1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 8-1 Chapter 8 Surgery Coding, Part 2

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives 8.1 Correctly apply the guidelines for coding procedures on the musculoskeletal system. 8.2 Recognize the details required to accurately report procedures on the respiratory system. 8.3 Identify guidelines to direct reporting services to the cardiovascular system. 8-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives (cont.) 8.4 Distinguish the various procedures on the digestive system. 8.5 Ascertain the elements of coding services to the urinary system. 8.6 Determine how to accurately report procedures to the male genital system. 8.7 Apply the guidelines to report procedures to the female genital system. 8-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives (cont.) 8.8 Interpret documentation to accurately report procedures on the nervous system. 8.9 Recognize the necessary details to report procedures on the eye and ocular adnexa. 8.10 Report accurately procedures on the auditory system. 8-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Allotransplantation Arthrodesis Closed treatment Laminectomy Manipulation 8-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Open treatment Percutaneous skeletal fixation Saphenous vein Transplantation 8-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgery In CPT, the term surgery does not limit itself to just those services performed in an operating room –Incision and drainage of a cyst –Debridement –Simple repair of superficial wound 8-7

8. © 2016 McGraw-Hill Education. All rights reserved. MUSCULOSKELETAL SYSTEM 1-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System The Code Package –The application of a cast or traction device –The removal of a cast or traction device If second cast needed, code separately for application and removal –Codes 29000–29799 8-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System (cont.) Open Treatment –Procedure provided to treat a fractured bone that is surgically or remotely opened Closed Treatment –Procedure performed With or without manipulation With or without traction Without fracture being opened and visualized 8-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System (cont.) Penetrating Trauma Wounds –Differ from other types of wounds because they require Surgery to explore the wound Determination of depth & complexity Identification of additional damage Debridement Ligation of subcutaneous tissue 8-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System (cont.) Bone Grafts and Implants –Differ from skin grafts –Bone, cartilage, tendon, and fascia lata grafts are coded from this subsection 8-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System (cont.) Spine –Arthrodesis Lateral extracavitary technique Anterior transoral or extraoral technique Anterior interbody technique Posterior technique: craniocervical or atlas-axis Posterior or posterolateral technique Posterior interbody technique with number of interspaces treated 8-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System (cont.) Spine (cont.) –Laminotomy Used to treat lumbar disc herniation Codes 63020 and 63030 Differentiate cervical or lumbar Spinal Fusion –Permanently locks two or more spinal vertebrae together so that they move as a single unit 8-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System (cont.) Lumbar Puncture (Spinal Tap) –Needle inserted between two lumbar vertebrae to collect cerebrospinal fluid (CSF) –Codes 62270, 62272 –Differentiate reason for procedure 8-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Musculoskeletal System (cont.) Fractures and Dislocations –Closed treatments –Open treatments –Percutaneous skeletal fixation Fracture Treatments –Reduction or manipulation may be necessary to realign the bone pieces –Internal fixation and external fixation 8-16

17. © 2016 McGraw-Hill Education. All rights reserved. RESPIRATORY SYSTEM 1-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Respiratory System Sinus Endoscopy –Standard includes assessment of interior nasal cavity, the middle and superior meatus, the turbinates, and the sphenoethmoid recess –Code descriptions include both the sinusotomy and a diagnostic endoscopy 8-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Respiratory System (cont.) Lung Transplantation –Cadaver Donor Pneumonectomy Code 32850 –Backbench work Preparation of the cadaver prior to the transplant procedure Codes 32855,32856 Differentiate unilateral or bilateral 8-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Respiratory System (cont.) Lung Transplantation (cont.) –Recipient Lung Allotransplantation Identifies allograft in patient Codes 32851–32854 Differentiate unilateral, bilateral, with or without cardiopulmonary bypass 8-20

21. © 2016 McGraw-Hill Education. All rights reserved. CARDIOVASCULAR SYSTEM 1-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System Pacemakers –Single-chamber pacemaker includes pulse generator and one electrode in atrium or ventricle –Dual-chamber includes pulse generator and electrode in both the atrium and ventricle 8-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Pacing Cardioverter-Defibrillators –Similar to pacemaker with the addition of several leads in one to two chambers Battery Replacement –Removal of the old pulse generator and the insertion of a new pulse generator 8-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Bypass Grafting –Venous Grafts Codes 33510–33516 include saphenous vein graft Combined Arterial-Venous Grafts –Use two codes when venous and arterial grafts are used during the same procedure –First code combined arterial-venous graft from the range 33517–33523 8-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Arterial Grafts –Codes 33533–33545 –Additional code needed if harvested from another site From an upper extremity artery, add code 35600 From an upper extremity vein, add code 35500 From the femoropopliteal vein, use code 35572 8-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Composite Grafts –When two or more vein segments are harvested from a limb other than that part of the body undergoing the bypass –Use codes 35682–35683 8-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Heart/Lung Transplantation –Three steps performed by single physician or team Cadaver donor cardiectomy with or without a pneumonectomy –Code 33930 heart and lungs –Code 33940 heart only 8-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Heart/Lung Transplantation (cont.) –Backbench work Preparation of the cadaver prior to the transplant procedure Code 33933 heart and lung Code 33944 heart only 8-28

29. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Heart/Lung Transplantation (cont.) –Recipient Heart with or without Lung Allotransplantation Placement of the allograft into the patient Code 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy Code 33945 Heart transplant with or without recipient cardiectomy Codes for the insertion of the transplanted organs include the removal of the damaged or diseased organs 8-29

30. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Arteries and Veins –Primary vascular procedure codes 34001– 37799 include Ensuring both the inflow and the outflow of the arteries and/or veins involved The operative arteriogram that is performed by the surgeon during the procedure Sympathectomy for aortic procedures 8-30

31. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Repair of Abdominal Aortic Aneurysm –Codes 34800–34826 include: Placement of an endovascular graft for an abdominal aortic aneurysm repair Open femoral or iliac artery exposure Manipulation and deployment of the device used Closure of the arteriotomy site(s) Balloon angioplasty and/or stent deployment, as long as it is within the target treatment area for the endoprosthesis 8-31

32. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Repair of Abdominal Aortic Aneurysm (cont.) –Other procedures performed at the same time coded separately The introduction of guidewires and/or catheters Extensive repair or replacement of an artery Renal transluminal angioplasty Arterial embolization Intravascular ultrasound Balloon angioplasty Stenting of the native artery outside of the endoprosthesis area Fluoroscopic guidance in conjunction with the repair 8-32

33. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Repair of Iliac Aneurysm –Code 34900 –Services that are included: Introduction, positioning, and operation of an endovascular graft of the iliac artery All balloon angioplasty and/or stent deployments within the treatment area 8-33

34. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Services that are coded separately –Open femoral or iliac artery exposure –Introduction of guidewires and/or catheters –Extensive repair or replacement of the artery –Transluminal angioplasty outside the aneurysm area –Arterial embolization –Intravascular ultrasound –Fluoroscopic guidance in conjunction with the iliac aneurysm repair 8-34

35. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Central Venous Access Procedures Entry Site: Centrally Inserted or Peripherally Inserted –Centrally Enters the body at the jugular, subclavian, or femoral vein or the inferior vena cava –Peripherally A VAD or catheter that enters the body at either the basilic vein or the cephalic vein is called a peripherally inserted central catheter, often referred to as a PICC line 8-35

36. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Cardiovascular System (cont.) Nontunneled or Tunneled –A tunneled catheter Tunnels under the skin Is more flexible Is inserted into a vein at one location –A nontunneled catheter Is inserted directly into the vein by venipuncture 8-36

37. © 2016 McGraw-Hill Education. All rights reserved. DIGESTIVE SYSTEM 1-37

38. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Digestive System Endoscopic –Physician visually examines interior of organ Esophagogastroduodenoscopy (EGD) Endoscopic retrograde cholangiopancreatography (ERCP) Sigmoidoscopy/colonoscopy examine the lower digestive system Therapeutic endoscopy 8-38

39. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Common Bariatric Surgeries –Adjustable gastric band (ABD) Codes 43770–43774 Placement of proximal pouch to limit passage of food –Roux-en-Y gastric bypass (RYGB) Codes 43846, 43847, 43644 Limits passage of food and reduce contact of stomach, duodenum, and upper intestine with food 8-39

40. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Common Bariatric Surgeries (cont.) –Biliopancreatic diversion with a duodenal switch (BPD-DS) Codes 43775 and 43843 Routes digested material away from the small intestine –Vertical sleeve gastrectomy (VSG) Code 43775 Connects segment of duodenum to the small intestine 8-40

41. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Digestive System (cont.) Liver Transplantation –Donor Hepatectomy Code determined by living or non-living donor and portion of liver donated 47133 from cadaver donor 47140 from living donor; left lateral segment only 47141 from living donor; total left lobectomy 47142 from living donor; total right lobectomy 8-41

42. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Digestive System (cont.) Liver Transplantation –Backbench Work Preparation of whole liver graft prior to transplant Code 47143 from cadaver donor Code 47146 venous and/or arterial anastomosis performed 8-42

43. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Digestive System (cont.) Liver Transplantation –Recipient Liver Allotransplantation Placement of allograft in patient Orthotopic …Code 47135 –Normal positon Heterotopic … Code 47136 –Other than normal positon 8-43

44. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Digestive System (cont.) Pancreas Transplantation –Cadaver Donor Pancreatectomy Code 48550 –Backbench Work Preparation of the pancreas graft prior to transplant …Code 48551 Code 48552 with required reconstruction –Recipient Pancreatic Allotransplantation Placement of allograft in patient Code 48554 8-44

45. © 2016 McGraw-Hill Education. All rights reserved. URINARY SYSTEM 1-45

46. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Urinary System Renal (Kidney) Transplantation –Donor Nephrectomy Code 50300 cadaver donor Code 50320 living donor Code 50547 laparoscopy living donor –Backbench Work Preparation of allograft Code 50323 cadaver donor Code 50325 living donor Code 50328 reconstruction; arterial anastomosis Code 50329 reconstruction; ureteral anastomosis 8-46

47. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Urinary System (cont.) –Renal (Kidney) Transplantation (cont.) Recipient Renal Allotransplantation –Placement of allograft in patient –Code 50360 without recipient nephrectomy –Code 50365 with recipient nephrectomy –Urodynamics Codes 51725–51798 Includes services performed and instruments required Modifier 26 used if physician only interpreted results 8-47

48. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Urinary System (cont.) Transurethral Surgery –Diagnostic or therapeutic cystourethroscopic intervention –Includes insertion and removal of temporary stent Code 52332 with the modifier 51, with cystourethroscopy code for a unilateral procedure Code 52332 with modifiers 50 and 51 with the cystourethroscopy code for a bilateral procedure Removal of stent, use either 52310 or 52315 with modifier 58 8-48

49. © 2016 McGraw-Hill Education. All rights reserved. GENITAL SYSTEMS: MALE AND FEMALE 1-49

50. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Male Genital System Penile Plaque –Treatments Injection of steroids and chemotherapy agents Surgical removal of plaque Reconstruction 8-50

51. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Female Genital System Vulvectomy –Identify from documentation whether Simple Partial Radical Complete 8-51

52. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Maternity Care and Delivery Antepartum –Initial patient history –Subsequent patient history –Physical examinations –Documentation of weight, blood pressure, fetal heart tones, routine chemical urinalysis –Monthly visits from conception up to 28 weeks gestation –Bi-weekly visits from 28 weeks to 36 weeks gestation –Weekly visits from 36 weeks gestation to delivery 8-52

53. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Maternity Care and Delivery Delivery services –Admission to the hospital –Admission history and physical examination (H&P) –Management of uncomplicated labor –Delivery: Vaginal (with or without episiotomy, with or without forceps) or Cesarean section Postpartum care –Hospital and office visits following the delivery 8-53

54. © 2016 McGraw-Hill Education. All rights reserved. NERVOUS SYSTEM 1-54

55. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Nervous System Often involves more than one surgeon –The approach Anterior cranial fossa Middle cranial fossa Posterior cranial fossa –The definitive Base of anterior cranial fossa Base of middle cranial fossa Base of posterior cranial fossa 8-55

56. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Nervous System (cont.) –The repair/reconstruction Extensive dural grafting Cranioplasty Local or regional myocutaneous pedicle flaps Extensive skin grafts 8-56

57. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Nervous System (cont.) Pain Management –Pain scale 0 to 10 Treatments –Electrical Reprocessing Uses electrical impulses to interrupt pain signals –Epidural/Intratecal Medication Administration Pump for continuous drug delivery via spinal cord –Intravenous Therapy Drug delivery via patient’s vein 8-57

58. © 2016 McGraw-Hill Education. All rights reserved. OPTICAL & AUDITORY SYSTEMS 1-58

59. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Eye and Ocular Adnexa The services of an Ophthalmologist The eye is the most complex organ system Implants Keratoplasty Removal of cataracts Removal of foreign materials 8-59

60. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Auditory System Tympanostomy –Used to treat middle ear infection –Insertion of ventilating tube to relieve pressure –Coding depends on anesthesia Code 69433 tube insertion with local anesthesia Code 69436 tube insertion with general anesthesia –Modifier 50 for bilateral procedure –Code 69424 tube removal with general anesthesia 8-60

61. © 2016 McGraw-Hill Education. All rights reserved. OPERATING MICROSCOPE 1-61

62. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Operating Microscope Microsurgeries require use of operating microscope Code 69990 in addition to procedure Guidelines –Use of microscope does not require a modifier –Some codes include the use of the operating microscope Code 69990 is redundant in those cases 8-62

63. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary Identify the components of the operation. Determine which services are in the code’s description and which services require a separate code. 8-63