1. Chapter 15
CPT Surgery V

2. General Guidelines
CPT guidelines that apply to subsections are located at beginning of Surgery section
Unique code guidelines for each system are located in notes below headings or codes
Notes located beneath headings and/or subheadings apply to all codes in heading or subheading, respectively

3. Male Genital System Prostate Seminal vesicles Penis Testicles (testes)
Epididymis
Tunica vaginalis
Vas deferens
Scrotum
Spermatic cord
(continued)

4. Male Genital System
Delmar/Cengage Learning

5. Male Testicle
Delmar/Cengage Learning

6. Vasectomy Procedure
Delmar/Cengage Learning

7. Code Assignment Determine: Approach Reason for surgery
e.g., incision, destruction, excision, introduction
Reason for surgery

8. Varicocele Review operative report to locate type of approach
Laparoscopic
Abdominal
(continued)

9. Varicocele
Varicocele affecting left testicle
Delmar/Cengage Learning

10. Benign Prostatic Hypertrophy (BPH) Treatment
TURP
Subtotal open prostatectomy
Subtotal prepubic prostatectomy
Subtotal retropubic prostatectomy

11. TURP Performed to treat benign prostatic hypertrophy
Delmar/Cengage Learning

12. Prostate Biopsy
Review operative report to locate type of biopsy performed
Needle
Punch
Incisional

13. Intersex Surgery
Performed as series of staged procedures to transform normal adult genitalia of one sex to that of the other sex
Two codes
Male to female
Female to male

14. Female Genital System Vulva Perineum Introitus Vagina Cervix uteri
Uterus
Oviduct (fallopian tube)
Ovary
(continued)

15. Female Genital System
Delmar/Cengage Learning

16. Vulvectomy Procedures
Simple
Removal of skin and superficial subcutaneous tissue
Radical
Removal of skin and deep subcutaneous tissue
(continued)

17. Vulvectomy Procedures
Partial
Removal of less than 80 percent of vulvar area
Complete
Removal of greater than 80 percent of vulvar area

18. Hysteroscopy
Direct visualization of cervical canal and uterine cavity to examine endometrium to carry out surgical procedures
Dilation and curettage (D&C)
Removal of foreign body
Cervical polyp
Biopsy
Polypectomy

19. Laparoscopy (Hysteroscopy)
Delmar/Cengage Learning

20. Dilation
Expansion of cervical opening
Delmar/Cengage Learning

21. Curettage Removal of material from endometrial lining of uterus
Delmar/Cengage Learning

22. Vaginal Hysterectomy
(A) For vaginal hysterectomy, just uterus and cervix are removed; (B) For vaginal hysterectomy with bilateral salpingo-oophorectomy, cervix, uterus, fallopian tubes, and ovaries are removed
Delmar/Cengage Learning

23. Tubal Ligation
Delmar/Cengage Learning

24. Conization Removal of cone-shaped piece of tissue
Loop electrodissection conization
Thin wire loop used to perform deep dissection of cervix
Loop electrosurgical excision procedure (LEEP) electrodissection conization
Superficial dissection of cervix

25. Maternity Care and Delivery (Obstetrics)
Antepartum
Delivery
Postpartum

26. Pregnancy Divided into trimesters First Second Third
Fetal organ development
Second
Well visits
Third
Baby maturity
Delivery at 38 to 40 weeks

27. Coding Pregnancy
Three stages of pregnancy care include services provided as part of total obstetrical care
Antepartum
Delivery of baby
Postpartum

28. Total Obstetrical Care
Does not include the following:
Diagnostic procedures
e.g., ultrasound, amniocentesis, special screening tests
Physician office visits for conditions unrelated to pregnancy
Codes for these services reported separately from E/M and Medicine sections of CPT

29. Maternity Care and Delivery
Additional procedures performed on same day as maternity care and delivery service reported separately, except:
Fetal monitoring during labor
Episiotomy
Delivery of placenta

30. Antepartum Care Includes the following Initial and subsequent history
Physical examinations
Documentation of weight, blood pressure, and fetal heart tones
Routine chemical urinalysis
(continued)

31. Antepartum Care Includes the following
Monthly visits up to 28 weeks gestation
Biweekly visits up to 36 weeks gestation
Weekly visits until delivery
Included with total obstetrical care
Not reported separately

32. Delivery Services
Begins with admission to hospital and ends with delivery of placenta
(continued)

33. Delivery Services Includes the following Admission to hospital
Admission history and physical exam
Management of uncomplicated labor
Vaginal delivery
Induction of labor
Artificial rupture of membranes (AROM)

34. Stages of Labor
Delmar/Cengage Learning

35. Delivery Services
Report the following services separately with code from E/M or Surgery section of CPT
Management of surgical problems
Admission for observation prior to delivery
Medical complications that complicate management of labor and delivery
Tubal ligation performed after delivery

36. Endocrine System Includes 13 glands Two adrenal
Two gonads (female ovaries and male testes)
One pancreas (islets of Langerhans)
Four parathyroid
One pituitary (two lobes)
One thymus
Two thyroid

37. Endocrine Glands
Delmar/Cengage Learning

38. Nervous System Central nervous system Peripheral nervous system
Codes for procedures performed on pituitary and pineal glands located in nervous system subsection

