Chapter 15 CPT Surgery V

General Guidelines CPT guidelines that apply to subsections are located at beginning of Surgery section Unique code guidelines for each system are located in notes below headings or codes Notes located beneath headings and/or subheadings apply to all codes in heading or subheading, respectively

Male Genital System Prostate Seminal vesicles Penis Testicles (testes) Epididymis Tunica vaginalis Vas deferens Scrotum Spermatic cord (continued)

Male Genital System Delmar/Cengage Learning

Male Testicle Delmar/Cengage Learning

Vasectomy Procedure Delmar/Cengage Learning

Code Assignment Determine: Approach Reason for surgery e.g., incision, destruction, excision, introduction Reason for surgery

Varicocele Review operative report to locate type of approach Laparoscopic Abdominal (continued)

Varicocele Varicocele affecting left testicle Delmar/Cengage Learning

Benign Prostatic Hypertrophy (BPH) Treatment TURP Subtotal open prostatectomy Subtotal prepubic prostatectomy Subtotal retropubic prostatectomy

TURP Performed to treat benign prostatic hypertrophy Delmar/Cengage Learning

Prostate Biopsy Review operative report to locate type of biopsy performed Needle Punch Incisional

Intersex Surgery Performed as series of staged procedures to transform normal adult genitalia of one sex to that of the other sex Two codes Male to female Female to male

Female Genital System Vulva Perineum Introitus Vagina Cervix uteri Uterus Oviduct (fallopian tube) Ovary (continued)

Female Genital System Delmar/Cengage Learning

Vulvectomy Procedures Simple Removal of skin and superficial subcutaneous tissue Radical Removal of skin and deep subcutaneous tissue (continued)

Vulvectomy Procedures Partial Removal of less than 80 percent of vulvar area Complete Removal of greater than 80 percent of vulvar area

Hysteroscopy Direct visualization of cervical canal and uterine cavity to examine endometrium to carry out surgical procedures Dilation and curettage (D&C) Removal of foreign body Cervical polyp Biopsy Polypectomy

Laparoscopy (Hysteroscopy) Delmar/Cengage Learning

Dilation Expansion of cervical opening Delmar/Cengage Learning

Curettage Removal of material from endometrial lining of uterus Delmar/Cengage Learning

Vaginal Hysterectomy (A) For vaginal hysterectomy, just uterus and cervix are removed; (B) For vaginal hysterectomy with bilateral salpingo-oophorectomy, cervix, uterus, fallopian tubes, and ovaries are removed Delmar/Cengage Learning

Tubal Ligation Delmar/Cengage Learning

Conization Removal of cone-shaped piece of tissue Loop electrodissection conization Thin wire loop used to perform deep dissection of cervix Loop electrosurgical excision procedure (LEEP) electrodissection conization Superficial dissection of cervix

Maternity Care and Delivery (Obstetrics) Antepartum Delivery Postpartum

Pregnancy Divided into trimesters First Second Third Fetal organ development Second Well visits Third Baby maturity Delivery at 38 to 40 weeks

Coding Pregnancy Three stages of pregnancy care include services provided as part of total obstetrical care Antepartum Delivery of baby Postpartum

Total Obstetrical Care Does not include the following: Diagnostic procedures e.g., ultrasound, amniocentesis, special screening tests Physician office visits for conditions unrelated to pregnancy Codes for these services reported separately from E/M and Medicine sections of CPT

Maternity Care and Delivery Additional procedures performed on same day as maternity care and delivery service reported separately, except: Fetal monitoring during labor Episiotomy Delivery of placenta

Antepartum Care Includes the following Initial and subsequent history Physical examinations Documentation of weight, blood pressure, and fetal heart tones Routine chemical urinalysis (continued)

Antepartum Care Includes the following Monthly visits up to 28 weeks gestation Biweekly visits up to 36 weeks gestation Weekly visits until delivery Included with total obstetrical care Not reported separately

Delivery Services Begins with admission to hospital and ends with delivery of placenta (continued)

Delivery Services Includes the following Admission to hospital Admission history and physical exam Management of uncomplicated labor Vaginal delivery Induction of labor Artificial rupture of membranes (AROM)

Stages of Labor Delmar/Cengage Learning

Delivery Services Report the following services separately with code from E/M or Surgery section of CPT Management of surgical problems Admission for observation prior to delivery Medical complications that complicate management of labor and delivery Tubal ligation performed after delivery

Endocrine System Includes 13 glands Two adrenal Two gonads (female ovaries and male testes) One pancreas (islets of Langerhans) Four parathyroid One pituitary (two lobes) One thymus Two thyroid

Endocrine Glands Delmar/Cengage Learning

Nervous System Central nervous system Peripheral nervous system Codes for procedures performed on pituitary and pineal glands located in nervous system subsection

