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A: The 1993 Coding Clinic stated that "although it can be argued that sick sinus syndrome (SSS) is an ongoing condition controlled by a pacemaker, no code assignment is required if no attention or treatment is provided to the condition or device".  I would apply the same logic for 426.0, complete heart block. You may want to query the physician for underlying cause of dyspnea and chest tightness.

June Wang, MS, RHIT, CCS, CCS-P

Q: Would this procedure be coded CPT 58550 for the laparoscopic assisted vaginal hysterectomy, CPT 58267 for the retropubic suspension of the uretha and CPT 57260 for the posterior colporrhapy?

PROCEDURE: Laparoscopic assisted transvaginal hysterectomy, retropubic urethral suspension, posterior colporrhaphy. A crescent shaped supraumbilical incision was then made after infiltration of skin with 0.25% Marcaine solution with epinephrine. A Veress needle inserted into abdominal cavity followed by approximately 3 L of carbon dioxide gas. After insufflating the abdominal cavity a 5 mm trocar was then placed within the abdominal cavity. Followed by the laparoscope under direct visualization, the additional two 5 mm trocar were placed five fingerbreadths below the umbilicus and five fingerbreadths laterally both avoiding the inferior epigastric artery and vein. Examination of the upper abdomen revealed a normal appearing liver. Examination of the pelvic organs revealed a globular shaped enlarged uterus possibly consistent with adenomyosis and or fibroids. The ovaries appeared to be normal bilaterally. There was no evidence of endometriosis in the anterior, bladder flap and posterior cul-de-sac area as the patient has had a previous history of endometriosis. With the aid of an EnSeal cauterization and resection was then performed through the subdural ligament of the ovary on the left side. Dissection was continued through the broad ligament, round ligament, portion of the fallopian tube down through including the uterine artery and vein. This was again accomplished on the right side. Bladder flap was also created with the EnSeal cautery. The abdomen was irrigated and suctioned cleared and then the remainder of the dissection was continued vaginally. Both the anterior and posterior ellipse of the exocervix was then grasped with single-toothed tenaculum. Traction applied using a Bovie cautery, the cervix was circumscribed using sharp and blunt dissection. Both the anterior and posterior peritoneum were identified and entered. Using Heaney clamps the cardinal ligaments were then grasped bilaterally, cut with the curved Mayo scissor and transfixed with 1 Vicryl suture. Dissection was continued in the cephalad direction on each side. All the pedicles were clamped with a straight valentine clamp, cut with curved Mayo scissor and transfixed with 1 Vicryl suture._____dissection________ above the enlarged uterus was then removed. The vaginal cuff was then closed using 0 Vicryl sutures, tying each end of the incision in the midline incorporating the cardinal ligaments for support. Gentle traction of the Foley catheter was performed which showed mobility of the urethral angle and so a small incision in the vaginal mucosa was then performed measuring approximately 4 to 5 cm. Dissection was continued along each side of the urethra so the symphysis pubis could be identified bilaterally undermining the mucosa from the pubovesicocervical fascia. Using a 2-0 Prolene suture, a buttress type stitch was then performed elevating the urethral angle giving an additional support. Redundant vaginal tissue was excised and the vaginal mucosa closed with 2-0 chromic suture in a continuous type manner. Posterior repair was then performed again with the use of Allis clamps the vaginal mucosa was excised in a T-shaped area. Dissection under the vaginal mucosa was performed down to identifying the rectocele using 0 Vicryl suture. A pursestring type stitch was then placed in the rectal defect area giving additional support. The levator ani muscles were then pulled towards the midline. Redundant vaginal tissue was excised and the vaginal closure was performed in a similar manner to that of an episiotomy using 2-0 Vicryl suture.

A: I would use codes 58550 and 57250. Code 58550 would be the correct code for the hysterectomy. CPT code 57260 that you question would not be appropriate here as this code is for Anteroposterior colporrhapy and the documentation states this was a posterior procedure, so code 57250 is the most appropriate. Code 58267 for the retropubic suspension of the urtetha would not be appropriate here either because it is a duplicate of the first procedure. It has a different approach, which is not the procedure performed. 

 Dawson Ballard, Jr., CCS-P, CPC-Coding Educator

Q: Is it appropriate to bill the I&D CPT 10060 when the provider did not actually make an "incision" as the wound was already open? See documentation below:

Knee examination does reveal a moderate amount of swelling in the prepatellar area and does not appear to have any intraarticular effusion. He does have a small open lesion in the front of the knee just below the tibial plateau just to the right of the midline. There is a significant amount of serosanguineous drainage expressed from this. Using forceps a mucus plug is removed and then there is a mild amount of purulent/serous fluid which is obtained from it then. Culture swab is obtained; Another example: Patient has a small fluctuating erythemous area on left hip that is de-roofed with 16 g needle of significant amount of mucopurulent discharge.

A: No, it would not be correct to use code 10060 if an incision was not part of the procedure that was performed. Here is some information from CPT Assistant to assist with this discussion.

CPT ^®Assistant, February 2008, Volume 18, Issue 2, page 8 

Surgery: Integumentary System

Question:

What is the difference between an incision and drainage procedure and an aspiration procedure?

Answer:

From a CPT coding perspective, an incision must be performed in order for an incision and drainage procedure to be reported; an aspiration procedure does not involve an incision. For example, an abscess formation may be drained by making an incision through the skin or mucosa in close proximity and into the abscess formation. The contents of the abscess are then removed (i.e., drained) through the incision. For an aspiration procedure, the contents of the area to be aspirated are generally approached by inserting a needle and the contents are drawn into a syringe.

So, for your second example I would use the aspiration code 10021. For the first example I would use the unlisted code 17999.

Lisa L. Withers, RHIT, CCS

Q: What code would you assign for "post op pain" (not stated as acute)? And what code for "non-weight bearing in the L. upper limb" (S/P fracture)?

A: The code you would use for post-op pain is 338.18. The ICD-9-CM Official guidelines say "Post-thoracotomy pain and other postoperative pain are classified to subcategories 338.1 and 338.2, depending on whether the pain is acute or chronic. The default for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the acute form. Routine or expected postoperative pain immediately after surgery should not be coded."

There is no ICD-9 code for "non weight bearing in the L. upper limb." 

Amy Hodges, CPC, CPC-I

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