you know whether to look for an open or laparoscopic code.

After the incision, they usually describe the organs they encounter and lysing of adhesions. These are almost always not separately payable since they are preparing their surgical field, so I do not highlight this part. When they get to the organ involved in the surgery I will highlight until they mention closure.

Now I take the approach and the surgery info and I use that to select a CPT code.

Here's an example of a laparoscopic cholecystectomy:

Description: Laparoscopic cholecystectomy. <-- you should be looking in the Biliary Tract section of the CPT book

PROCEDURE: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced. The patient was then prepped and draped in the usual sterile fashion. An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline. The fascia was elevated between two Ochsner clamps and then incised. A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges. The 11-mm port without the trocar engaged was then placed into the abdomen. A pneumoperitoneum was established. After an adequate pneumoperitoneum had been established, the laparoscope was inserted. Three additional ports were placed all under direct vision. An 11-mm port was placed in the epigastric area. Two 5-mm ports were placed in the right upper quadrant. <--- here is the description of the approach

The patient was placed in reverse Trendelenburg position and slightly rotated to the left. The fundus of the gallbladder was retracted superiorly and laterally. The infundibulum was retracted inferiorly and laterally. Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder. The triangle of Calot was carefully opened up. The cystic duct was identified heading up into the base of the gallbladder. The cystic artery was also identified within the triangle of Calot. After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder. The cystic artery was clipped twice proximally and once distally. Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided. Two clips were then placed distal to the ductotomy on the cystic duct. The cystic duct was then divided using scissors. The gallbladder was then removed up away from the liver bed using electrocautery. The gallbladder was easily removed through the epigastric port site. The liver bed was then irrigated and suctioned. All dissection areas were inspected. They were hemostatic. There was not any bile leakage. All clips were in place. The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry. All ports were then removed under direct vision.The abdominal cavity was allowed to deflate. The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl. The fascia at the umbilical port was closed by tying the previously placed stitch. All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites. <--- Here's the bulk of the surgical procedure

The patient tolerated the procedure well. The patient is currently being aroused from general endotracheal anesthesia. I was present during the entire case.

So we have a laparoscopic gallbladder removal which would be CPT 47562. This is a very basic example but I hope it helps!