PCS help!

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I have a pt that the surgeon removed a giant villous ademona on a prolapsed rectum. The op report states: The adenoma was prolapsed as far as possible and rectal speculum placed. The upper end of the adenoma was identified, and a stay suture placed approximately a centimeter above this. The
adenoma was then removed with serial cauterization of mucosa and rectal wall. My options for the excision is Open, Percutaneous Endoscopic and Via Natural or Artificial Openiing Endoscopic. I checked with coding, they say OPEN. I am not sure????

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • catladyrncatladyrn
    edited April 2016
    In order to code an endoscopic procedure of any kind, there'd have to be evidence that endoscopy was used and I don't see it in your scenario. Therefore I agree with your coders.

    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
  • ssalinasssalinas
    edited April 2016
    I'm thinking via natural or artificial opening endoscopic since the site was visualized through instrumentation. There was no incision through skin or mucous membrane to expose the site so I don't think open would be correct.

    Thoughts?

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

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