Tracheostomy and Bronchoscopy Operative Reports
The reports below describe a patient undergoing a tracheostomy operation and a bronchoscopy operation. Both procedures have been documented in detail, describing the step-by-step process used by doctors to carry out each surgery. Keep reading for more on how each procedure was performed.nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. nn– Click Here to Submit Redacted Surgery Case Study –nn nnOPERATIVE REPORT (1 of 2)nn12/XX/20nnPREOPERATIVE DIAGNOSIS: Ventilator Dependence, Metabolic EncephalopathynPOSTOPERATIVE DIAGNOSES: SamenPROCEDURES: Tracheostomy with 8-French Shiley tracheostomy under moderate sedation.nSURGEON: M. K., D.O.nASSISTANT: W. F., DO.nANESTHESIA: General. (the patient is already intubated and sedated on precedex with fentanyl. 5mg of versed was administered)nBLOOD LOSS: Less than 1 mL.nBLOOD REPLACEMENT: None.nPOSTOPERATIVE CONDITION: Stable.nnDESCRIPTION OF PROCEDURE:nAfter all risks and benefits were explained and discussed with the patient’s husband including but not limited to blood loss, infection, as well as injury to the tracheal structures and intraabdominal perforation. All questions were answered. Written informed consent was obtained and is in the chart for review. The patient is already intubated in the ICU, she is on precedex and fentanyl. 5mg of versed is given. A time-out was completed. Neck was prepped and draped in a sterile fashion. Sterile technique was utilized throughout the procedure with gown, gloves, face mask, and hat. The abdomen was also prepped in a similar fashion. Local anesthetic was provided. 2 cm cephalad to the suprasternal notch, a transverse incision was created, and the trachea was palpated. The assistant is doing the bronchoscopy and the endotracheal tube is full back by the assistant until the finder needle was fully visualized by bronchoscopy. The wires passed into the trachea, the needle is removed, the dilator is placed over the wire and then removed, the larger dilators placed over the wire and then removed. Finally, the final dilator inside of the tracheostomy tube is passed until the balloon is within the trachea, the dilator is removed and the tracheostomy tube is left in place. It is attached to the ventilator and bronchoscopy confirms is physician above the level of the carina. The endotracheal tube was removednfrom the mouth. The tracheostomy is sutured in place. She tolerated the procedure well.nn nn nn
OPERATIVE REPORT (2 of 2)nnPREOPERATIVE DIAGNOSIS: Respiratory FailurenPOSTOPERATIVE DIAGNOSES: SamenPROCEDURES: BronchoscopynSURGEON: William Fulton, DO, FACOSnASSISTANT: Majid Kianmajd, DOnFINDINGS: Intact trachea with minimal mucous secretionsnSPECIMEN(S) REMOVED: NonenBLOOD LOSS: NonenANESTHESIA: General Endotracheal nANESTHESIOLOGIST(S): NonenCULTURES: NonenDRAINS: NonenBLOOD REPLACEMENT: NonenPOSTOPERATIVE CONDITION: StablenCOMPLICATIONS: Nonenn nnDESCRIPTION OF PROCEDURE:nnPatient was prepared for procedure of bedside bronchoscopy to use concurrently with placement of a tracheostomy. The bronchoscope was advanced into the ET and the trachea was directly visualized. Minimal saline irrigation was utilized to assist with visualization. The carina was visualized and the tracheobronchial tree grossly appeared intact with polyps or lesions or bleeding noted. During the bronchoscopy placement of the needle and guidewire were visualized for the procedure of percutaneous tracheostomy. Ventilation and O2 saturation were monitored through the procedure and patient remained stable throughout. The tracheostomy was visualized in placed with the bronchoscope also advanced directly into the tracheostomy as well. The bronchoscope was withdrawn without difficulty. Patient tolerated procedure well.n
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The pandemic may have negatively impacted many things, but the health industry may emerge stronger in 2021 because of Covid-19 impacts. Virtual care, clinical trials, and digital relationships between patients and physicians are a few of many areas that executives should focus on. Continue reading below to learn more about how healthcare might change or continue to improve in 2021.nnWhat will the healthcare landscape look like in 2021?nnPricewaterhouseCoopers (PwC) Health Research Institute (HRI) released its annual health industry forecast Wednesday morning detailing how the healthcare system of 2021 can be reimagined and emerge from the COVID-19 pandemic in a stronger position. While the 2020 forecast focused on returns from digital investment, M&A activity, and DEI, the top health industry issues of 2021 are likely to center around how the healthcare system will built itself back up after the struggles created by the coronavirus outbreak. Healthcare organizations saw struggles with finances, the national supply chain, staffing shortages, and staying afloat during the pandemic. According to PwC, there are opportunities for the health industry to rebound in a stronger and smarter way in 2021. “As this pandemic makes painfully visible, medicine alone—ventilators, drugs, ICUs—will not save us. Medical care contributes only 10% to 20% of positive health outcomes. Rather than facing these realities, we too often continue to reactively Band-Aid,” Dr. Mona Hanna-Attisha said during PwC’s 180 Health