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1 Anatomy, Conditions, and Coding Concerns Coding Concerns Encountered in Pediatric Otolaryngology Ronda Hamaker MD 1 All Rights Reserved Ronda Hamaker, MD 1 Objectives Understand why a good relationship Understand why a good relationship between surgeon and coder is important Understand different physician personalities and stressors; how to 2 All Rights Reserved approach with questions Be able to start to visualize teamwork needed in your setting to succeed 2

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Anatomy, Conditions, and Coding ConcernsCoding Concerns

Encountered in Pediatric Otolaryngology

Ronda Hamaker MD

1All Rights Reserved

Ronda Hamaker, MD

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Objectives

• Understand why a good relationship• Understand why a good relationship between surgeon and coder is important

• Understand different physician personalities and stressors; how to

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approach with questions

• Be able to start to visualize teamwork needed in your setting to succeed

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Why Talk?

• Each have different knowledge bases• Each have different knowledge bases from our experience, education, and brain style

• Increase correct coding

• Increase revenue

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Increase revenue

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Barriers

• Time• Time

• Language

• Stress

• Fear

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Time

• Coder typically in office 8 am to 5 pm• Coder typically in office 8 am to 5 pm. This is when the surgeon is in the operating room or in the clinic seeing patients. Trying to discuss an issue will add stress and poor attention

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• Possible solution: weekly or monthly meeting time that works for both coder and surgeon

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Language

• Coder is using the medical vocabulary• Coder is using the medical vocabulary learned in the classroom while the surgeon is using jargon used in the operating room

• Need to talk with each other, use the

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CPT® guidebooks and tools, so begin to use a common language

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Stress

• Coder wants to get the codes for diagnosis andCoder wants to get the codes for diagnosis and procedures correct, matched correctly, be sure edits addressed if need be, and maximize payment decreasing rejections – all this in a timely manner

• Surgeon wants to get his work done and get some sleep, worried about patient with a complication, family not seen all week lecture not done etc –

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family not seen all week, lecture not done, etc. billing not on radar

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Fear

• Coder afraid of Surgeon:• Coder afraid of Surgeon:– boss, knowledge, attitude or anger

received

• Surgeon afraid of Coder– knowledge, not paid again, more work

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Things to Help it Work

• Coder’s MUSTS:• Coder s MUSTS:– educate surgeon about documentation

– educate surgeon about coding

– discuss coding of complicated cases

– be prepared, knowledgable, ready with

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g ycorrective suggestions

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Ways to Motivate Surgeon

• Depends on Surgeon• Depends on Surgeon– money

– recognition complex care

– audit risks

– partners apply pressure

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y

– kill them with kindness

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Personalities

• Long thought that surgeons were• Long thought that surgeons were “different” from other medical doctors – Turns out with the exception of psychiatry

they all score the same on personality testing

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• The differences you see: scars from training, life’s lessons, stress

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Coding Misconception

• Surgeon: coding for payment• Surgeon: coding for payment

• Coder: coding for data

Coder is correct

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• Coder is correct

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Comon Doctor Errors

• Not enough detail in documentation• Not enough detail in documentation

• Not utilizing modifiers: depending on the coder to use them for us

• Not taking a coding course every few years to stay current

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years to stay current

• Depending on the computer to do the coding

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General Approach to Mass in Child

• History• History

• Physical Exam

• Labs

• Radiology

Specials

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• Specials

History Guidance

• Congenital: present at birth onset with• Congenital: present at birth, onset with infection, multiple family members with same

• Inflammatory: onset with infection, calor, rubor, pain, recent

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• Malignant: rapid growth, no or little pain

