1 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. CHAPTER 6 RESPIRATORY SYSTEM

2 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Respiratory System Anatomic site arrangementAnatomic site arrangement –Nose –Larynx Further subdivided by procedureFurther subdivided by procedure –Incision –Excision –Introduction –Removal of foreign body –Destruction –Endoscopy –Other procedures

3 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Endoscopy Endoscopy in all subheadings except NoseEndoscopy in all subheadings except Nose Each preceded by “Notes”Each preceded by “Notes”

4 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Endoscopy Rule One Code full extentCode full extent –Example: Procedure begins at mouth and ends at bronchial tube –Bronchial tube = full extent

5 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Endoscopy Rule Two Code correct approachCode correct approach Example, for removal:Example, for removal: –Interior lung lesion via endoscopy inserted through mouth –Exterior lung lesion via endoscopy inserted through skin Incorrect approach = incorrect code = incorrect reimbursementIncorrect approach = incorrect code = incorrect reimbursement

6 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Endoscopy Rule Three Surgical always includes diagnosticSurgical always includes diagnostic –Example: Diagnostic bronchial endoscopy beginsDiagnostic bronchial endoscopy begins Identifies foreign bodyIdentifies foreign body Removed (surgical endoscopy)Removed (surgical endoscopy)

7 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Multiple Procedures Frequent in respiratory codingFrequent in respiratory coding –Watch for bundled services –Medicare—reference the CCI edits Sequence primary procedure first, no modifierSequence primary procedure first, no modifier Sequence secondary procedures next, with -51Sequence secondary procedures next, with -51

8 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Bilateral Procedures (…Cont’d) Bilateral procedures often performedBilateral procedures often performed Format for reporting chosen by payerFormat for reporting chosen by payer –Example: Nasal lavage x x and and RT and LT31000-RT and LT Medicare requires one line item with modifier -50Medicare requires one line item with modifier -50

9 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Laryngoscopic Procedures Laryngoscopic Procedures Uses terms indirect and directUses terms indirect and direct Indirect: Tongue depressor with mirror used to view larynxIndirect: Tongue depressor with mirror used to view larynx Direct: Endoscopy passed into larynx; physician directly views vocal cordsDirect: Endoscopy passed into larynx; physician directly views vocal cords

10 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose ( ) Nose ( ) Used extensively by otorhinolaryngologists (ear, nose, and throat specialists ENT)Used extensively by otorhinolaryngologists (ear, nose, and throat specialists ENT) But also used by a wide variety of physiciansBut also used by a wide variety of physicians(Cont’d…)

11 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose ( ) (…Cont’d) When approach to nose:When approach to nose: External approach, use Integumentary System codesExternal approach, use Integumentary System codes Internal approaches use Respiratory System codesInternal approaches use Respiratory System codes

12 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Incision (30000, 30020) Bundled into Incision codes, drain or gauze insertion and removalBundled into Incision codes, drain or gauze insertion and removal Supplies reported separatelySupplies reported separately

13 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Excision ( ) From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby. Contains intranasal biopsy codesContains intranasal biopsy codes Polyp excision, by complexityPolyp excision, by complexity “Simple” involves polyps that are easy to remove“Simple” involves polyps that are easy to remove “Extensive” involves sessile polyps (thick base)“Extensive” involves sessile polyps (thick base) – More time consuming and requires a greater skill level (30115) Excision includes any method of destruction, even laserExcision includes any method of destruction, even laser Use -50 (bilateral) for both sidesUse -50 (bilateral) for both sides Reduction of turbinates, Reduction of turbinates,

14 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Introduction ( ) Common proceduresCommon procedures Example: Injections to shrink nasal turbinate tissueExample: Injections to shrink nasal turbinate tissue Displacement therapy (saline flush) performed through nose to remove mucusDisplacement therapy (saline flush) performed through nose to remove mucus Insertion of nasal buttonInsertion of nasal button

15 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Removal of Foreign Body ( ) Divided by whether removal at office or hospital (requires general anesthesia)Divided by whether removal at office or hospital (requires general anesthesia)