39. Divisions of the Nervous System

40. Nervous System Structures
Delmar/Cengage Learning

41. Nervous System Central nervous system Peripheral nervous system
Brain and spinal cord
Peripheral nervous system
12 pairs of cranial nerves extending from brain
31 pairs of spinal nerves extending from spinal cord
(continued)

42. Nervous System Arranged anatomically Skull, meninges, and brain
Spine and spinal cord
Extracranial nerves, peripheral nerves, and autonomic nervous system

43. Skull, Meninges, and Brain
Injection, drainage, or aspiration
Twist drill, burr hole(s), or trephine
Craniectomy or craniotomy
(continued)

44. Skull, Meninges, and Brain
Surgery of skull base
Approach procedures
Definitive procedures
Repair and/or reconstruction of surgical defects of skull base
Endovascular therapy
(continued)

45. Skull, Meninges, and Brain
Surgery of aneurysm, arteriovenous malformation, or vascular disease
Stereotaxis
Neuroendoscopy
Repair
Cerebrospinal fluid (CSF) shunt
(continued)

46. Skull, Meninges, and Brain
Delmar/Cengage Learning

47. Skull Base Surgery Review operative report to identify the following
Size of lesion or tumor
Anatomy of patient
Whether initial procedure to treat condition or reoperation
Codes arranged anatomically
Anterior, middle, and posterior cranial fossae

48. Cerebrospinal Shunt
Allows drainage of CSF from brain into peritoneal cavity
Delmar/Cengage Learning

49. Spine and Spinal Cord Anatomic site
Epidural
Facet joint nerves
Diagnostic or therapeutic procedure
(continued)

50. Spine and Spinal Cord Type of substance injected
Contrast media
Neurolytic substance
Whether injections are continuous

51. Catheter Implantation
Penetration of dura
Epidural
Intrathecal
Percutaneous placement

52. Posterior Extradural Laminotomy
Exploration/decompression of neural element
Excision of herniated intervertebral disks
Laminotomy (hemilaminectomy)
Anatomic site
Surgical approach
Type of procedure performed

53. Exploration/Decompression
Posterolateral extradural
Transpedicular approach
Costovertebral approach
Discectomy or corpectomy
Anterior approach
Anterolateral approach
Lateral extracavitary approach (LECA)

54. Excision by Laminectomy
Lesion other than herniated disk
Anatomic site
Cervical
Thoracic
Lumbar
Sacral
(continued)

55. Excision by Laminectomy
Type of procedure performed
Excision of occlusion of arteriovenous malformation of spinal cord
Excision or evacuation of intraspinal lesion other than neoplasm extradural
(continued)

56. Excision by Laminectomy
Type of procedure performed
Excision of intraspinal lesion other than neoplasm intradural
Biopsy/excision of intraspinal neoplasm, extradural, or intradural

57. Extracranial, Peripheral Nerves, and Autonomic Nervous System
Anatomic site
Somatic nerve
Sympathetic nerve
Type of procedure
Injection
Neurostimulator

58. Introduction/Injection of Anesthetic Agent
Nerve block
Diagnostic
Therapeutic
Type of substance
Anesthetic
Neurolytic
(continued)

59. Introduction/Injection of Anesthetic Agent
Nerve involved
Somatic
Sympathetic
Type of block
Single
Multiple
Regional
Duration of infusion

60. Destruction by Neurolytic Agent
Chemical
Thermal
Electrical
Radiofrequency

61. Neuroplasty Exploration Neurolysis Nerve decompression
Carpal tunnel release

62. Eye and Ocular Adnexa Eyeball Anterior segment Posterior segment
Conjunctiva
(continued)

63. Eye and Ocular Adnexa
Delmar/Cengage Learning

64. Ophthalmologic Procedures
Also located in Surgery section of CPT, with subsections
Integumentary system
Musculoskeletal system

65. Anterior Segment
Corneal transplant
Radial keratotomy
(continued)

66. Anterior Segment Included in cataract removal
Anterior and posterior capsulotomy
Iridectomy
Iridotomy
Lateral canthotomy
Subconjunctival or subtenon injections
Use of viscoelastic agent
Implantation of intraocular lens (IOL) prosthesis

67. Cataract Surgical Methods
Intracapsular cataract extraction (ICCE)
Extracapsular cataract extraction (ECCE)

68. Cataract Extraction Placement of intraocular lens
Delmar/Cengage Learning

69. Posterior Segment Reported procedure performed on: Vitreous Retina
Choroid
Sclera

70. Ocular Adnexa Orbit Eye muscles Eyelids Conjunctiva Lacrimal apparatus
Eye socket
Eye muscles
Eyelids
Conjunctiva
Lacrimal apparatus
Tear apparatus
(continued)

71. Ocular Adnexa
Do not report code microsurgical techniques requiring use of operating microscope

72. Auditory System External ear Middle ear
Auricle and external auditory meatus
Middle ear
Tympanic membrane and auditory ossicles
(continued)

73. Auditory System Inner ear Temporal bone (middle fossa approach)
Cochlea, saccule, acoustic nerve, semicircular canals, utricle, superior vestibular nerves, and inferior vestibular nerves
Temporal bone (middle fossa approach)

74. The Ear
Delmar/Cengage Learning

75. Removal of Impacted Cerumen
Delmar/Cengage Learning

76. Tympanoplasty
Delmar/Cengage Learning

77. Operating Microscope Subsection
When operating microscope used during surgical procedure to perform microsurgery techniques, report add-on code in addition to primary procedure code