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Wiki New To Surgery Coding

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jifnif

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I have never coded surgery before and my job gave me op reports to audit so i can learn but i think the reports might be missing codes. Do i code for anesthesia, drains and specimens separately? Forgive my ignorance but I do not know ANY surgical coding. Also, when there is a bilateral procedure (say a femoral endarterectomy) is it a 50 mod or LT and RT mods? Thanks very very much!
 
Who are you coding for?

The answer to you question partly depends upon for whom you code.

If you are coding strictly for the surgeon ... then NO, you don't include anesthesia or specimen pathology (drain placement is usually an integral part of the surgery so is not separately reportable ... just as suturing the surgical wound is not usually separatley reportable)

Hope that helps

F Tessa Bartels, CPC, CEMC
 
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