Medical Coding CPT & ICD-10-CM Surgical Case Study - Step-by-Step Walkthrough

Contempo Coding

22 Sept 202218:47

EducationalLearning

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TLDRIn this informative video, Victoria, a medical coder and educator, demonstrates how to code a surgical case study using ICD-10-CM and CPT codes. She guides viewers through a knee procedure case, explaining the importance of post-operative diagnoses and the process of identifying and coding the correct procedures and diagnoses. Victoria emphasizes the necessity of thorough documentation review and provides practical tips for new coders, including the use of a CCI validator for code verification. The video serves as both an introduction to medical coding and a valuable resource for those considering a career in the field.

Takeaways

📚 Medical coding involves using ICD-10-CM and CPT codes to document surgical cases.
👩‍🏫 Victoria, a medical coder auditor and educator, provides guidance on coding practices.
📈 The video demonstrates coding for a knee procedure, including pre- and post-operative diagnoses.
🔍 Coding is based on post-operative diagnoses, as they may differ from pre-operative assumptions.
📋 The operative report is a crucial source for identifying procedures and diagnoses for coding.
🩺 Pathology reports can change diagnoses, affecting how codes are assigned.
🤝 Reviewing the entire operative report ensures that all procedures are accurately documented.
🔗 The video provides a link to the operative report for viewers to follow along.
📝 The process of coding involves verifying that the procedure descriptions match what was done.
🌟 Medical coding can be a rewarding career, with Victoria offering a masterclass for beginners.
📊 The video concludes with a summary of the CPT and ICD-10 codes used for the case study.

Q & A

What is the main focus of the video?
-The main focus of the video is to demonstrate how to code a surgical case study using ICD-10-CM and CPT codes, providing an understanding of how these codes work together with the report and offering practice on coding real-life scenarios.
Who is Victoria in the context of the video?
-Victoria is a medical coder auditor, educator, and content creator who provides tips, tricks, and tutorials to help individuals succeed in a medical coding career.
What is the procedure being discussed in the video?
-The procedure being discussed is a knee surgery, specifically arthroscopy of the left knee with partial medial meniscectomy, three compartment synevectomy, and chondroplasty.
Why is it important to code based on post-operative diagnoses?
-Coding based on post-operative diagnoses is important because the initial diagnosis may change based on findings during surgery or pathology results, ensuring accurate and correct coding.
What does Victoria recommend for someone interested in a medical coding career?
-Victoria recommends signing up for her medical coding Master Class, which provides a roadmap on how to become job-ready as a medical coder in as little as six months.
How does the video script handle the coding of the arthroscopy procedure?
-The video script explains that the arthroscopy procedure code will be bundled with other procedures, as per the guidelines, and therefore will not be coded separately.
What is the significance of the CCI validator mentioned in the video?
-The CCI validator is used to check for any CCI (Correct Coding Initiative) edits between two codes, ensuring that they are not incorrectly coded together and to determine the appropriate order of the codes based on RVU (Relative Value Units).
How are the ICD-10-CM codes determined for the diagnoses in the video?
-The ICD-10-CM codes are determined by looking up the specific conditions in the ICD-10 book, considering the guidelines for coding, and adding the appropriate seventh character to indicate the nature of the encounter (e.g., initial encounter or sequela).
What are the final CPT and ICD-10-CM codes provided in the video?
-The final CPT codes provided are 29876 for the three compartment synevectomy and 29881 for the partial medial meniscectomy. The ICD-10-CM codes are S83242 for the torn medial meniscus of the left knee and M94.29 for chondromalacia of multiple sites.
What is the purpose of the additional resources Victoria offers in the video description?
-The additional resources, such as the medical coding Master Class and the ICD-10 book, are offered to provide further education and tools for individuals interested in medical coding, helping them to understand the field better and advance their careers.
How does the video script emphasize the learning process of medical coding?
-The video script emphasizes the learning process by breaking down the steps of coding a surgical case study, highlighting the importance of understanding the guidelines, using correct references, and practicing coding real-life scenarios to build proficiency in medical coding.

Outlines

00:00

📚 Introduction to Medical Coding with Case Study

Victoria, a medical coder auditor and educator, introduces the video's purpose: to demonstrate coding a surgical case study using ICD-10-CM and CPT codes. She emphasizes the importance of understanding how codes work with the report and provides practice with real-life scenarios. Victoria invites new viewers to subscribe for more medical coding content and mentions a Master Class for those interested in starting a career in medical coding. The video focuses on a knee procedure case study, with a link provided in the description for viewers to access the operative report.

05:01

🔍 Detailed Examination of the Operative Report

The operative report is analyzed in detail, highlighting the process of coding based on post-operative diagnoses, which may differ from pre-operative diagnoses due to findings during surgery or pathology results. The report's description of the procedure performed, including the arthroscopy of the left knee and associated findings, is used as a guide for coding. Victoria stresses the importance of verifying the completeness and accuracy of the procedure description in the operative report and correcting any omissions through addenda if necessary.

10:03

🩺 Coding Procedures and Guidelines

Victoria explains the coding process for the surgical procedures performed, including arthroscopy, partial medial meniscectomy, synevectomy, and chondroplasty. She discusses the importance of following coding guidelines, such as the bundling of certain procedures and the use of the ICD-10 and CPT coding systems. The video demonstrates how to identify and apply the correct codes, including the use of the CCI validator to ensure proper code sequencing and to avoid CCI edits.