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Physical Exam

• Color of skin overlying• Color of skin overlying

• Consistancy on palpation

• Location in patient

• Pain/tenderness with exam

Torticollis

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• Torticollis

Labs

• CBC with Diff• CBC with Diff

• Cultures

• FNAs

• TFT

Titres

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• Titres

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Radiology

• Ultrasound• Ultrasound

• CT Scan

• MRI

• Esophagram

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Ultrasound of Masses

• Tells cystic vs solid vs mixed• Tells cystic vs. solid vs. mixed

• Encapsulation

• Vascularity and relationship to vessels

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CT Scan of Masses

• Do with contrast if possible• Do with contrast if possible

• Tells location

• Bone Integrity

• Inflammatory changes

Abscess s Cell litis

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• Abscess vs. Cellulitis

• Can combine with image guidance

MRI of Masses

• Soft tissue better defined• Soft tissue better defined

• Fluid planes (ie glioma)

• Abcess vs. cellulitis

• Vascularity (lymphangioma vs. hemangioma)

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hemangioma)

• Less radiation exposure than CT Scan

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Specials

• TB test• TB test

• Fistulagram

• Thyroid Scan

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Lymphadenitis Causes

• USUALLY Staph or Strep pyogenes (grpA)• USUALLY Staph or Strep pyogenes (grpA)

• Areobic (Strep grp B and C)

• Anaerobic (mouth!)

• Viral (EBV, Adenovirus)

• Toxoplasmosis

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• Cat Scratch

• Abcess

• Sialadenitis

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Lymphadenitis Emperic Thx

• Augmentin• Augmentin

• Cephalosporins

• Macrolides

• IV: Clindamycin/Cefuroxime/Unasyn

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Lymphadenitis Surgical Tx

• Incision and Drainage: worry about TB• Incision and Drainage: worry about TB, immunocompromised pt., skin contamination

• FNA

• Excisional Biopsy

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Excisional Biopsy

• Incisional Biopsy

Lymphadenitis LN Pathology

• Reactive Hyperplasia 50%• Reactive Hyperplasia 50%

• Bacterial Infection 25%

• Neoplasm 15%

• Miscellaneous 10%

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Coding of Treatment Choices

• 38300 Drainage of lymph node abscess or38300 Drainage of lymph node abscess or lymphadenitis, simple

• 38500 Bx or Excision of Lymph Node(s) open, superficial

• 38505 by needle, superficial

• 10021/10022 FNA without and with imaging

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guidance

• 38510 Bx/Excision LN, Deep cervical

• 38542 Dissection deep jugular node(s)

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Skin Tags

• Can occur anywhere• Can occur anywhere

• ENT sees most commonly in preauricular area– sometimes called Hillocks or accessory

lobules

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• Excision is usually for benign reasons

• Cartilage may be found underlying these lesions

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Coding Excision

• 11200 removal with or without• 11200 removal with or without anesthesia up to 15 lesions any method

• what if there is cartilidge in the base?

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Congenital Masses

• Hemangioma • LaryngoceleHemangioma

• Lymphangioma

• Branchial Cleft Cyst/Sinus/Fistula

• Thyroglossal Duct Remnant

y g

• Saccular Cyst

• Esophageal Diverticulum/Duplication

• Cyst Bronchogenic

C t T t

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Remnant

• Dermoid• Cyst Teratoma

• Thymic Cyst

Hemangioma

• Most common neoplasm of childhoodMost common neoplasm of childhood

• 10-12% of Caucasians

• Women 3: men 1

• Several types: cavernous, capillary, lobular

• Color/bluish helpful

• Compressable and mildly firm

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• 90% involute by age 2 yrs

• Dx: physical exam, CT Scan, MRI

• Thx: observation, steroids, interferon, sclerosis, surgical intervention with laser or knife

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Hemangioma

• Less commonlyLess commonly involve the airway

• Usually subglottic• Size of airway lesion

does not correlate with external lesions

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• Symptoms appear within the first 8 weeks

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Coding Options

• Observation: All E&M CodesObservation: All E&M Codes

• Biopsy: 11100 single including closures +11101 is more than one

• Laser: No good code!! 17000 likely one lesion and it could be huge and you may not be destroying but shrinking

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• Sclerosis: 11900 Injection intralesional up to 7 lesions or 96405 intralesional chemo. or 38999 unlisted heme/lymph

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Coding Options con’t

• Excise: benign lesion 11400’s with size• Excise: benign lesion 11400 s with size deciding if a graft or flap is needed or 17999 unlisted procedure skin/mucous membrane or subcutaneous tissue

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Lymphangioma

• Painless compressible mass• Painless compressible mass

• Usually present by age 2 yrs.

