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Chapter 12 CPT Surgery II.

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Presentation on theme: "Chapter 12 CPT Surgery II."— Presentation transcript:

1 Chapter 12 CPT Surgery II

2 Musculoskeletal Subsection
Arranged from head to toe according to body area Headings include the following General Head Neck Back and flank (continued)

3 Musculoskeletal Subsection
Headings include the following Spine Abdomen Shoulder Humerus Forearm and wrist Hand and fingers (continued)

4 Musculoskeletal Subsection
Headings include the following Pelvis and hip joint Femur (thigh region) and knee joint Leg (tibia and fibula) and ankle joint Foot and toes Application of casts and strapping Endoscopy/arthroscopy

5 Musculoskeletal Subheadings
Incision Excision Introduction or removal Repair, revision, and/or reconstruction Fracture or dislocation (continued)

6 Musculoskeletal Subheadings
Manipulation Arthrodesis Amputation Other procedures

7 Types of Fractures Closed fracture Dislocation Open fracture
Simple fracture Dislocation Luxation Open fracture Compound fracture

8 Fractures and Dislocations
Delmar/Cengage Learning (continued)

9 Fractures and Dislocations
Delmar/Cengage Learning (continued)

10 Fractures and Dislocations
Delmar/Cengage Learning

11 Fracture Treatment Three methods of closed fracture treatment
Manipulation Reduction Without manipulation Stabilize or immobilize With or without skeletal traction

12 Closed Manipulation (Reduction)
Fractured left humerus Delmar/Cengage Learning

13 Open Fracture Treatment
Percutaneous skeletal fixation Two types External fixation device Internal fixation device

14 External Fixation Fracture of femur epiphysis External fixation stabilizes bone and is removed after bone has healed Delmar/Cengage Learning

15 Internal Fixation Fracture of femoral neck Internal fixation pins are placed to stabilize bone permanently Delmar/Cengage Learning

16 Fracture Management Codes
Found throughout musculoskeletal subsection Pinning Open or closed treatment of fracture Application and removal of cast or splint Normal, uncomplicated follow-up care

17 General Subheadings include the following Incision Wound exploration
Excision Introduction or removal Replantation Grafts or implants Other procedures

18 Wound Exploration: Trauma
Results from penetrating trauma Surgical exploration Debridement Removal of foreign body Ligation or coagulation of blood vessels

19 Introduction or Removal
Removal of foreign body Insertion of surgical hardware Aspirations Injections

20 Replantation Surgical reattachment of finger, hand, toe, foot, leg, or arm that has been completely severed from person’s body (continued)

21 Replantation Includes the following Arthrodesis Cleansing Debridement
Internal fixation Repair of tendons

22 Modifier -52 Add to replantation code to indicate that patient suffered partially severed finger, hand, toe, foot, leg, or arm

23 Grafts (Implants) Key terms Autogenous Harvesting Allogenous grafts
Xenografts

24 Repair, Revision, and/or Reconstruction
LeFort I LeFort II Pyramidal fracture Colpocleisis LeFort procedure Wagstaff-LeFort fracture

25 Head Incision Excision Manipulation Head prosthesis
Temporomandibular joint (TMJ) disorder Head prosthesis Repair, revision, and/or reconstruction Fracture and/or dislocation

26 Neck and Thorax I&D Excisional biopsies
Repairs, revisions, and reconstruction Fracture and/or dislocation Back and flank

27 Spine (Vertebral Column)
Includes procedures performed on cervical, thoracic, and lumbar spine When reporting codes for spinal procedures, be sure to differentiate between spinal segments and interspaces

28 Spinal Deformities (a) Kyphosis (b) Lordosis (c) Scoliosis
Delmar/Cengage Learning

29 Incision Cervical Thoracic Cervicothoracic Lumbar Sacral Lumbosacral

30 Excision Add modifier -62 when two surgeons work together to perform spinal procedure during same operative session on same patient

31 Vertebral Body Percutaneous vertebroplasty
Performed to relieve pain due to vertebral compression fractures E.g., pathologic fractures due to osteoporosis

32 Arthrodesis Artificial ankylosis Lateral extracavitary approach
Surgical fixation of joint Lateral extracavitary approach Anterior or anterolateral approach Posterior, posterolateral, or lateral transverse process