15:04

📈 Finalizing the Coding with Diagnosis Codes

The final part of the video focuses on assigning ICD-10 diagnosis codes based on the operative report's findings. Victoria identifies the codes for a torn medial meniscus (S83242) and chondromalacia (M94.29). She explains the significance of the seventh character in ICD-10 codes and how to determine it based on the encounter type. The video concludes with a recap of the CPT and ICD-10 codes used in the case study, encouraging viewers to sign up for the medical coding Master Class for further learning opportunities.

Mindmap

Keywords

💡Medical Coding

Medical coding is the process of converting healthcare services and diagnoses into standardized codes, which are used for billing and record-keeping purposes. In the video, the focus is on coding surgical case studies using ICD-10-CM and CPT codes, demonstrating how these codes work together to document and process medical procedures and diagnoses.

💡ICD-10-CM

ICD-10-CM stands for the International Classification of Diseases, 10th Revision, Clinical Modification. It is a coding system used in the United States for documenting and reporting diseases, symptoms, and procedures. In the video, ICD-10-CM codes are used to classify the patient's diagnoses, such as a torn medial meniscus and chondromalacia.

💡CPT Codes

CPT Codes, or Current Procedural Terminology codes, are a standardized set of codes used primarily to report medical procedures and services to health insurance companies. The video provides an example of how to use CPT codes to document surgical procedures like arthroscopy, meniscectomy, synovectomy, and chondroplasty.

💡Surgical Case Study

A surgical case study is a detailed report of a patient's surgical procedure, including pre-operative and post-operative diagnoses, the procedure performed, and the findings. In the video, Victoria uses a knee surgery case study to demonstrate the coding process, highlighting the importance of reviewing the operative report to ensure all procedures and diagnoses are accurately documented and coded.

💡Operative Report

An operative report is a written record of a surgical procedure, detailing the steps taken, the patient's condition before and after the surgery, and any findings made during the operation. In the context of the video, the operative report serves as the primary source document for medical coders to extract information needed for accurate coding of the surgical procedure and diagnoses.

💡Arthroscopy

Arthroscopy is a minimally invasive surgical procedure that allows doctors to view the inside of a joint, typically using a camera inserted through a small incision. In the video, arthroscopy of the left knee is one of the procedures performed, and it is important for the medical coder to identify and code this procedure correctly.

💡Meniscectomy

Meniscectomy is a surgical procedure to remove or repair a damaged meniscus, which is a type of cartilage in the knee joint. In the video, a partial medial meniscectomy is performed, and the medical coder must understand the specifics of this procedure to assign the correct CPT code.

💡Synovectomy

Synovectomy is a surgical procedure to remove the synovial tissue, which lines the joints and tendon sheaths. In the video, a three-compartment synovectomy is mentioned, indicating that the procedure involved the removal of synovial tissue from three different areas of the knee joint.

💡Chondroplasty

Chondroplasty is a surgical procedure that involves reshaping or smoothing the cartilage in a joint to reduce symptoms of arthritis. In the context of the video, chondroplasty was performed on areas of the knee with grade 3 articular cartilage changes, and the coder must identify this procedure to code it accurately.

💡CCI Editor

The CCI Editor, or Correct Coding Initiative Editor, is a tool used by medical coders to check for coding errors and ensure that the codes assigned for a procedure do not conflict with each other. In the video, Victoria uses the CCI Editor to validate the codes for the surgical procedures and to determine the correct order of the codes based on RVUs (Relative Value Units).

💡Medical Coding Masterclass

The Medical Coding Masterclass is a comprehensive educational program designed to teach individuals how to become proficient in medical coding. In the video, Victoria encourages viewers interested in a career in medical coding to sign up for her Masterclass to learn more about the field and gain the skills needed to succeed.

Highlights

The video provides a tutorial on coding a surgical case study using ICD-10-CM and CPT codes.

The presenter, Victoria, is a medical coder auditor, educator, and content creator.

The video is designed to help viewers understand how medical codes work together and practice coding real-life scenarios.

Victoria offers a Medical Coding Master Class for those interested in starting a career in medical coding.

The case study involves a knee procedure, with the operative report and related documents provided for reference.

Coding is based on post-operative diagnoses, which can change from pre-operative diagnoses.

The video emphasizes the importance of reviewing the entire operative report to ensure nothing is omitted from the coding.

The procedure performed includes arthroscopy of the left knee with partial medial meniscectomy and other related procedures.

Arthroscopic findings include a tear in the posterior horn of the medial meniscus and chondromalacia in multiple joints.

The video explains how to identify and code the correct procedures from the operative report.

Some procedures may bundle into each other, such as the arthroscopy being included in the meniscectomy code.

The video demonstrates how to use the ICD-10 and CPT coding books effectively.

The video provides an example of how to determine the correct ICD-10 code for a torn medial meniscus.

Chondromalacia affecting multiple sites is coded as M94.29.

The final coded procedures for the case study are two CPT codes and two ICD-10 codes.

Victoria encourages viewers to sign up for her Medical Coding Master Class for a comprehensive guide to medical coding.

The video serves as a practical guide for both beginners and experienced medical coders.

Transcripts

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Takeaways

Q & A

What is the main focus of the video?

Who is Victoria in the context of the video?

What is the procedure being discussed in the video?

Why is it important to code based on post-operative diagnoses?

What does Victoria recommend for someone interested in a medical coding career?

How does the video script handle the coding of the arthroscopy procedure?

What is the significance of the CCI validator mentioned in the video?

How are the ICD-10-CM codes determined for the diagnoses in the video?

What are the final CPT and ICD-10-CM codes provided in the video?

What is the purpose of the additional resources Victoria offers in the video description?

How does the video script emphasize the learning process of medical coding?