• Growth continues

• Infection risks

Associated ith poor T cell f nction

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• Associated with poor T cell function

• Sclerosis (macrocystic better results)

• Surgical Excision

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Coding for Lymphangioma Tx

• Sclerosis: again visit the 96405 or• Sclerosis: again visit the 96405 or 38999 debate – not 11900 because deeper than the skin

• Excise: 38550 axial or cervical without

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Excise: 38550 axial or cervical without deep neuromuscular dissection

• Excise: 38555 with neuromuscular dissection

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What about other components?

• Facial or Chest wall or Nasal?• Facial or Chest wall or Nasal?

• Do you add each of these seperately for example: parotid dissection 42420 and a neck dissection or the lymphangioma code and parotid dissection

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Teratoma

• Frequently diagnosis is prenatal (EXIT• Frequently diagnosis is prenatal (EXIT procedures)

• Benign

• Three tissue types represented

• Compression causes problem

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• Compression causes problem

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Coding the Resection

• Neck Dissection CodesNeck Dissection Codes– 38700 Suprahyoid lymphadenectomy

– 38720 Cervical lymphadenectomy (complete)

– 38724 Cervical lymphadenectomy ( difi d)

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(modified)

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Return at End if Time

• Where do we go with intrauterine• Where do we go with intrauterine consults?

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Branchial Cleft Anomalies

• Think about arches and associated artery, nerve, and muscles

• 1st Arch has type I and II classification (Dr. Walter Work)

• 2nd is most common

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• 4th is questionable existence• If bilateral anomalies question Brachio-oto-

renal Syndrome

BCA Con’t

• Look over drawings note travel lines• Look over drawings…note travel lines. The keys to note are BCA I has type I short and to canal and type II thru parotid (work), BCA II between carotids and over both nerves, BCA III behind

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both carotids and between the nerves.

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From Cummings Text

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From Cummings Text

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From Cummings Text

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From Cummings Text

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Branchial Cleft Coding

• 42810 Exc Branchial Cleft Cyst or Vestige• 42810 Exc. Branchial Cleft Cyst or Vestige (confined to skin and subcutaneous tissue)

• 42815 Exc. Branchial Cleft Cyst or Vestige (extending beneath subcutaneous tissue and/or into pharynx)

• What about the ones that necessitate a

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• What about the ones that necessitate a parotidectomy? – 42415 added on or instead of?

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Thyroglossal Duct Cyst

• 0 5 years old (rare cases of later)• 0-5 years old (rare cases of later)

• Enlarges after a viral illness

• Controversy if need to verify normal thyroid

• Sistrunk procedure (1920 decrease

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• Sistrunk procedure (1920 decrease recurrence from 40% to 10%)

• Recurrence rate increases after infection

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Thyroglossal Duct Cyst Excision Codes

• 60280 Exc TGDC or Sinus• 60280 Exc. TGDC or Sinus

• 60281 Exc. Recurrent TGDC

• What to do with a recurrance that requires an anterior neck? 38542? (neck dissection) Bilateral? or is this a

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(neck dissection) Bilateral? or is this a 38999 (unlisted heme/lymph) or a 21556 (excision tumor soft tissue neck, deep superfascial, intramuscular)?

