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Surgery Section Overview: CPT Surgery Codes and Descriptions

This chapter provides an overview of the largest section in CPT, the Surgery Section, which contains codes and code descriptions for various procedures organized anatomically. It also discusses services integral to a procedure and the organization of the Surgery Section into subsections.

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Surgery Section Overview: CPT Surgery Codes and Descriptions

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  1. Chapter 11 CPT Surgery I

  2. Surgery Section • Largest section • Contains code and code descriptions • Multiple codes describe similar procedures

  3. Overview • Subsections organized anatomically • Categories and subcategories organized within subsections

  4. Operative Report • Review • Body system (e.g., digestive) • Anatomic site (e.g., stomach) • Surgical approach (e.g., laparotomy) • Type of procedure (e.g., removal) • Whether multiple procedures were performed

  5. Services Integral to a Procedure • No separate code reported for the following • Cleansing • Shaving and prepping patient’s skin • Draping and positioning patient • Inserting intravenous access for medication • Administering sedatives • Administering local, topical, or regional anesthesia (continued)

  6. Services Integral to a Procedure • No separate code reported for the following • Making incisions • Evaluating surgical fields • Treating simple adhesions • Irrigating wounds • Inserting and removing drains

  7. Organization of Surgery Section • Guidelines • Located at beginning • Apply to all codes in section • Notes • Located throughout surgery section • Apply to specific subsection, heading, or subheading (continued)

  8. Organization of Surgery Section • 17 subsections (organ systems or anatomic sites): • General (10021-10022) • Integumentary system (10040-19499) • Musculoskeletal system (20000-29999) • Respiratory system (30000-32999) • Cardiovascular system (33010-37799) • Hemic and lymphatic systems (38100-38999) (continued)

  9. Organization of Surgery Section • 17 subsections (organ systems or anatomic sites): • Mediastinum and diaphragm (39000-39599) • Digestive system (40490-49999) • Urinary system (50010-53899) • Male genital system (54000-55899) • Intersex surgery (55970-55980) • Female genital system (56405-58999) (continued)

  10. Organization of Surgery Section • 17 subsections (organ systems or anatomic sites): • Maternity care and delivery (59000-59899) • Endocrine system (60000-60699) • Nervous system (61000-64999) • Eye and ocular adnexa (65091-68899) • Auditory system (69000-69979)

  11. Surgery Subsections • Diagnostic procedures • Therapeutic surgical procedures (continued)

  12. Surgery Subsections • Headings include • Incision or incision and drainage (I&D) • Excision • Introduction or removal • Endoscopy • Repair, revision, and/or reconstruction • Destruction • Other procedure

  13. Key Terms • Incision • I&D • Excision • Endoscopy • Repair • Revision • Reconstruction • Graft • Suture

  14. Types of Sutures (a) Simple interrupted sutures; (b) Buried sutures; (c) Running subcuticular sutures Delmar/Cengage Learning

  15. Methods of Destruction • Chemosurgery • Cryosurgery • Electrosurgery • Laser • Surgical curettement

  16. Surgery Guidelines • Physician services • CPT surgical package definition • Follow-up care for diagnostic procedures • Follow-up care for therapeutic procedures • Material supplied • Reporting more than one procedure and/or service (continued)

  17. Surgery Guidelines • Separate procedure • Subsection information • Unlisted service or procedure • Special report • Surgical destruction

  18. Surgical Package • Includes the following services: • Local infiltration, digital block, or topical anesthesia • One related E/M service following decision for surgery • History and physical (H&P) on date of procedure or immediately prior to procedure • Immediate postoperative care (continued)

  19. Surgical Package • Includes the following services: • Documentation of postoperative physician orders • Evaluation of patient in postanesthesia recovery area • Typical postoperative follow-up care • e.g., removal of sutures

  20. Global Surgical Package • Includes surgical procedure and standard package of preoperative, intraoperative, and postoperative services (continued)

  21. Global Surgical Package • Includes the following: • Preoperative services • Day before the day of surgery for major procedures • Day of surgery for minor procedures • Intraoperative services • Complications following surgery (continued)

