Chapter 12 CPT Surgery II

Musculoskeletal Subsection Arranged from head to toe according to body area Headings include the following General Head Neck Back and flank (continued)

Musculoskeletal Subsection Headings include the following Spine Abdomen Shoulder Humerus Forearm and wrist Hand and fingers (continued)

Musculoskeletal Subsection Headings include the following Pelvis and hip joint Femur (thigh region) and knee joint Leg (tibia and fibula) and ankle joint Foot and toes Application of casts and strapping Endoscopy/arthroscopy

Musculoskeletal Subheadings Incision Excision Introduction or removal Repair, revision, and/or reconstruction Fracture or dislocation (continued)

Musculoskeletal Subheadings Manipulation Arthrodesis Amputation Other procedures

Types of Fractures Closed fracture Dislocation Open fracture Simple fracture Dislocation Luxation Open fracture Compound fracture

Fractures and Dislocations Delmar/Cengage Learning (continued)

Fractures and Dislocations Delmar/Cengage Learning (continued)

Fractures and Dislocations Delmar/Cengage Learning

Fracture Treatment Three methods of closed fracture treatment Manipulation Reduction Without manipulation Stabilize or immobilize With or without skeletal traction

Closed Manipulation (Reduction) Fractured left humerus Delmar/Cengage Learning

Open Fracture Treatment Percutaneous skeletal fixation Two types External fixation device Internal fixation device

External Fixation Fracture of femur epiphysis External fixation stabilizes bone and is removed after bone has healed Delmar/Cengage Learning

Internal Fixation Fracture of femoral neck Internal fixation pins are placed to stabilize bone permanently Delmar/Cengage Learning

Fracture Management Codes Found throughout musculoskeletal subsection Pinning Open or closed treatment of fracture Application and removal of cast or splint Normal, uncomplicated follow-up care

General Subheadings include the following Incision Wound exploration Excision Introduction or removal Replantation Grafts or implants Other procedures

Wound Exploration: Trauma Results from penetrating trauma Surgical exploration Debridement Removal of foreign body Ligation or coagulation of blood vessels

Introduction or Removal Removal of foreign body Insertion of surgical hardware Aspirations Injections

Replantation Surgical reattachment of finger, hand, toe, foot, leg, or arm that has been completely severed from person’s body (continued)

Replantation Includes the following Arthrodesis Cleansing Debridement Internal fixation Repair of tendons

Modifier -52 Add to replantation code to indicate that patient suffered partially severed finger, hand, toe, foot, leg, or arm

Grafts (Implants) Key terms Autogenous Harvesting Allogenous grafts Xenografts

Repair, Revision, and/or Reconstruction LeFort I LeFort II Pyramidal fracture Colpocleisis LeFort procedure Wagstaff-LeFort fracture

Head Incision Excision Manipulation Head prosthesis Temporomandibular joint (TMJ) disorder Head prosthesis Repair, revision, and/or reconstruction Fracture and/or dislocation

Neck and Thorax I&D Excisional biopsies Repairs, revisions, and reconstruction Fracture and/or dislocation Back and flank

Spine (Vertebral Column) Includes procedures performed on cervical, thoracic, and lumbar spine When reporting codes for spinal procedures, be sure to differentiate between spinal segments and interspaces

Spinal Deformities (a) Kyphosis (b) Lordosis (c) Scoliosis Delmar/Cengage Learning

Incision Cervical Thoracic Cervicothoracic Lumbar Sacral Lumbosacral

Excision Add modifier -62 when two surgeons work together to perform spinal procedure during same operative session on same patient

Vertebral Body Percutaneous vertebroplasty Performed to relieve pain due to vertebral compression fractures E.g., pathologic fractures due to osteoporosis

Arthrodesis Artificial ankylosis Lateral extracavitary approach Surgical fixation of joint Lateral extracavitary approach Anterior or anterolateral approach Posterior, posterolateral, or lateral transverse process