Divisions of the Nervous System

Nervous System Structures Delmar/Cengage Learning

Nervous System Central nervous system Peripheral nervous system Brain and spinal cord Peripheral nervous system 12 pairs of cranial nerves extending from brain 31 pairs of spinal nerves extending from spinal cord (continued)

Nervous System Arranged anatomically Skull, meninges, and brain Spine and spinal cord Extracranial nerves, peripheral nerves, and autonomic nervous system

Skull, Meninges, and Brain Injection, drainage, or aspiration Twist drill, burr hole(s), or trephine Craniectomy or craniotomy (continued)

Skull, Meninges, and Brain Surgery of skull base Approach procedures Definitive procedures Repair and/or reconstruction of surgical defects of skull base Endovascular therapy (continued)

Skull, Meninges, and Brain Surgery of aneurysm, arteriovenous malformation, or vascular disease Stereotaxis Neuroendoscopy Repair Cerebrospinal fluid (CSF) shunt (continued)

Skull, Meninges, and Brain Delmar/Cengage Learning

Skull Base Surgery Review operative report to identify the following Size of lesion or tumor Anatomy of patient Whether initial procedure to treat condition or reoperation Codes arranged anatomically Anterior, middle, and posterior cranial fossae

Cerebrospinal Shunt Allows drainage of CSF from brain into peritoneal cavity Delmar/Cengage Learning

Spine and Spinal Cord Anatomic site Epidural Facet joint nerves Diagnostic or therapeutic procedure (continued)

Spine and Spinal Cord Type of substance injected Contrast media Neurolytic substance Whether injections are continuous

Catheter Implantation Penetration of dura Epidural Intrathecal Percutaneous placement

Posterior Extradural Laminotomy Exploration/decompression of neural element Excision of herniated intervertebral disks Laminotomy (hemilaminectomy) Anatomic site Surgical approach Type of procedure performed

Exploration/Decompression Posterolateral extradural Transpedicular approach Costovertebral approach Discectomy or corpectomy Anterior approach Anterolateral approach Lateral extracavitary approach (LECA)

Excision by Laminectomy Lesion other than herniated disk Anatomic site Cervical Thoracic Lumbar Sacral (continued)

Excision by Laminectomy Type of procedure performed Excision of occlusion of arteriovenous malformation of spinal cord Excision or evacuation of intraspinal lesion other than neoplasm extradural (continued)

Excision by Laminectomy Type of procedure performed Excision of intraspinal lesion other than neoplasm intradural Biopsy/excision of intraspinal neoplasm, extradural, or intradural

Extracranial, Peripheral Nerves, and Autonomic Nervous System Anatomic site Somatic nerve Sympathetic nerve Type of procedure Injection Neurostimulator

Introduction/Injection of Anesthetic Agent Nerve block Diagnostic Therapeutic Type of substance Anesthetic Neurolytic (continued)

Introduction/Injection of Anesthetic Agent Nerve involved Somatic Sympathetic Type of block Single Multiple Regional Duration of infusion

Destruction by Neurolytic Agent Chemical Thermal Electrical Radiofrequency

Neuroplasty Exploration Neurolysis Nerve decompression Carpal tunnel release

Eye and Ocular Adnexa Eyeball Anterior segment Posterior segment Conjunctiva (continued)

Eye and Ocular Adnexa Delmar/Cengage Learning

Ophthalmologic Procedures Also located in Surgery section of CPT, with subsections Integumentary system Musculoskeletal system

Anterior Segment Corneal transplant Radial keratotomy (continued)

Anterior Segment Included in cataract removal Anterior and posterior capsulotomy Iridectomy Iridotomy Lateral canthotomy Subconjunctival or subtenon injections Use of viscoelastic agent Implantation of intraocular lens (IOL) prosthesis

Cataract Surgical Methods Intracapsular cataract extraction (ICCE) Extracapsular cataract extraction (ECCE)

Cataract Extraction Placement of intraocular lens Delmar/Cengage Learning

Posterior Segment Reported procedure performed on: Vitreous Retina Choroid Sclera

Ocular Adnexa Orbit Eye muscles Eyelids Conjunctiva Lacrimal apparatus Eye socket Eye muscles Eyelids Conjunctiva Lacrimal apparatus Tear apparatus (continued)

Ocular Adnexa Do not report code 69990 microsurgical techniques requiring use of operating microscope

Auditory System External ear Middle ear Auricle and external auditory meatus Middle ear Tympanic membrane and auditory ossicles (continued)

Auditory System Inner ear Temporal bone (middle fossa approach) Cochlea, saccule, acoustic nerve, semicircular canals, utricle, superior vestibular nerves, and inferior vestibular nerves Temporal bone (middle fossa approach)

The Ear Delmar/Cengage Learning

Removal of Impacted Cerumen Delmar/Cengage Learning

Tympanoplasty Delmar/Cengage Learning

Operating Microscope Subsection When operating microscope used during surgical procedure to perform microsurgery techniques, report add-on code in addition to primary procedure code