© 2010 Delmar, Cengage Learning Chapter 11 CPT Surgery I

© 2010 Delmar, Cengage Learning Surgery Section Largest section Contains code and code descriptions Multiple codes describe similar procedures

© 2010 Delmar, Cengage Learning Overview Subsections organized anatomically Categories and subcategories organized within subsections

© 2010 Delmar, Cengage Learning Operative Report Review the operative report –Body system (e.g., digestive) –Anatomic site (e.g., stomach) –Surgical approach (e.g., laparotomy) –Type of procedure (e.g., removal) –Whether multiple procedures were performed

© 2010 Delmar, Cengage Learning Services Integral to a Procedure No separate code reported for: –Cleansing –Shaving and prepping patient’s skin –Draping and positioning patient –Inserting intravenous access for medication –Administering sedatives –Administering local, topical, or regional anesthesia (continued)

© 2010 Delmar, Cengage Learning Services Integral to a Procedure No separate code reported for: –Making incisions –Evaluating surgical fields –Treating simple adhesions –Irrigating wounds –Inserting and removing drains

© 2010 Delmar, Cengage Learning Organization of Surgery Section Guidelines –Located at beginning –Apply to all codes in the section Notes –Located throughout surgery section –Apply to a specific subsection, heading, or subheading (continued)

© 2010 Delmar, Cengage Learning Organization of Surgery Section 17 subsections (organ systems or anatomic sites): –General –Integumentary system (10040–19499) –Musculoskeletal system (20000–29999) –Respiratory system (30000–32999) –Cardiovascular system (33010–37799) –Hemic and lymphatic systems (38100–38999) (continued)

© 2010 Delmar, Cengage Learning Organization of Surgery Section 17 subsections (organ systems or anatomic sites): –Mediastinum and diaphragm (39000–39599) –Digestive system (40490–49999) –Urinary system (50010–53899) –Male genital system (54000–55899) –Intersex surgery (55970–55980) –Female genital system (56405–58999) (continued)

© 2010 Delmar, Cengage Learning Organization of Surgery Section 17 subsections (organ systems or anatomic sites): –Maternity care and delivery (59000–59899) –Endocrine system (60000–60699) –Nervous system (61000–64999) –Eye and ocular adnexa (65091–68899) –Auditory system (69000–69979)

© 2010 Delmar, Cengage Learning Surgery Subsections Diagnostic procedures Therapeutic surgical procedures (continued)

© 2010 Delmar, Cengage Learning Surgery Subsections Headings include: –Incision or incision and drainage (I&D) –Excision –Introduction or removal –Endoscopy –Repair, revision, and/or reconstruction –Destruction –Other procedure

© 2010 Delmar, Cengage Learning Key Terms Incision I&D Excision Endoscopy Repair Revision Reconstruction Graft Suture

© 2010 Delmar, Cengage Learning Types of Sutures (a) Simple interrupted sutures (b) Buried sutures (c) Running subcuticular sutures

© 2010 Delmar, Cengage Learning Methods of Destruction Chemosurgery Cryosurgery Electrosurgery Laser Surgical curettement

© 2010 Delmar, Cengage Learning Surgery Guidelines Physician services CPT surgical package definition Follow-up care for diagnostic procedures Follow-up care for therapeutic procedures Material supplied Reporting more than one procedure and/or service (continued)

© 2010 Delmar, Cengage Learning Surgery Guidelines Separate procedure Subsection information Unlisted service or procedure Special report Surgical destruction

© 2010 Delmar, Cengage Learning Surgical Package Includes the following services: –Local infiltration, digital block, or topical anesthesia –One related E/M service following decision for surgery History and physical (H&P) on date of procedure or immediately prior to procedure –Immediate postoperative care (continued)

© 2010 Delmar, Cengage Learning Surgical Package Includes the following services: –Documentation of postoperative physician orders –Evaluation of patient in postanesthesia recovery area –Typical postoperative follow-up care (e.g., removal of sutures)

© 2010 Delmar, Cengage Learning Global Surgical Package Includes surgical procedure and a standard package of preoperative, intraoperative, and postoperative services (continued)

© 2010 Delmar, Cengage Learning Global Surgical Package Includes: –Preoperative services –The day before the day of surgery for major procedures –The day of surgery for minor procedures –Intraoperative services –Complications following surgery (continued)

© 2010 Delmar, Cengage Learning Global Surgical Package Does not include: –Initial consultation to determine need for surgery –Visits unrelated to diagnosis –Services provided by other physicians –Diagnostic tests and procedures (continued)

© 2010 Delmar, Cengage Learning Global Surgical Package Does not include: –Clearly distinct surgical procedures during postoperative period that are not for treatment of complications –Treatment for postoperative complications that require a return trip to the operating room (OR) –Performance of a more extensive procedure if a less extensive procedure has failed

© 2010 Delmar, Cengage Learning Global Period Major surgery –90-day postoperative period Begins the day following surgery Includes a one-day preoperative period

