1. SURGERY GUIDELINES AND GENERAL SURGERY
CHAPTER 17
SURGERY GUIDELINES AND GENERAL SURGERY
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2. Surgery Section 69990 Largest CPT Section Section format:
10021-_____
Divided by subspecialty
Integumentary
Cardiovascular
69990
How many subsections are included in the Surgery section of the CPT manual? (It has 19 subsections, with codes ranging from to Within the Surgery section, the Integumentary and Cardiovascular are among the more complex subsections.)
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3. Notes and Guidelines Throughout section
Information varied and extensive
“Must” reading
Guidelines are provided at the start of each section of the CPT. The information they contain allows the coder to appropriately interpret and report on the procedures and services included in that section.
Can subsections have their own notes with special instructions? (In addition to the general guidelines, each subsection, subheading, category, and subcategory of information included in the CPT is likely to have its own set of notes, including special instructions for use of the codes contained in that part of the CPT. These instructions must be followed for coding to be accurate.)
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4. CPT Manual Text Changes
Figure: 17.1
►◄ Indicates text changes from previous edition
Why is it important to note any changes in the CPT guidelines accompanying a revision of the CPT? (Revisions to the CPT are periodically released. New or revised text included in the CPT guidelines is indicated by an arrow placed at the start and end of the changed information, as shown here in Fig. 17–1.)
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5. Subsection Notes Subsection notes apply to entire subsection
Figure: 17.2
Subsection notes apply to entire subsection
As an example, consider the following notes from the Musculoskeletal System subsection shown in Fig. 17–2. Because this note is provided at the start of the subsection, it applies to the entire subsection.
Three critical pieces of information are provided:
Location of cast and strapping procedures—knowing this may speed up the process of locating a code.
If more than one cast or traction device is applied, an additional listing may be required. Failure to follow this note could result in underpayment for services rendered.
Definitions are provided for key terms that will be used throughout the section.
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6. Subheading Notes Subheading notes apply to entire subheading
Figure: 17.3
Subheading notes apply to entire subheading
On what basis are subheadings clustered within a subsection? (Subsections of the CPT may include subheadings to cluster together a group of related procedures or services. As with notes that appear under subsections, notes placed under a subheading will apply to all procedures and services within that portion of the CPT. The note listed in this example [Fig. 17–3] provides guidelines for coding bone grafting procedures within the Spine section and indicates that these instructions apply solely to this section.)
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7. Category Notes Category notes apply to entire category Figure: 17.4
Notes may also be placed at the start of a category of procedures or services, in which case they apply to all procedures and services within the category. Consider the example from the Grafts (Implants) category shown in Fig. 17–4. The note restricts use of certain codes to situations in which the graft has not already been used as part of the procedure.
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8. Subcategory Notes Subcategory notes apply to entire subcategory
Figure: 17.5
Subcategory notes apply to entire subcategory
The CPT also includes notes for subcategories of procedures and services, as shown in Fig. 17–5.
These notes apply to the entire subcategory.
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9. Additional Helpful Notes
Figure: 17.6
Parenthetical information
Parenthetical notes provide additional information that will aid the coder in making correct coding decisions (as shown in Fig. 17–6).
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10. Unlisted Procedure Codes
Used only when more specific Category I or Category III code not found
Written report accompanies submission
Each unlisted code service paid on case-by-case basis
Are there any circumstances for which one cannot assign a listed procedure code to a procedure or service? (Yes, when the procedure is not listed in the CPT, you would use an unlisted procedure code.)
What documentation is required for an unlisted procedure code? (A Special Report describing the procedure)
Category III codes may exist for procedures that lack a specific code within the CPT. In this case, the Category III code, and not the unlisted procedure code, must be used.
