The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 8 Surgery Coding: Part 2 Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

Learning Outcomes Correctly apply the guidelines for coding surgical procedures. Recognize when an add-on code is required. Identify services included in a procedure code. 8-2

Learning Outcomes Distinguish separately reportable services. Ascertain the elements of coding an organ transplant. Determine how and when to use modifiers. 8-3

Introduction In CPT, the term surgery does not limit itself to just those services performed in an operating room but also to tests, treatments, and other services. 8-4

Musculoskeletal System All codes in this subsection already include: The application of a cast or traction device. The removal of a cast or traction device. 8-5

Musculoskeletal System Penetrating Trauma Wounds Differ from other types of wounds because they require: –Surgery to explore the wound. –Determination of depth & complexity. –Identification of additional damage. –Debridement. –Ligation of subcutaneous tissue. 8-6

Musculoskeletal System Bone Grafts and Implants Different than skin grafts Bone, cartilage, tendon, and fascia lata grafts are coded from this subsection. 8-7

Musculoskeletal System Spinal Procedures Arthrodesis Osteotomy Fracture care Vertebral corpectomy Laminectomy 8-8

Musculoskeletal System Fractures and Dislocations Closed treatments Open treatments Percutaneous skeletal fixation 8-9

Respiratory System Lung Transplantation Cadaver donor pneumonectomy Backbench work Recipient lung allotransplantation 8-10

Cardiovascular System Pacemakers Pacing Cardioverter- Defibrillators Battery replacement 8-11

Cardiovascular System Bypass Grafting Venous grafts: Codes include the acquisition of the saphenous vein (only) graft Combined Arterial-Venous grafts Arterial grafts Composite grafts 8-12

Cardiovascular System Heart/Lung Transplantation Cadaver donor cardiectomy with or without pneumonectomy Backbench work Recipient heart with or without lung allotransplantation 8-13

Cardiovascular System Arteries and Veins Primary vascular procedures Repair of an abdominal aortic aneurysm Endovascular repair of an iliac aneurysm 8-14

Digestive System Intestinal Transplantation Cadaver or living donor enterectomy Backbench work Recipient intestinal allotransplantation with or without recipient enterectomy 8-15

Digestive System Liver Transplantation Cadaver or living donor hepatectomy Backbench work Recipient liver allotransplantation 8-16

Digestive System Pancreas Transplantation Cadaver donor pancreatectomy Backbench work Recipient pancreatic allotransplantation 8-17

Urinary System Renal (kidney) Transplantation Cadaver or living donor nephrectomy Backbench work Recipient renal allotransplantation 8-18

Urinary System Urodynamics Includes two parts: Technical component Professional component 8-19

Urinary System Transurethral Surgery Diagnostic or therapeutic cystourethroscopic intervention Includes insertion and removal of temporary stent 8-20

Genital Systems Female Genital System Vulvectomy Identify from documentation whether: - Simple - Partial - Radical - Complete 8-21

Nervous System Skull Surgery Often involves more than one surgeon Code includes: Insertion of epidural catheter Removal of catheter Procedure injections Fluoroscopic guidance Multiple adhesiolysis sessions 8-22

Chapter Summary Coding surgical procedures will require determining those services included and those that must be coded separately. 8-23