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Thymic Cyst

• Occur from angle of mandible to midline• Occur from angle of mandible to midline of neck

• 3rd pharyngeal pouch is source of thymus

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Coding Thymic Cyst Excision

• 60520 Thymectomy partial or total• 60520 Thymectomy partial or total transcervical approach

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Ranula

• Mucocele of FOM• Mucocele of FOM

• Can be minor gland, submandibular gland, or submandibular duct related

• Surgical excision usual

• New tx: sclerosis

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• New tx: sclerosis

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Rannula Coding

• 42408 Excision of sublingual salivary• 42408 Excision of sublingual salivary cyst

• 42409 Marsupulization of salivary cyst

• 42699 for sclerosis or the chemo code?

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• ADD ON gland resections too!!!

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Dermoid

• Occur in midline anywhere in the body• Occur in midline anywhere in the body

• Benign growths

• Continuous growth

• Tends to attach to skin

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Dermoid Coding

• 30124/5 NO!!! this is nasal dermoid• 30124/5 NO!!! this is nasal dermoid

• 21555 Excision tumor soft tissue of neck or thorax subcutaneous

• 21556 Excision tumor soft tissue of neck deep or subfascial; intramuscular

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neck deep or subfascial; intramuscular

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The THREE

• Need to be able to distinguish from• Need to be able to distinguish from each other

• Encephalocele

• Glioma

• Dermoid

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• Dermoid

• BE CAREFUL…no biopsy, until sure, no brain

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Encephalocele

• Meninges and brain in hernia sac in• Meninges and brain in hernia sac in nose

• Anterior neuropore failed to close

• Positive Furstenberg test

• Can have meningitis

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• Can have meningitis

• Have neurosurgery there too

• Often need CT and MRI

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Encephalocele

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Sinusitis: Encephalocele

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Glioma

• Heterotopic glial tissue in nose• Heterotopic glial tissue in nose

• 15% with dural stalk

• Negative Furstenberg test

• CT +/- MRI

Consider Ne ros rger on standb

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• Consider Neurosurgery on standby

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Dermoid

• Ecto and mesoderm: hair follicles• Ecto and mesoderm: hair follicles, sebaceous glands

• Comes from division of dura and ectoderm

• Assoc. with nasal pit (+/- hair), can be intra or extranasal

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• CT +/- MRI

• Consider Neurosurgery on standby

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Fibromatosis Coli

• Infants within 6 weeks• Infants within 6 weeks

• Within the body of the SCM

• Torticollis noted

• US can confirm

PT ma be needed

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• PT may be needed

• Can cut SCM, but last resort

Fibromatosis Coli Codes

• 21720 Division of SCM open operation• 21720 Division of SCM open operation (biopsy done too?)

• 64613 Botox injection

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Neurilemmoma

• Aka: benign schwannoma• Aka: benign schwannoma

• Women > men

• Lateral neck (other is middle ear and sinonasal)

• Solitary painless neck mass

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• Solitary painless neck mass

Chondroma

• Men > women• Men > women

• Cricoid most common, then thyroid, arytenoid, and epiglottis

• Globus sensation, dysphagia, hoarseness

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hoarseness

• Smooth round fixed mass

• CT, can see calcifications

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Paraganglioma

• Aka: carotid body tumor• Aka: carotid body tumor, chemodectoma

• Painless neck mass

• Slow growing

• Sx: neck mass hoarseness CN deficits

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• Sx: neck mass, hoarseness, CN deficits

• Familial

• Multicentric

Neurofibroma

• Bengin peripheral nerve sheath• Bengin peripheral nerve sheath neoplasm

• Not von Recklinghausen’s disease (that is multiple)

• Sx’s based on site of mass

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Sx s based on site of mass

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Hamartoma

• Benign tumor like proliferation or• Benign tumor-like proliferation or overgrowth of tissue indigenous to a specific anatomic location

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Malignant Lymphoma

• Hodgkin’s and non-Hodgkin’sHodgkin s and non Hodgkin s• MALT (mucosa associated lymphoid tissue)

share: tendancy to remain local, evolve slowly, Bcell

• Non-Hodgkin’s: 2-12yrs, 50% of extranodal lymphomas in H&N, M>W, staged I-IV,

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includes Burkitt’s• Hodgkin’s rare in <5yr, F:M=1:2,

