8-1
Chapter 8
Surgery Coding, Part 2
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-2
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.
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-3
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.
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-4
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.
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-5
Key Terms
•
•
•
•
•
Allotransplantation
Arthrodesis
Closed treatment
Laminectomy
Manipulation
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-6
Key Terms (cont.)
•
•
•
•
Open treatment
Percutaneous skeletal fixation
Saphenous vein
Transplantation
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-7
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-8
MUSCULOSKELETAL SYSTEM
© 2016 McGraw-Hill Education. All rights reserved.
8-9
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-10
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-11
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-12
Musculoskeletal System (cont.)
• Bone Grafts and Implants
– Differ from skin grafts
– Bone, cartilage, tendon, and fascia lata grafts
are coded from this subsection
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-13
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-14
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-15
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-16
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-17
RESPIRATORY SYSTEM
© 2016 McGraw-Hill Education. All rights reserved.
8-18
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-19
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-20
Respiratory System (cont.)
• Lung Transplantation (cont.)
– Recipient Lung Allotransplantation
• Identifies allograft in patient
• Codes 32851–32854
• Differentiate unilateral, bilateral, with or
without cardiopulmonary bypass
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-21
CARDIOVASCULAR SYSTEM
© 2016 McGraw-Hill Education. All rights reserved.
8-22
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-23
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-24
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-25
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-26
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-27
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-28
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-29
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-30
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-31
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-32
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-33
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-34
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
Transluminal angioplasty outside the aneurysm area
Arterial embolization
Intravascular ultrasound
Fluoroscopic guidance in conjunction with the iliac
aneurysm repair
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-35
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-36
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-37
DIGESTIVE SYSTEM
© 2016 McGraw-Hill Education. All rights reserved.
8-38
Digestive System
• Endoscopic
– Physician visually examines interior of organ
• Esophagogastroduodenoscopy (EGD)
• Endoscopic retrograde
cholangiopancreatography (ERCP)
• Sigmoidoscopy/colonoscopy examine the
lower digestive system
• Therapeutic endoscopy
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-39
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-40
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-41
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-42
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-43
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-44
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-45
URINARY SYSTEM
© 2016 McGraw-Hill Education. All rights reserved.
8-46
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-47
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-48
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-49
GENITAL SYSTEMS: MALE
AND FEMALE
© 2016 McGraw-Hill Education. All rights reserved.
8-50
Male Genital System
• Penile Plaque
– Treatments
• Injection of steroids and chemotherapy agents
• Surgical removal of plaque
• Reconstruction
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-51
Female Genital System
• Vulvectomy
– Identify from documentation whether
•
•
•
•
Simple
Partial
Radical
Complete
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-52
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-53
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-54
NERVOUS SYSTEM
© 2016 McGraw-Hill Education. All rights reserved.
8-55
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-56
Nervous System (cont.)
– The repair/reconstruction
•
•
•
•
Extensive dural grafting
Cranioplasty
Local or regional myocutaneous pedicle flaps
Extensive skin grafts
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-57
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-58
OPTICAL & AUDITORY
SYSTEMS
© 2016 McGraw-Hill Education. All rights reserved.
8-59
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-60
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
1-61
OPERATING MICROSCOPE
© 2016 McGraw-Hill Education. All rights reserved.
8-62
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
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
8-63
Chapter Summary
• Identify the components of the operation.
• Determine which services are in the
code’s description and which services
require a separate code.
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.