Forum in October. “We can’t afford to do that anymore. … Addressing the upstream root causes is the only answer … with crisis comes opportunity.”nnBelow are some key areas of the report that healthcare executives should focus on:nnVIRTUAL CAREnPwC found that over 90% of surveyed healthcare organizations are using telehealth for primary care services. Nearly 70% of those leaders said that “telehealth has been most useful for follow-up appointments. According to PwC, health leaders should “pay equal attention to revenue and customer experience” when it comes to the success of telehealth in their organizations.nnCLINICAL TRIALSnDue to the pandemic, pharmaceutical and life sciences, companies recognized that clinical trials can be conducted remotely. These companies are hoping to continue this trend by conducting trials with “few in-person interactions.” The FDA created special guidance for trial sponsors during the pandemic, and PwC stated that these changes could be here to stay. Pharmaceutical and life science executives were nearly unanimous in saying that they expect digital investments in clinical trials to increase in 2021.nnDIGITAL RELATIONSHIPS FOR PHYSICIANSnMore than 90% of executives from the provider, life sciences, and health plan sectors answered that “improving the clinician experience is a priority for their organizations as they enter 2021.” According to PwC, digital technology can help improve the physician experience. Due to the pandemic, “administrative burdens” for physicians were reduced due to relaxed rules from CMS. Some private insurers also made claims a faster and easier process, and PwC believes there will be an increase of payers’ investments in automation by 2021. Health plan executives also said that a big focus for 2021 will be on “the physician-patient relationship verses members directly.”nnHEALTHCARE FORECASTINGnAlmost three-quarters of healthcare executives said that their organizations will be investing more in predictive modeling in 2021. According to PwC, “this capability to forecast the future could be as important to healthcare survival in 2021 as a mask may be for slowing the spread.” Moving forward, healthcare executives should focus on regional forecasting and collaborating with others in their area. More than 70% of healthcare executives said they were either starting to collaborate with other healthcare organizations or had plans to, due to the pandemic. Nearly two-thirds of leaders said they were either starting to collaborate or were planning to collaborate with public health agencies.nnHEALTH PORTFOLIOSnIn 2021, PwC expects healthcare organizations to increase their investments in the “gaps exposed by the pandemic.” Hospitals and health systems who had invested in telehealth, home care, and digital capabilities that laid the groundwork for the rapid expansion of telemedicine due to the pandemic, have also “mostly recovered” from the initial hit of the pandemic. Meanwhile, organizations who are struggling financially may look into options such as M&A.nnSUPPLY CHAINnForward-looking, PwC expects there will be a transformation of the national supply chain after the pandemic revealed flaws in the current system. “In 2021, HRI expects distributors and health systems to consider establishing contracts with secondary suppliers, joining new group purchasing organizations, relocating facilities and approaching storage and distribution on a more regional scale,” the report stated. Ninety-four percent of life sciences executives and 86% of provider executives see “improving supply chain transparency” as their top priority for 2021.nnINTEROPERABILITYnAlmost a quarter of providers and health plan executives said that their organizations view the new federal rules on interoperability as a “strategic opportunity.” PwC suggests that healthcare organizations should have a “compliance-focused approach” and develop strategies for interoperability if they don’t want to be left behind. More than two-fifths of executives said that they have identified a leader to guide interoperability efforts for their organizations going into 2021. PwC also stated that consumer education should be a priority in 2021 so there is trust built between healthcare organizations. According to the report, “A comprehensive strategy that considers how the rules can lead to a more effective healthcare system that puts the consumer in the center would put the organization on offense in this new data-sharing environment.”nn nnOriginal 
nn2021 has brought on new CPT changes and they’re not just in E/M. We’ve compiled a list of 30 FAQ’s so that you can start your 2021 E/M office and other outpatient visit reporting off right. Continue reading below for the top 5 FAQ’s or click here for the complete list! nnBy Ginger Avery, CPC, CPMA, CRCnJanuary 5, 2021nn1.Where can the CPT E/M code and guidelines be found? The CPT E/M code and guideline changes for 2021 can not only be found on the American Medical Associations (AMA) site at this link, but they can also be found in their entirety within the 2021 CPT Code books themselves. These guidelines include the new level of medical decision-making table and the 22 new definitions that help clarify what the MDM terms mean.nn2.Does pulling the lab results into the note constitute a “review of results” or do I need to