  22. Global Surgical Package • Does not include the following: • Initial consultation to determine need for surgery • Visits unrelated to diagnosis • Services provided by other physicians • Diagnostic tests and procedures (continued)

  23. Global Surgical Package • Does not include the following: • Clearly distinct surgical procedures during postoperative period not for treatment of complications • Treatment for postoperative complications that require return trip to operating room (OR) • Performance of more extensive procedure if less extensive procedure has failed

  24. Global Period • Major surgery • 90-day postoperative period • Begins the day following surgery • Includes one-day preoperative period

  25. CMS Global Periods

  26. Services to be Coded during Postoperative Period • Complications • Exacerbations • Recurrence • Presence of other disease • Injuries

  27. Materials Supplied • Supplies commonly included in surgical packages • Dressings • Tubing • Steri-Strips

  28. Add-On Codes • Plus symbol (+) • Located next to add-on codes to describe service that only can be reported in addition to primary procedure

  29. Unlisted Service or Procedure • Assigned when no specific code accurately describes procedure performed

  30. Special Report • Includes the following • Description of nature, extent, and need for procedure • Time, effort, and equipment necessary • Complexity of symptoms • Concurrent problems • Final diagnosis • Pertinent physical findings • Follow-up care

  31. General Subsection • 10021 fine-needle aspiration; without imaging guidance • 10022 fine-needle aspiration; with imaging guidance • Fine-needle aspiration • Removal of fluid from cyst or cells from solid mass

  32. Integumentary Section Key Terms • Adjacent tissue transfer or rearrangement • Biopsy • Flap • Graft • Mohs microsurgery • Paring and curettement • Shaving

  33. Lesion Removal • Excision – debridement • Paring or cutting • Biopsy • Removal of skin tags • Shaving of epidermal or dermal lesions (continued)

  34. Lesion Removal • Excision – benign lesions • Excision – malignant lesions • Destruction

  35. Tips for Accurate Coding • Review patient record to determine: • Method of removing lesion • Malignant or benign status of lesion • Site or body part where lesion is located • Size of lesion in centimeters (cm) • Type of wound closure/repair • Simple repair included with removal • Intermediate and complex repair can be coded

  36. Wound Repair Procedures • Calculate size of wound • Add lengths of all wounds • Report code for most complicated repair first • Report codes 11040-11044 for skin debridement

  37. Measuring Lesions Lesions are measured in centimeters Note: 2.5 cm = 1 inch

  38. Adjacent Tissue Transfer • Advancement flap • Double pedicle flap • Rotation flap • Tissue rearrangement • Z-plasty • W-plasty • V-Y plasty

  39. Graft Codes • Autograft/tissue cultured autograft • Acellular dermal replacement • Allograft/tissue cultured allogeneic skin substitute • Allograft, skin • Xenograft, skin

  40. Types of Skin Grafts • Free skin graft • Full-thickness • Split-thickness • Pedicle skin graft

  41. Coding Skin Grafts • Identify • Type of graft • Permanent or temporary • Natural or manufactured graft material • Use of skin components • Recipient site • Surface area of recipient site

  42. Other Key Terms • Dermabrasion • Abrasion • Chemical peel • Cervicoplasty • Blepharoplasty • Rhytidectomy

  43. Dermabrasion Delmar/Cengage Learning

  44. Other Key Terms • Excision • Pressure or decubitus ulcers • Graft for facial nerve paralysis • Burn local treatment • Rule of nines • Removal of sutures under anesthesia (continued)

  45. Other Key Terms • Dress change under anesthesia • Intravenous injection of agent • Suction-assisted lipectomy

  46. Destruction • Ablation of tissue by any method treatments • Benign, pre-malignant, or malignant lesions • Electrosurgery • Cryosurgery • Laser • Chemical

  47. Breast Biopsies • Fine-needle aspiration • Needle core biopsy • Hand-operated needle • Stereotactic localization • Open biopsy • Excisional biopsy • Incisional biopsy (continued)

  48. Breast Biopsies Needle aspiration Incisional biopsy Delmar/Cengage Learning

  49. Mastectomy • Partial mastectomy • Simple or total mastectomy • Radical • Modified radical

  50. Types of Mastectomy Procedures Delmar/Cengage Learning

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