33 Spinal Instrumentation
Spinal instrumentation procedures reported in addition to arthrodesis codes Add modifier -51 to code for instrumentation Bone graft procedures reported in addition to arthrodesis

34 Abdomen Subheadings Excision Other procedures

35 Shoulder Heading contains codes for the following Clavicle Scapula
Humerus head and neck Sternoclavicular joint Acromioclavicular joint Shoulder joint

36 Humerus (Upper Arm) and Elbow
Heading contains codes for the following Humerus Elbow Head and neck of radius Olecranon process

37 Forearm and Wrist Radius Ulna Carpal bones and joints

38 Hands and Fingers Two types of tendons Flexor Extensor (continued)

39 Hands and Fingers Tendon repair codes include the following procedures
Application of immobilization Extending excision Repair and closure of tendon sheath

40 Pelvis and Hip Joint Head and neck of femur (hip joint)

41 Femur (Thigh Region) and Knee Joint
Long bone to thigh Tibial plateaus Lower portion of femur Articulates with tibial (continued)

42 Femur (Thigh Region) and Knee Joint
Tibial Larger of two lower bones Knee Hinge joint comprised of bone, cartilage, ligaments, and tendons

43 Leg (Tibia and Fibula) and Ankle Joint

44 Foot and Toes Procedures Keller McBride Mitchell

45 Application of Cast and Strapping
Report codes when cast or splint application is the following Replacement procedure performed during or after period of follow-up care Initial service performed without restorative treatment or procedure to stabilize or protect fracture, dislocation, or another injury to provide comfort to patient

46 Endoscopy/Arthroscopy
Visual examination of interior of body cavity or organ Arthroscopy Visual examination of inside of joint Surgical endoscopy/arthroscopy Always includes diagnostic endoscopy/arthroscopy procedure

47 Arthroscope in Use Delmar/Cengage Learning

48 Respiratory System Subsection
Headings include the following Nose Accessory sinuses Larynx Trachea and bronchi Lungs and pleura Endoscopy

49 Respiratory System Delmar/Cengage Learning

50 Respiratory System Subheadings
Incision Excision Introduction and removal Removal of foreign body Repair (continued)

51 Respiratory System Subheadings
Destruction Endoscopy Other procedures

52 Nose Subheading Nose Nasal Septum Intranasal tissue Nasal turbinates
Inferior, middle, and superior Skin of nose

53 Upper Respiratory System
Structures of the upper respiratory system Delmar/Cengage Learning

54 Accessory Sinuses Subheading
Maxillary Frontal Ethmoid Sphenoid

55 Endoscopy Codes classify unilateral procedure unless code indicates otherwise Add modifier -50 to code if procedure performed bilaterally Diagnostic endoscopy includes inspection of interior of nasal cavity and its meatus, turbinates, and sphenoethmoid recess (continued)

56 Endoscopy Diagnostic endoscopy includes and is bundled into surgical endoscopy Administration of local anesthesia Electrocautery Access to different cavities Some shaving/debridement Extensive shaving/debridement has separate code (continued)

57 Endoscopy Diagnostic endoscopy includes and is bundled into surgical endoscopy Add right (-Rt) or left (-Lt) modifier to indicate which side endoscopy occurred Do not report if surgical procedure done

58 Larynx Subheading Epiglottis Larynx Inside trachea

59 Larynx and Vocal Cords View of larynx and vocal cords from above (A) Open during breathing (B) Cords vibrate together during speech Delmar/Cengage Learning

60 Laryngoscopy Laryngoscopy Direct Indirect Operating microscope
Visualization of back of throat, larynx, and vocal cords Direct Indirect Operating microscope Fiberoptic scope

61 Trachea and Bronchi Subheadings
Tracheoscopy Interior of trachea Bronchoscopy Interior of bronchus Tracheobronchoscopy Interior of trachea and bronchus

62 Trachea and Bronchi Trachea, bronchi, bronchial tree, and alveoli (air sacs) Delmar/Cengage Learning

63 Bronchoscopy Delmar/Cengage Learning

64 Lungs and Pleura Subheadings
Transplantation Surgical collapse therapy and thoracoplasty

65 Lungs and Pleura Delmar/Cengage Learning

66 Thoracentesis Thoracentesis Lung with pleural effusion
Delmar/Cengage Learning

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