© 2010 Delmar, Cengage Learning CMS Global Periods CPT Code Brief Description Global Period 59050Fetal monitoring with reportXXX 59160Dilatation and curettage after delivery Insertion of cervical dilator Obstetrical careMMM 59525Removal of uterus after Cesarean sectionZZZ 59812Treatment of miscarriage Maternity care procedureYYY

© 2010 Delmar, Cengage Learning Services to Be Coded during Postoperative Period Complications Exacerbations Recurrence Presence of other disease Injuries

© 2010 Delmar, Cengage Learning Materials Supplied Supplies commonly included in surgical packages: –Dressings –Tubing –Steri-Strips

© 2010 Delmar, Cengage Learning Add-On Codes Plus symbol (+) –Located next to add-on codes to describe a service that only can be reported in addition to a primary procedure

© 2010 Delmar, Cengage Learning Unlisted Service or Procedure Assigned when there is no specific code that accurately describes procedure performed

© 2010 Delmar, Cengage Learning Special Report Includes the following: –Description of the nature, extent, and need for the procedure –Time, effort, and equipment necessary –Complexity of symptoms –Concurrent problems –Final diagnosis –Pertinent physical findings –Follow-up care

© 2010 Delmar, Cengage Learning General Subsection fine-needle aspiration; without imaging guidance fine-needle aspiration; with imaging guidance Fine-needle aspiration –Removal of fluid from a cyst or cells from a solid mass

© 2010 Delmar, Cengage Learning Integumentary Section Key Terms Adjacent tissue transfer or rearrangement Biopsy Flap Graft Mohs microsurgery Paring and curettement Shaving

© 2010 Delmar, Cengage Learning Lesion Removal Excision—debridement Paring or cutting Biopsy Removal of skin tags Shaving of epidermal or dermal lesions (continued)

© 2010 Delmar, Cengage Learning Lesion Removal Excision—benign lesions Excision—malignant lesions Destruction

© 2010 Delmar, Cengage Learning Tips for Accurate Coding Review patient record to determine: –Method of removing lesion –Malignant or benign status of lesion –Site or body part where lesion is located –Size of lesion in centimeters (cm) –Type of wound closure/repair Simple repair is included with removal Intermediate and complex repair can be coded

© 2010 Delmar, Cengage Learning Wound Repair Procedures Calculate size of wound Add lengths of all wounds Report code for most complicated repair first Report codes 11040–11044 for skin debridement

© 2010 Delmar, Cengage Learning Measuring Lesions Lesions are measured in centimeters (cm) NOTE: 2.5 cm = 1 inch

© 2010 Delmar, Cengage Learning Adjacent Tissue Transfer Advancement flap Double pedicle flap Rotation flap Tissue rearrangement Z-plasty W-plasty V-Y plasty

© 2010 Delmar, Cengage Learning Graft Codes Autograft/Tissue cultured autograft Acellular dermal replacement Allograft/Tissue cultured allogeneic skin substitute Allograft, skin Xenograft, skin

© 2010 Delmar, Cengage Learning Types of Skin Grafts Free skin graft –Full-thickness –Split-thickness Pedicle skin graft

© 2010 Delmar, Cengage Learning Coding Skin Grafts Identify: –Type of graft Permanent or temporary Natural or manufactured graft material Use of skin components –Recipient site –Surface area of recipient site

© 2010 Delmar, Cengage Learning Other Key Terms Dermabrasion Abrasion Chemical peel Cervicoplasty Blepharoplasty Rhytidectomy

© 2010 Delmar, Cengage Learning Dermabrasion

© 2010 Delmar, Cengage Learning Other Key Terms Excision –Pressure or decubitus ulcers Graft for facial nerve paralysis Burn local treatment –Rule of nines Removal of sutures under anesthesia (continued)

© 2010 Delmar, Cengage Learning Other Key Terms Dress change under anesthesia Intravenous injection of agent Suction-assisted lipectomy

© 2010 Delmar, Cengage Learning Destruction Ablation of tissue by any method treatments Benign, pre-malignant, or malignant lesions –Electrosurgery –Cryosurgery –Laser –Chemical

© 2010 Delmar, Cengage Learning Breast Biopsies Fine-needle aspiration Needle core biopsy –Hand-operated needle –Stereotactic localization Open biopsy –Excisional biopsy –Incisional biopsy (continued)

© 2010 Delmar, Cengage Learning Breast Biopsies (a) Needle aspiration (b) Incisional biopsy

© 2010 Delmar, Cengage Learning Mastectomy Partial mastectomy Simple or total mastectomy –Radical –Modified radical

© 2010 Delmar, Cengage Learning Types of Mastectomy Procedures

© 2010 Delmar, Cengage Learning Breast Repair Elevation and transfer of flap Closure of donor site Breast contouring Insertion of breast implant or prosthesis when performed

© 2010 Delmar, Cengage Learning Breast Reconstruction Creation of breast pocket Elevation of abdominal flap Muscle dissection Flap transfer (continued)

© 2010 Delmar, Cengage Learning Breast Reconstruction Fascial closure (donor site) with or without mesh Abdominal closure including umbilicoplasty Breast contouring