16 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Repair ( ) Many plastic surgery procedures, such as:Many plastic surgery procedures, such as: –Rhinoplasty (reshaping nose, internal and/or external) –Stated as “revision” or “primary” –Rhinoplasty for nasal deformity secondary to congenital cleft lip/palate –Septoplasty (rearrangement of nasal septum) Not included in a rhinoplasty Not included in a rhinoplasty

17 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Destruction (30801, 30802) Use of cauterization or ablation (removing by cutting)Use of cauterization or ablation (removing by cutting) Used for removal of excess nasal mucosa or to reduce turbinate inflammationUsed for removal of excess nasal mucosa or to reduce turbinate inflammation

18 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nasal Hemorrhage ( ) Code based on:Code based on: –Site of hemorrhage (anterior or posterior) –Control was simple or complex If a posterior hemorrhage, was it the initial or a subsequent procedure?If a posterior hemorrhage, was it the initial or a subsequent procedure?

19 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nasal Turbinates Figure: 6.4 Nasal turbinatesNasal turbinates Excision of turbinates is considered unilateralExcision of turbinates is considered unilateral If performed bilaterally, use modifier -50If performed bilaterally, use modifier -50

20 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nasal Reconstruction Codes for obtaining grafts for nasal reconstruction surgery are in Musculoskeletal subsectionCodes for obtaining grafts for nasal reconstruction surgery are in Musculoskeletal subsection Codes for other procedures on the nose are in Integumentary subsectionCodes for other procedures on the nose are in Integumentary subsection

21 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Destruction (30801, 30802) Based on intramural or superficial extent of destructionBased on intramural or superficial extent of destruction Intramural: Deeper mucosaIntramural: Deeper mucosa Superficial: Outer layer of mucosaSuperficial: Outer layer of mucosa

22 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Other Procedures ( ) Control of nasal hemorrhageControl of nasal hemorrhage –Packing –Ligation –Cauterization Anterior packing placed through noseAnterior packing placed through nose Posterior packing placed at very back of throatPosterior packing placed at very back of throat Code (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same sessionCode (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same session (Cont’d … )

23 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Other Procedures Anterior packingAnterior packing When surgery is performed solely to improve the patient’s appearance (no signs/symptoms), it is cosmeticWhen surgery is performed solely to improve the patient’s appearance (no signs/symptoms), it is cosmetic Non-covered under the Medicare program (diagnosis code V50.1)Non-covered under the Medicare program (diagnosis code V50.1) Figure: 6.5 (…Cont’d) (Cont’d…)

24 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Nose, Other Procedures A balloon may be inserted to further control bleedingA balloon may be inserted to further control bleeding Posterior hemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packingPosterior hemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packing Simple packing with gauze or anterior packing suggests a simple procedureSimple packing with gauze or anterior packing suggests a simple procedure Figure: 6.6 (…Cont’d)

25 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Accessory Sinuses, Incision, Excision, Endoscopy ( ) Codes for lavage (washing) of sinusesCodes for lavage (washing) of sinuses –Cannula (hollow tube) placed into sinus, saline solution flushed through Use -50 (bilateral) for both sidesUse -50 (bilateral) for both sides Sinusectomy: All sinus contents including mucous membranes are removedSinusectomy: All sinus contents including mucous membranes are removed Antrostomy: Making an opening into the sinusAntrostomy: Making an opening into the sinus An “antrotomy” means cutting into the sinusAn “antrotomy” means cutting into the sinus

26 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Larynx, Excision ( ) Laryngotomy: open surgical procedure to expose larynxLaryngotomy: open surgical procedure to expose larynx –For removal procedure (e.g., tumor) Sometimes confused with Trachea/Bronchi codes for tracheostomySometimes confused with Trachea/Bronchi codes for tracheostomy –Used to establish airflow

27 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Larynx, Introduction (31500, 31502) Endotracheal intubation is establishment of airwayEndotracheal intubation is establishment of airway Numerous CCI editsNumerous CCI edits Figure: 6.8

28 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Larynx, Repair ( ) Several plastic procedures and fracture repairsSeveral plastic procedures and fracture repairs Laryngoplasty procedures based on purposeLaryngoplasty procedures based on purpose

29 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Trachea and Bronchi, Incision ( ) Most codes: TracheostomyMost codes: Tracheostomy –Planned (ventilation support) –Emergency Divided by type:Divided by type: –Transtracheal or cricothyroid (Cont’d…)

