1. Chapter 14
CPT Surgery IV

2. Mediastinum and Diaphragm Subsection
Space in thoracic cavity between lungs that contains aorta, esophagus, heart, and other structures
Diaphragm
Thin muscle below heart and lungs that separates chest from abdomen

3. Digestive System Organs
Delmar/Cengage Learning

4. Digestive Subsections
Excision
Incision
Repair
Excision/destruction
Introduction
Manipulation
(continued)

5. Digestive Subsections
Laparoscopy
Endoscopy
Enterostomy
Liver transplantation
Pancreas transplantation

6. Large Intestine
Delmar/Cengage Learning

7. Digestive System Subsection
Procedures classified first by anatomic site and then by type
Codes reported for open, endoscopic, and laparoscopic procedures
CPT Medicine section contains codes for digestive system procedures

8. Gastrostomy Surgical creation of artificial opening into the stomach
Delmar/Cengage Learning

9. Oral Cavity Lips Vestibule of mouth Tongue and floor of mouth
Dentoalveolar structures
Palate and uvula
Salivary glands and ducts
(continued)

10. Oral Cavity
Delmar/Cengage Learning

11. Cleft Palate and Nasal Deformities
Review operative record to identify whether procedure is:
Primary or secondary
One-stage or two-stage
More complicated plastic repair of cleft lip or nasal using cross-lip pedicle flap

12. Child with Cleft Palate
Before and after treatment
Delmar/Cengage Learning

13. Vestibule of Mouth Incision Excision/destruction Repair
Other procedure (unlisted)

14. Tongue and Floor of Mouth
Incision
Excision
Repair
Other procedure (unlisted)
(continued)

15. Tongue and Floor of Mouth
When reporting codes for excision of tongue lesion, review operative note to identify:
Location of lesion
Type of lesion

16. Dentoalveolar Structures
reported for procedures on teeth or gums
Most commonly performed dental procedures found in Current Dental Terminology (CDT) and HCPCS level II

17. Palate and Uvula
reported for procedures on hard and soft palates
Palatopharyngoplasty
Treat oropharyngeal obstruction to cure extreme cases of snoring with or without sleep apnea

18. Pharynx, Adenoids, and Tonsils
Pharynx contains three segments
Nasopharynx
Oropharynx
Hypopharynx

19. Tonsillectomy and Adenoidectomy
Code determined by:
Type of procedure
e.g., primary, secondary
Age of patient
Separate codes included to report hemorrhage control following tonsillectomy and adenoidectomy procedures
(continued)

20. Tonsillectomy and Adenoidectomy
Procedure:
Cryogenic
Electrocautery
Laser
Add modifier -78 to indicate return to OR for related procedure performed during global period

21. Esophagus 43020-43499 reported for procedure on esophagus
When assigning codes, review documentation to identify approach
(continued)

22. Esophagus Endoscopy Endoscopic injection Ligation Manipulation
Esophagogastroscopy
Esophagogastroduodenoscopy (EGD)
Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic injection
Ligation
Manipulation

23. Endoscopy Diagnostic Surgical
Performed to visualize abnormality or determine extent of disease
Surgical
Performed when anything in addition to visualization performed
(continued)

24. Endoscopy
When both procedures performed, report code for surgical endoscopy only

25. EGD
Delmar/Cengage Learning

26. Laparoscopy
Peritoneoscopy
Closed laparoscopy
Open laparoscopy

27. Stomach Gastrostomy Bariatric surgery Laparoscopic techniques
Gastric restriction procedures
Laparoscopic techniques
Roux-en-Y gastric bypass and small bowel restriction
Adjustable gastric band
(continued)

28. Stomach Gastrectomy Remove all/part of stomach to treat: Ulcers
Malignancy of the stomach

29. Gastrostomy Feeding
Delmar/Cengage Learning

30. Intestines Incision Excision Colectomy Remove all/part of right colon
Remove all/part of left colon
Remove all/part of rectosigmoid colon, rectum, and anus

31. Enterostomy
-ostomy
Surgically creating opening for discharge of body wastes
Classified according to portion of digestive tract brought to surface
May be permanent or temporary
(continued)

