2006 Panel on Coding2006 Panel on CodingDiagnostic Coding and DocumentationDiagnostic Coding and Documentation

David R. Vandersteen, MDDavid R. Vandersteen, MDChildren’s Hospitals of MinnesotaChildren’s Hospitals of Minnesota

Mayo Graduate School of MedicineMayo Graduate School of Medicine

Coding and Documentation TipsCoding and Documentation Tips

““Code Pairing”Code Pairing”– List appropriate diagnoses to match the List appropriate diagnoses to match the

procedures performedprocedures performedExample: If doing a circumcision, use the Example: If doing a circumcision, use the redundant prepuce ICD-9 diagnostic code.redundant prepuce ICD-9 diagnostic code.

If Code Pairing not possibleIf Code Pairing not possible– Document what you doDocument what you do– Document why you did it!Document why you did it!– Be specific!Be specific!

General coding tipsGeneral coding tips

Describe details of the procedure to justify the Describe details of the procedure to justify the “unpaired” codes“unpaired” codes

Example:Example:– 1404014040 Adjacent tissue transfer or rearrangement, Adjacent tissue transfer or rearrangement,

forehead, cheeks, chin, mouth, neck, axillae, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or lessgenitalia, hands and/or feet; defect 10 sq cm or less

– DictateDictate “Dorsal preputial rotational flaps were “Dorsal preputial rotational flaps were mobilized on a vascular pedicle, rotated ventrally, and mobilized on a vascular pedicle, rotated ventrally, and used to resurface a 1 sq cm surface of deficient used to resurface a 1 sq cm surface of deficient ventral penile skin.”ventral penile skin.”

Case #1:Case #1:

6 month old male with distal (1 cm) 6 month old male with distal (1 cm) hypospadias with moderate chordee and hypospadias with moderate chordee and tethering of the scrotum to the ventral tethering of the scrotum to the ventral penis.penis.

Case #1:Case #1:

Diagnoses and ICD-9 codesDiagnoses and ICD-9 codes– HypospadiasHypospadias

752.61752.61 Hypospadias Hypospadias

– ChordeeChordee752.63752.63 Congenital chordee Congenital chordee

– Penoscrotal tetheringPenoscrotal tethering  752.81752.81 Scrotal transposition  Scrotal transposition 

– Preputial redundancy/asymmetryPreputial redundancy/asymmetry605605 Redundant prepuce and phimosis Redundant prepuce and phimosis

Case #1:Case #1:

Diagnosis and Procedural “Code Pairing”Diagnosis and Procedural “Code Pairing”– HypospadiasHypospadias

752.61752.61 Hypospadias Hypospadias

54324 54324 One stage distal hypospadias repair (with or without One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap)flaps (eg, flip-flap, prepucial flap)

– ChordeeChordee752.63 Congenital chordee752.63 Congenital chordee

5430054300 Plastic operation of penis for straightening of chordee Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra(eg, hypospadias), with or without mobilization of urethra

Case #1:Case #1:

Diagnosis and Procedural code “pairing”Diagnosis and Procedural code “pairing”– Penoscrotal tetheringPenoscrotal tethering

  752.81752.81 Scrotal transposition Scrotal transposition

  5517555175 Scrotoplasty; simple Scrotoplasty; simple

– Excessive/asymmetric prepuceExcessive/asymmetric prepuce 605605 Redundant prepuce and phimosis Redundant prepuce and phimosis

5416154161 Circumcision, surgical excision other than clamp, Circumcision, surgical excision other than clamp, device or dorsal slit; except newborndevice or dorsal slit; except newborn

Case #2:Case #2:

6 month old male with buried or concealed 6 month old male with buried or concealed penis along with penoscrotal web.penis along with penoscrotal web.

Case #2:Case #2:

Diagnoses and ICD-9 codesDiagnoses and ICD-9 codes– Buried penisBuried penis

  752.65752.65 Hidden penis Hidden penis

– Penoscrotal webPenoscrotal web  752.81752.81 Scrotal transposition Scrotal transposition

752.63752.63 Congenital chordee Congenital chordee

– Preputial redundancy/asymmetryPreputial redundancy/asymmetry 605605 Redundant prepuce and phimosis Redundant prepuce and phimosis

Case #2:Case #2:

Diagnosis and Procedural “code pairing”Diagnosis and Procedural “code pairing”– Buried penisBuried penis

  752.65752.65 Hidden penis Hidden penis

???? ???? CPT code CPT code

– ChordeeChordee752.63 Congenital chordee752.63 Congenital chordee

5430054300 Plastic operation of penis for straightening Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without of chordee (eg, hypospadias), with or without mobilization of urethramobilization of urethra