Spinal Instrumentation Spinal instrumentation procedures reported in addition to arthrodesis codes Add modifier -51 to code for instrumentation Bone graft procedures reported in addition to arthrodesis

Abdomen Subheadings Excision Other procedures

Shoulder Heading contains codes for the following Clavicle Scapula Humerus head and neck Sternoclavicular joint Acromioclavicular joint Shoulder joint

Humerus (Upper Arm) and Elbow Heading contains codes for the following Humerus Elbow Head and neck of radius Olecranon process

Forearm and Wrist Radius Ulna Carpal bones and joints

Hands and Fingers Two types of tendons Flexor Extensor (continued)

Hands and Fingers Tendon repair codes include the following procedures Application of immobilization Extending excision Repair and closure of tendon sheath

Pelvis and Hip Joint Head and neck of femur (hip joint)

Femur (Thigh Region) and Knee Joint Long bone to thigh Tibial plateaus Lower portion of femur Articulates with tibial (continued)

Femur (Thigh Region) and Knee Joint Tibial Larger of two lower bones Knee Hinge joint comprised of bone, cartilage, ligaments, and tendons

Leg (Tibia and Fibula) and Ankle Joint

Foot and Toes Procedures Keller McBride Mitchell

Application of Cast and Strapping Report codes when cast or splint application is the following Replacement procedure performed during or after period of follow-up care Initial service performed without restorative treatment or procedure to stabilize or protect fracture, dislocation, or another injury to provide comfort to patient

Endoscopy/Arthroscopy Visual examination of interior of body cavity or organ Arthroscopy Visual examination of inside of joint Surgical endoscopy/arthroscopy Always includes diagnostic endoscopy/arthroscopy procedure

Arthroscope in Use Delmar/Cengage Learning

Respiratory System Subsection Headings include the following Nose Accessory sinuses Larynx Trachea and bronchi Lungs and pleura Endoscopy

Respiratory System Delmar/Cengage Learning

Respiratory System Subheadings Incision Excision Introduction and removal Removal of foreign body Repair (continued)

Respiratory System Subheadings Destruction Endoscopy Other procedures

Nose Subheading Nose Nasal Septum Intranasal tissue Nasal turbinates Inferior, middle, and superior Skin of nose

Upper Respiratory System Structures of the upper respiratory system Delmar/Cengage Learning

Accessory Sinuses Subheading Maxillary Frontal Ethmoid Sphenoid

Endoscopy Codes classify unilateral procedure unless code indicates otherwise Add modifier -50 to code if procedure performed bilaterally Diagnostic endoscopy includes inspection of interior of nasal cavity and its meatus, turbinates, and sphenoethmoid recess (continued)

Endoscopy Diagnostic endoscopy includes and is bundled into surgical endoscopy Administration of local anesthesia Electrocautery Access to different cavities Some shaving/debridement Extensive shaving/debridement has separate code (continued)

Endoscopy Diagnostic endoscopy includes and is bundled into surgical endoscopy Add right (-Rt) or left (-Lt) modifier to indicate which side endoscopy occurred Do not report if surgical procedure done

Larynx Subheading Epiglottis Larynx Inside trachea

Larynx and Vocal Cords View of larynx and vocal cords from above (A) Open during breathing (B) Cords vibrate together during speech Delmar/Cengage Learning

Laryngoscopy Laryngoscopy Direct Indirect Operating microscope Visualization of back of throat, larynx, and vocal cords Direct Indirect Operating microscope Fiberoptic scope

Trachea and Bronchi Subheadings Tracheoscopy Interior of trachea Bronchoscopy Interior of bronchus Tracheobronchoscopy Interior of trachea and bronchus

Trachea and Bronchi Trachea, bronchi, bronchial tree, and alveoli (air sacs) Delmar/Cengage Learning

Bronchoscopy Delmar/Cengage Learning

Lungs and Pleura Subheadings Transplantation Surgical collapse therapy and thoracoplasty

Lungs and Pleura Delmar/Cengage Learning

Thoracentesis Thoracentesis Lung with pleural effusion Delmar/Cengage Learning