BAL
I really hesitate bringing this subject up since mucous plug removal was thoroughly discussed previously. However would appreciate your opinion on the appropriate code(s) for the procedure(s) described below. I have 0BC78ZZ for the mucous plug removal.
My question is in regards to what the MD calls bronchoalveolar lavage. What code would you use?
[cid:image001.png@01D19A5A.B51213D0]
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
Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
My question is in regards to what the MD calls bronchoalveolar lavage. What code would you use?
[cid:image001.png@01D19A5A.B51213D0]
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
Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
Comments
In this case the physician used approximately 80 ml of normal saline and did not collect any specimen. No additional code is necessary for this, correct?
That is how I looked at it but a reviewer did not agree with me. I was hoping for verification of my reasoning.
[cid:image002.png@01D19ADF.456645D0]
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Would you use the code below designating 'diagnostic' even though no sample of fluids was obtained?
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
No...in the case of your example, I'd modify to indicate no sample was obtained. Sorry to confuse the issue, I was posting a typical example of the type of BAL we encounter at our sites. I should have specified that in your question, no sample was obtained.
Bronchial Procedures can be tricky.
Key Points
Was procedure confined within lumen of bronchus or was lung tissue obtained in a transbronchial approach?
Remember, the Bronchi have lobes, too, and ensure anatomical location for coding purpose - lung versus bronchus.
If the intent and scope of the procedure and type of any tissue obtained is unclear, the physician should be queried.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, April 20, 2016 8:55 AM
To: Salinas, Sharon
Subject: RE: [External] [cdi_talk] BAL
H, Sharon
No...in the case of your example, I'd modify to indicate no sample was obtained. Sorry to confuse the issue, I was posting a typical example of the type of BAL we encounter at our sites. I should have specified that in your question, no sample was obtained.
Bronchial Procedures can be tricky.
Key Points
Was procedure confined within lumen of bronchus or was lung tissue obtained in a transbronchial approach?
Remember, the Bronchi have lobes, too, and ensure anatomical location for coding purpose - lung versus bronchus.
If the intent and scope of the procedure and type of any tissue obtained is unclear, the physician should be queried.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Below is my original post with the entire report. Is it coming through in the email? I was hoping that the saline lavage could be considered an integral part of the removal of the mucous (since that was the intent) and not coded as a separate procedure since I really do not feel this procedure warrants placing this encounter in the Major Chest Procedure DRGs.
Thanks,
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, April 19, 2016 4:43 PM
To: Salinas, Sharon
Subject: [cdi_talk] BAL
I really hesitate bringing this subject up since mucous plug removal was thoroughly discussed previously. However would appreciate your opinion on the appropriate code(s) for the procedure(s) described below. I have 0BC78ZZ for the mucous plug removal.
My question is in regards to what the MD calls bronchoalveolar lavage. What code would you use?
[cid:image001.png@01D19B15.33BB81C0]
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
Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: ssalinas@barlow2000.org
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12538092.1a48df689a710d0d4e067dc4c85563ef@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.