Case #2:Case #2:

Diagnosis and Procedural code “pairing”Diagnosis and Procedural code “pairing”– Penoscrotal tetheringPenoscrotal tethering

  752.81752.81 Scrotal transposition Scrotal transposition

  5517555175 Scrotoplasty; simple Scrotoplasty; simple

– Excessive/asymmetric prepuceExcessive/asymmetric prepuce 605605 Redundant prepuce and phimosis Redundant prepuce and phimosis

5416154161 Circumcision, surgical excision other than Circumcision, surgical excision other than clamp, device or dorsal slit; except newbornclamp, device or dorsal slit; except newborn

Case #3:Case #3:

6 month old male with chordee without 6 month old male with chordee without hypospadias.hypospadias.

Case #3:Case #3:

Diagnoses and ICD-9 codesDiagnoses and ICD-9 codes– ChordeeChordee

752.63752.63 Congenital chordee Congenital chordee

– Preputial redundancy/asymmetryPreputial redundancy/asymmetry 605605 Redundant prepuce and phimosis Redundant prepuce and phimosis

Case #3:Case #3:

Diagnosis and Procedural “code pairing”Diagnosis and Procedural “code pairing”– ChordeeChordee

752.63 Congenital chordee752.63 Congenital chordee

5430054300 Plastic operation of penis for straightening Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without of chordee (eg, hypospadias), with or without mobilization of urethramobilization of urethra

– Excessive/asymmetric prepuceExcessive/asymmetric prepuce 605605 Redundant prepuce and phimosis Redundant prepuce and phimosis

5416154161 Circumcision, surgical excision other than Circumcision, surgical excision other than clamp, device or dorsal slit; except newbornclamp, device or dorsal slit; except newborn

Case #4:Case #4:

1 year old with high testis at level of 1 year old with high testis at level of internal ring.internal ring.– Intra-op findings of large patent processus Intra-op findings of large patent processus

vaginalis/ herniavaginalis/ hernia

Case #4:Case #4:

Diagnoses and ICD-9 codesDiagnoses and ICD-9 codesUndescended testisUndescended testis

– (752.51) Undescended testis(752.51) Undescended testis

Case #4:Case #4:

Diagnoses and ICD-9 codesDiagnoses and ICD-9 codesInguinal herniaInguinal hernia

– (550.9) Inguinal hernia, without mention of obstruction or (550.9) Inguinal hernia, without mention of obstruction or gangrene gangrene

  550.90550.90 unilateral or unspecified (not specified as unilateral or unspecified (not specified as recurrent)recurrent)

  550.91550.91 unilateral or unspecified, recurrent unilateral or unspecified, recurrent

Congenital hydroceleCongenital hydrocele– (778.6) Congenital hydrocele(778.6) Congenital hydrocele

Congenital hydrocele of tunica vaginalisCongenital hydrocele of tunica vaginalis

Case #5:Case #5:

6 year old boy presents with a reducible 6 year old boy presents with a reducible communicating hydrocele. communicating hydrocele.

Case #5:Case #5:

Diagnoses and ICD-9 codesDiagnoses and ICD-9 codes– Inguinal hernia?Inguinal hernia?

(550.9) Inguinal hernia, without mention of (550.9) Inguinal hernia, without mention of obstruction or gangrene obstruction or gangrene

–   550.90550.90 unilateral or unspecified (not specified as unilateral or unspecified (not specified as recurrent)recurrent)

Case #5:Case #5:

Diagnoses and ICD-9 codesDiagnoses and ICD-9 codes– HydroceleHydrocele

(778.6) Congenital hydrocele(778.6) Congenital hydrocele– Congenital hydrocele of tunica vaginalisCongenital hydrocele of tunica vaginalis

(603) Hydrocele (603) Hydrocele Includes hydrocele of spermatic cord, testis, or Includes hydrocele of spermatic cord, testis, or tunica vaginalis tunica vaginalis

Excludes congenital hydrocele ( Excludes congenital hydrocele ( 778.6778.6 ) ) – 603.8603.8 Other specified types of hydrocele Other specified types of hydrocele– 603.9603.9 Hydrocele, unspecified Hydrocele, unspecified

General coding tipsGeneral coding tips

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Bundling info/ cross checkBundling info/ cross check

Updated EditsUpdated Edits

Access Medicare RVUs and Medicare fees for procedural Access Medicare RVUs and Medicare fees for procedural codescodes

Match ICD-9 codes to CPT codes Match ICD-9 codes to CPT codes – i.e. Match diagnosis with procedurei.e. Match diagnosis with procedure

Document!Document!