32. Enterostomy -ostomy Types: Colostomy Ileostomy
Continent ileostomy (Kock pouch)
(continued)

33. Enterostomy
-stoma
Located at end of ureter, small intestine, or large intestine
Can be viewed as protruding through abdominal wall

34. Coding Tips
Add modifier -52 when patient underwent full preparation and incomplete colonoscopy was performed
When multiple endoscopies performed during same operative session, report code for most extensive procedure

35. Endoscopy, Small Intestine, and Stoma
Jejunal feeding
Endoscopy for small intestine pouch
Ileoscopy through stoma
Colonoscopy through stoma
Introduction
(continued)

36. Endoscopy, Small Intestine, and Stoma
Repair codes ( ) are reported for procedures performed to repair small intestine
Other procedures
Implanting mesh or other prosthesis (44700)

37. Meckel’s Diverticulum and Mesentery
Diverticula
Small pouches (herniations) in colon
Diverticulosis
Presence of diverticula in mucosa and submucosal
Almost always in sigmoid colon
(continued)

38. Meckel’s Diverticulum and Mesentery
Common congenital abnormality of gastrointestinal (GI) tract that results in pouch in wall of small bowel
Excision
One of the treatments

39. Coding Tips Surgical endoscopy always includes diagnostic endoscopy
When multiple services provided during endoscopic procedure, report code for each
Multiple services reimbursed according to multiple endoscopic payment rules

40. Rectum
Proctosigmoidoscopy
Sigmoidoscopy
Colonoscopy

41. Removal of Polyps Hot biopsy forceps Bipolar cautery
Electrocautery snare
Cold biopsy forceps
Laser technique
e.g., YAG laser

42. Anus Hemorrhoidectomy Identify: Approach Location of hemorrhoids
e.g., internal, external
Whether fissurectomy also was performed
(continued)

43. Anus Fistulectomy Subcutaneous fistulectomy Submuscular fistulectomy
Complex fistulectomy
Second stage

44. Hemorrhoids: Internal and External
Delmar/Cengage Learning

45. Digestive Accessory Organs
Liver
Gallbladder
Bile ducts inside liver
Bile ducts outside liver
Hepatic ducts
(continued)

46. Digestive Accessory Organs
Common bile ducts
Cystic ducts
Pancreas
(continued)

47. Digestive Accessory Organs
Liver, gallbladder, and pancreas
Delmar/Cengage Learning

48. Cholecystectomy Open versus laparoscopically
When attempted laparoscopically and converted to open procedure, report code for open procedure only

49. Hernia Repair Determine: Hernia site Patient’s age Type of hernia
e.g., inguinal, femoral
Patient’s age
Type of hernia
Initial
Recurrent
(continued)

50. Hernia Repair
Determine:
Clinical presentation of hernia
Use of mesh

51. Inguinal and Umbilical Hernias
Delmar/Cengage Learning

52. Hernia Repair Includes the following Traditional/conventional Mesh
Laparoscopic

53. Urinary Subsection
Kidneys
Ureters
Urinary bladder
Urethra

54. Male Urinary System
Delmar/Cengage Learning

55. Female Urinary System

56. Urodynamic Procedures
Cystometrogram
Uroflowmetry
Urethral pressure profile (UPP)
Neuromuscular studies
Void pressure (VP) studies

57. Endoscopy of the Urinary System
Cystoscopy
Urethroscopy
Cystourethroscopy

58. Kidney Nephrectomy Type of procedure Surgical approach
Partial
Total
Surgical approach
Laparoscopic
Open
Other structures removed

59. Nephrolithotomy Removal of urinary calculi (stones) Code for site
Renal pelvis
Bladder
Urethra
(continued)

60. Nephrolithotomy Code for approach Open incision Percutaneous
Endoscopic
Extracorporeal shock wave lithotripsy (ESWL)

61. Locations of Renal Calculi
Common locations of renal calculi (stone) formation
Delmar/Cengage Learning

62. EWSL
Delmar/Cengage Learning

63. Ureter Procedures performed on ureters Open endoscopic or urethroscopy
Laparoscopic

64. Cystourethroscopy Diagnostic procedure Therapeutic procedure
Bladder biopsy
Therapeutic procedure
Removal of foreign body, calculus, and ureteral stent
Transurethral resection of the prostate (TURP)

65. Use of a Cystoscope
Delmar/Cengage Learning