30 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Trachea and Bronchi, Incision Figure: 6.9Figure: 6.10 (…Cont’d) Transtracheal approach and entryTranstracheal approach and entry

31 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Trachea and Bronchi, Incision Figure: 6.11Figure: 6.12 Cricothyroid approach and entryCricothyroid approach and entry (…Cont’d)

32 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Endoscopy ( ) Bronchoscope inserted into nose or mouthBronchoscope inserted into nose or mouth Rigid endoscopy performed under general anesthesiaRigid endoscopy performed under general anesthesia Flexible endoscopy performed under local or conscious sedationFlexible endoscopy performed under local or conscious sedation

33 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Trachea and Bronchi, Introduction ( ) CatheterizationCatheterization InstillationInstillation InjectionInjection AspirationAspiration Trachea tube placementTrachea tube placement Some include inhaled gas as contrast materialSome include inhaled gas as contrast material

34 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Intubation Endotracheal intubation involves a tube placed through the nose or mouth, through the pharynx and larynx, and into the trachea to establish an airwayEndotracheal intubation involves a tube placed through the nose or mouth, through the pharynx and larynx, and into the trachea to establish an airway

35 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Laryngoscopy Visual examination of the larynxVisual examination of the larynx Flexible lighted tube passed through mouth or nose into larynxFlexible lighted tube passed through mouth or nose into larynx

36 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Trachea and Bronchi, Excision, Repair ( ) Plastic repairs of tracheoplasty and bronchoplastyPlastic repairs of tracheoplasty and bronchoplasty

37 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Lungs and Pleura, Removal (32421, 32422) Figure: 6.14 Thoracentesis: needle or catheter inserted into pleural space for aspiration (withdrawal) of fluid or air for analysis, to drain pleural effusions, or to re-expand a collapsed lung (Cont’d…)

38 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Mediastinoscopy Visual examination of mediastinumVisual examination of mediastinum Procedure usually done in operating room with local or general anesthesiaProcedure usually done in operating room with local or general anesthesia Suprasternal (above the breastbone) incision is madeSuprasternal (above the breastbone) incision is made Procedure to remove biopsy samples of lymph nodes, tumors, or tuberculosisProcedure to remove biopsy samples of lymph nodes, tumors, or tuberculosis

39 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Lungs and Pleura, Removal (32421, 32422) Figure: 6.15 (Cont’d…) Chest tube may be inserted to drain fluid and is reported in addition to aspirationChest tube may be inserted to drain fluid and is reported in addition to aspiration(Cont’d…)

40 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Lungs and Pleura, Incision ( ) (…Cont’d) Thoracotomy: Surgical opening of chest to expose to viewThoracotomy: Surgical opening of chest to expose to view –Used for BiopsyBiopsy CystCyst Foreign body removalForeign body removal Cardiac massageCardiac massage

41 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Lungs and Pleura, Excision ( ) Biopsy codes in Excision and Incision categoriesBiopsy codes in Excision and Incision categories –Excisional biopsy done with percutaneous needle –Incisional biopsy done with chest open

42 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Lungs and Pleura, Excision/Incision Biopsy codes in Excision and Incision categoriesBiopsy codes in Excision and Incision categories –Excisional biopsy with percutaneous needle –Incisional biopsy with chest open Includes pneumocentesis and lung removalIncludes pneumocentesis and lung removal –Segmentectomy: 1 segment –Lobectomy: 1 lobe –Bilobectomy: 2 lobes –Total pneumonectomy: 1 lung

43 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Introduction (32550, 32551) Includes:Includes: –Insertion of tunneled indwelling pleural catheter –Tube thoracostomy Destruction (32560)Destruction (32560) –Chemical pleurodesis For recurrent persistent pneumothoraxFor recurrent persistent pneumothorax

44 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Thoracoscopy ( ) Diagnostic and surgical lung proceduresDiagnostic and surgical lung procedures Surgical thoracoscopy always includes diagnostic thoracoscopySurgical thoracoscopy always includes diagnostic thoracoscopy

45 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Conclusion CHAPTER 6 RESPIRATORY SYSTEM