document by stating that I have reviewed them? Moving forward information from old notes without comment does not add any value to the work that was performed and does not count. Did you review/analyze these results, what impact does this have on today’s visit? What is the clinical significance of this additional work?nn3.When tests are ordered during one visit and reviewed the same test during the next visit, can that count as a data point for both visits? With the new guidelines, we no longer have data “points”. Both encounters would support Limited data (low) with Category 1. The first encounter supports Category 1 for ordering of the test, the follow up encounter would support Category 1 for review of the results.nn4.Where does lifestyle counseling come into this? Preventive medicine counseling and/or risk factor reduction interventions (99401-99412) are time-based codes but do NOT follow the office visit E/M guidelines. Relevant visit details and total F2F time should be documented appropriately. Code selection is based on the F2F time spent with the patient.nn5.When reporting for total time, is it just time spent with patient at the encounter? No, in 2021, time is defined as the total encounter time on the date of service. This includes both F2F work and non-F2F work personally performed by the clinician.nnAs a reminder, documentation is about painting a clear picture of today’s encounter. The power of storytelling is evident with these new revisions. Quality documentation (not quantity or checkboxes) provides details to support the medical necessity and appropriate complexity of each unique encounter, as well as improves overall patient care and clinical outcomes. Clinicians are encouraged to focus their energy and documentation on the cognitive clinically relevant details, regardless of the clinical setting. Document what you do, code what you document.nn Welter Healthcare Partners provides robust coding and documentation training for these updates, as well as other topics. Please contact 
From our Welter Healthcare Partners family to yours, we hope you all have a merry holiday season and a safe, healthy, and happy New Year! We are grateful for the support and appreciation for the work that we do and are excited to continue in 2021!nnIn observance of the holidays, Welter Healthcare Partners will be closing at noon on December 24th and will be closed all day on December 25th and January 1st to spend time with our loved ones. Once again, happy holidays to you all and we hope you all have a great and prosperous New Year!nn 
CMS updated payment information for Covid-19 treatments. This new update includes the reimbursement of monoclonal antibody treatments authorized by the FDA. Continue reading below to learn more.nnMonoclonal antibody products are paid under the Medicare Part B COVID-19 vaccine benefit and therefore are not eligible for a New COVID-19 Treatments Add-on Payment. CMS released new and updated FAQs on Medicare Part B billing and reimbursement for COVID-19 treatments and vaccines. The information updated December 9 is included in Section BB, Drugs and Vaccines under Part B of CMS’ COVID-19 billing FAQs.nnFor the duration of the public health emergency, CMS will pay for monoclonal antibody treatments authorized or approved by the FDA. For payment purposes, CMS is treating these products as vaccines covered under Medicare Part B. If the product is acquired for free, CMS will only pay for the administration. If the provider or supplier purchases the product, CMS will pay for the product and the administration separately. Monoclonal antibody products are paid under the Medicare Part B COVID-19 vaccine benefit and therefore are not eligible for a New COVID-19 Treatments Add-on Payment.nnPayment for administration of an infusion of bamlanivimab or an infusion of casirivimab and imdevimad is approximately $310. The payment rate is based on one hour of infusion and post-infusion monitoring in the hospital outpatient setting. CMS may change the payment rate based on additional information from providers and suppliers. When organizations begin purchasing monoclonal antibody products, CMS plans to set the payment rate in the same way it will set the payment rate for COVID-19 vaccines. The payment rate will be reasonable cost or 95% of the average wholesale price. A chart on p. 123 of the FAQ document shows payments rates by setting.nnCurrently, there is no separate payment for preparation of monoclonal antibodies, even if prepared for another provider or supplier. Monoclonal antibody products administered at a nonexcepted off-campus, provider-based department (PBD) will be paid at the full Outpatient Prospective Payment System (OPPS) rate. They will not be subject to the reduced rate (40% of the OPPS) that applies to other services provided at these facilities.nnDocumentation must support the medical necessity of the treatment as well as demonstrate that the terms of the applicable FDA emergency use authorization are met. The documentation must include the name of the practitioner who ordered the infusion.nnOther new and updated FAQs in Section BB include payment for monoclonal antibody treatment provided:n
The report below describes a patient undergoing a right inguinal hernia operation. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. nn