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11. Separate Procedure “Separate procedure” follows code description
Incidental to more major related procedure
Breast biopsy
Before radical mastectomy, same operative session, would not be coded, as only procedure performed, would be coded
Under what circumstances are minor procedures coded as separate procedures? (When they are the only services performed, or when they are performed along with other procedures that affect other body sites. When performed with another procedure, they are incidental to that procedure. For example, a breast biopsy performed prior to a radical mastectomy would NOT be coded as a separate procedure because it has material significance to the mastectomy and affects the same body area. However, if the biopsy were the only procedure performed, it would be coded with use of the separate procedure code.)
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12. Separate Procedure Reported When
Only procedure performed
With another procedure
On different ___
Unrelated to major procedure
site
Remember, “separate procedure” doesn’t mean that it was the only one performed. It only indicates how the code can be used.
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13. Minor Procedures bundle Often on service-by-service basis
Often do not have ______ of services
Third-party payer decides what is in a surgical bundle
Minor procedure for Medicare has 0 or 10-day global period
bundle
Minor procedures are often provided on a service-by-service basis because they lack significant elements of preoperative and postoperative follow-up and tend to be straightforward and limited in scope. Major surgical procedures, on the other hand, are often coded as a bundle of services that reflects the standard care the surgical patient can be expected to receive in connection with the procedure.
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14. Major Guideline of Surgical Packages
Major surgical procedures usually include:
__________ (before)
___________ (during)
___________ (after—also known as global period)
Minor complications
(Cont’d…)
Preoperative
Intraoperative
Postoperative
The surgical package includes a global package that consists of the preoperative examination, the surgical procedure, and the postoperative period.
When a patient is hospitalized and it is determined that he or she needs surgery, he or she would have a preoperative exam, and no E/M charges after this day can be billed if they are due to the reason the patient is having surgery.
The insurance companies set the postoperative (global) days period. Typically it is 10 or 90 days.
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15. Major Guideline of Surgical Packages
(…Cont’d)
One bundle—one price
Minor procedure may have no bundle
Varies by payer
How are individual components of a complex procedure billed as a surgical bundle? (The package of services is billed, rather than the individual components. These include the operation itself, local anesthesia, and typical follow-up care, one related E/M encounter prior to the procedure, and immediate follow-up care, including written orders.)
Which party determines the components of a specific surgical package? (Each third-party payer may define the package differently. It is important to be clear on the definitions the third-party payer has applied to these procedures when determining how to bill for them.)
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16. Major Guideline Example
Most payers specify __ days after major surgery
All services related to surgery are in package
Including preop, intraop, and postop
Separate reporting = Unbundling 90
What procedures or services that are related to surgery are billed separately from the surgical package?
When bundled services are delivered, all services provided during the standard postoperative period are included in the surgical package price. For major surgery, this period typically covers the 90 days following surgery.
When minor surgical procedures are delivered, preoperative and postoperative care are not typically bundled into a surgical package. Instead, all services are reported separately. The global period for minor procedures is 10 days following surgery.
General anesthesia is typically not bundled but rather is billed separately by the anesthesiologist.
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17. Never in Bundle anesthesiologist General anesthesia services
Reported separately by _____________
anesthesiologist
General anesthesia is a separate specialty and performed by an anesthesiologist. This is always separately reportable.
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18. Surgical Package
Minor procedure: preop and postop services are sometimes reported separately
Same day may be included in performance of the procedure
Can be reported separately if specified by payer
Many minor procedures have zero global days assigned to them. This allows for separate charges to be billed for preoperative and postoperative services.
This varies by payers.
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19. Minor Surgery Example Needle biopsy in office Report ________ (biopsy)
_______ (surgical tray)
Procedure
Supplies
If there are no global days assigned to a minor procedure, could you bill for the postoperative visit 3 days following the minor procedure? (Yes)
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20. Surgical Tray Needles, suture materials, wipes, drugs
Report surgical tray with
_____ CPT, Medicine section (Medicare bundles into procedure)
_____ HCPCS (not separately reported to Medicare)
99070
A4550
Is a surgical tray billable as a separate item? (The surgical tray is commonly included in minor surgical procedures. It is billable as a separate line item because it contains items not typically required for an office visit.)
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