1. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Michelle Cranney, MBA, RHIT, CCS-P, CPC Chapter 11 CPT Surgery I

2. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Surgery Section Largest section Contains code and code descriptions Multiple codes describe similar procedures

3. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Overview Subsections organized anatomically Categories and subcategories organized within subsections

4. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Operative Report Review –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

5. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Services Integral to a Procedure No separate code reported for the following –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)

6. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Services Integral to a Procedure No separate code reported for the following –Making incisions –Evaluating surgical fields –Treating simple adhesions –Irrigating wounds –Inserting and removing drains

7. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Organization of Surgery Section Guidelines –Located at beginning –Apply to all codes in section Notes –Located throughout surgery section –Apply to specific subsection, heading, or subheading (continued)

8. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Organization of Surgery Section 17 subsections (organ systems or anatomic sites): –General (10021-10022) –Integumentary system (10040-19499) –Musculoskeletal system (20000-29999) –Respiratory system (30000-32999) –Cardiovascular system (33010-37799) –Hemic and lymphatic systems (38100-38999) (continued)

9. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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)

10. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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)

11. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Surgery Subsections Diagnostic procedures Therapeutic surgical procedures (continued)

12. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Surgery Subsections Headings include –Incision or incision and drainage (I&D) –Excision –Introduction or removal –Endoscopy –Repair, revision, and/or reconstruction –Destruction –Other procedure

13. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Key Terms Incision I&D Excision Endoscopy Repair Revision Reconstruction Graft Suture

14. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Types of Sutures (a) Simple interrupted sutures; (b) Buried sutures; (c) Running subcuticular sutures Delmar/Cengage Learning

15. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Methods of Destruction Chemosurgery Cryosurgery Electrosurgery Laser Surgical curettement

16. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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)

17. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Surgery Guidelines Separate procedure Subsection information Unlisted service or procedure Special report Surgical destruction

18. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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)

19. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

20. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Global Surgical Package Includes surgical procedure and standard package of preoperative, intraoperative, and postoperative services (continued)

21. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Global Surgical Package Includes the following: –Preoperative services –Day before the day of surgery for major procedures –Day of surgery for minor procedures –Intraoperative services –Complications following surgery (continued)

22. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Global Surgical Package Does not include the following: –Initial consultation to determine need for surgery –Visits unrelated to diagnosis –Services provided by other physicians –Diagnostic tests and procedures (continued)

23. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Global Surgical Package Does not include the following: –Clearly distinct surgical procedures during postoperative period not for treatment of complications –Treatment for postoperative complications that require return trip to operating room (OR) –Performance of more extensive procedure if less extensive procedure has failed

24. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Global Period Major surgery –90-day postoperative period Begins the day following surgery Includes one-day preoperative period

25. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CMS Global Periods CPT Code Brief Description Global Period 59050Fetal monitoring with reportXXX 59160Dilatation and curettage after delivery010 59200Insertion of cervical dilator000 59400Obstetrical careMMM 59525Removal of uterus after Cesarean sectionZZZ 59812Treatment of miscarriage090 59899Maternity care procedureYYY

26. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Services to be Coded during Postoperative Period Complications Exacerbations Recurrence Presence of other disease Injuries

27. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Materials Supplied Supplies commonly included in surgical packages –Dressings –Tubing –Steri-Strips

28. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Add-On Codes Plus symbol (+) –Located next to add-on codes to describe service that only can be reported in addition to primary procedure

29. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Unlisted Service or Procedure Assigned when no specific code accurately describes procedure performed

30. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Special Report Includes the following –Description of nature, extent, and need for procedure –Time, effort, and equipment necessary –Complexity of symptoms –Concurrent problems –Final diagnosis –Pertinent physical findings –Follow-up care

31. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. General Subsection 10021 fine-needle aspiration; without imaging guidance 10022 fine-needle aspiration; with imaging guidance Fine-needle aspiration –Removal of fluid from cyst or cells from solid mass

32. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Integumentary Section Key Terms Adjacent tissue transfer or rearrangement Biopsy Flap Graft Mohs microsurgery Paring and curettement Shaving

33. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Lesion Removal Excision – debridement Paring or cutting Biopsy Removal of skin tags Shaving of epidermal or dermal lesions (continued)

34. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Lesion Removal Excision – benign lesions Excision – malignant lesions Destruction

35. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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 included with removal Intermediate and complex repair can be coded

36. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

37. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Measuring Lesions Lesions are measured in centimeters Note: 2.5 cm = 1 inch

38. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Adjacent Tissue Transfer Advancement flap Double pedicle flap Rotation flap Tissue rearrangement Z-plasty W-plasty V-Y plasty

39. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Graft Codes Autograft/tissue cultured autograft Acellular dermal replacement Allograft/tissue cultured allogeneic skin substitute Allograft, skin Xenograft, skin

40. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Types of Skin Grafts Free skin graft –Full-thickness –Split-thickness Pedicle skin graft

41. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

42. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Other Key Terms Dermabrasion Abrasion Chemical peel Cervicoplasty Blepharoplasty Rhytidectomy

43. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Dermabrasion Delmar/Cengage Learning

44. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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)

45. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Other Key Terms Dress change under anesthesia Intravenous injection of agent Suction-assisted lipectomy

46. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Destruction Ablation of tissue by any method treatments Benign, pre-malignant, or malignant lesions –Electrosurgery –Cryosurgery –Laser –Chemical

47. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Breast Biopsies Fine-needle aspiration Needle core biopsy –Hand-operated needle –Stereotactic localization Open biopsy –Excisional biopsy –Incisional biopsy (continued)

48. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Breast Biopsies Needle aspiration Incisional biopsy Delmar/Cengage Learning

49. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Mastectomy Partial mastectomy Simple or total mastectomy –Radical –Modified radical

50. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Types of Mastectomy Procedures Delmar/Cengage Learning

51. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Breast Repair Elevation and transfer of flap Closure of donor site Breast contouring Insertion of breast implant or prosthesis when performed

52. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Breast Reconstruction Creation of breast pocket Elevation of abdominal flap Muscle dissection Flap transfer Fascial closure with or without mesh –Donor site (continued)

53. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Breast Reconstruction Abdominal closure –Including umbilicoplasty Breast contouring