Last week we discussed guidelines for biopsies. This week we will focus on the guidelines for Inspection procedures. Inspection is defined as visually and/or manually exploring a body part. Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers. We will go over the guidelines first followed by some coding procedures that will give you an opportunity to put these guidelines into practice.
Guideline B3.11a: Inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.
Example - Fiberoptic bronchoscopy performed for irrigation of bronchus, only the irrigation procedure is coded.
INSPECTION OF TUBULAR AND NON-TUBULAR BODY PARTS
Guideline B3.11b: If multiple tubular body parts are inspected, (e.g., esophagus, blood vessel, ureter), the most distal body part inspected is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded.
Examples - Cystoureteroscopy with inspection of bladder and ureters is coded to the ureter body part value.
Exploratory laparotomy with inspection of abdominal contents is coded to the peritoneal cavity body part value.
INSPECTION AND OTHER PROCEDURES PERFORMED ON SAME BODY PART
Guideline B3.11c: When both an Inspection procedure and another procedure are performed on the same body part during the same episode, if the Inspection procedure is performed using a different approach than the other procedure, the Inspection procedure is coded separately.
Example - ‘Endoscopic’ Inspection of the duodenum, (e.g, EGD), is coded separately when ‘open’.
Excision of the duodenum is performed during the same procedural episode.
PROCEDURES FOR THIS WEEK:
- Fiberoptic bronchoscopy performed for irrigation of bronchus.
- Cystoureteroscopy with inspection of bladder and ureters.
- EGD followed by open excision of the duodenum.