90%intranodal, rare Waldeyer’s ring

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Rhabdomyosarcoma

• Most common soft tissue malignancy ofMost common soft tissue malignancy of childhood (40% by age 5 yrs, 70% by age 12 yrs)

• Malignant tumor of skeletal muscle cells• 19% of all sarcomas• Most common sarcoma of kids, and most

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,common in H & N

• Peds: 50% of all rhabo’s in H&N• Orbit>NP> ear> sinonasal

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Histiocytosis

• Langerhan’s cellsLangerhan s cells• Eosinophilic Granuloma: monostotic,

50% diagnosis by age 5 yrs, good prog.• Hand-Christian-Schuller Dis: multifocal

lesions, chronic course, morbidity

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• Letterer-Siwe Dis: disseminated histio. Usually dx. by 3yr, multiple organs, rapidly progressive to mortality, men > women

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Neuroblastoma

• Malignant tumor cells from• Malignant tumor cells from neurofibromas

• 5% of sarcomas

• Surgery, chemo and XRT to treat

• 40% 5 year survival

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• 40% 5 year survival

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Fibrosarcoma

• Malignant tumor of fibroblasts• Malignant tumor of fibroblasts

• 10-15% occur in H&N

• Nasal cavity > paranasal sinuses > larynx > neck

• Unencapsulated polypoid or sessile

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• Unencapsulated polypoid or sessile, white/tan firm tumor

• Can erode bone

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Tumors

• Biopsy of site• Biopsy of site

• Await pathology to help with appropriate choice of code

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Thyroid Malignancies

• Think of MENs first• Think of MENs first

• Papillary is most common

• Usual F > M ratio

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Thyroid Codes

• 60300 Aspirate or Inject Cyst• 60300 Aspirate or Inject Cyst

• 60200 Excise Cyst

• 60210-60271 Thyroidectomy

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Squamous Cell Carcinoma

• Rare in children• Rare in children

• Grow fast and mets fast

• Tongue most common

• Follow adult tx protocols

Coding follo s site specifice g idlines

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• Coding follows site specifice guidlines

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Parotid and Submandibular Tumors

• Rare except hemangioma or vascular• Rare except hemangioma or vascular malformations

• Follow protocols for adults

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Salivary Coding

• 42450 Sublingual Excision• 42450 Sublingual Excision

• 42440 Submaxillary Gland Excision

• 42415-42426 Parotid Gland Excision

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Multiteam Procedures

• Aerodigestive Team (all same tax id#)• Aerodigestive Team (all same tax id#)– Pulmonary: flexible bronchoscopy with

BAL

– Gastroenterology: EGD with Bx/ Colonoscopy

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– Otolaryngology: direct laryngoscopy, bronchoscopy and other interventions

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CCI Edit

• Do not need two bronchs!• Do not need two bronchs!

• Flexible and Rigid provide different information

• Done with different instruments

• Talk with your doctors about clearly

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• Talk with your doctors about clearly documenting WHY both were of use or benefit for the patient

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Intrauterine Consults• Usually requested because of concern

f i b t ti t bi th d dof airway obstruction at birth and need for EXIT procedure

• No E/M of infant... cannot examine because in utero

• Hours of time looking at films phone

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• Hours of time looking at films, phone discussions, and meeting parents, and sometimes family answering questions… nothing can bill!!!

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Future

• Correct and COMPLETE diagnosis• Correct and COMPLETE diagnosis coding will help with showing more complex care

• Staff education to help capture diagnosis and ancillaries

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• 100% offices with Superbills

• ICD-10, no one likes change :)

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Visualize Teamwork

• How does your office work?How does your office work?

• Staff help with catching coding doctor missed?

• Monthly, Quarterly meeting with staff educating them on coding?

• Superbills?

• E/M forms?

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• Try something....can always try something else!!!

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It Takes a Team!

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