1 / 77

CPT Surgery V General Guidelines

This chapter provides CPT guidelines for male genital system, female genital system, intersex surgery, maternity care and delivery. Includes code assignment and procedures for various conditions.

olgag
Download Presentation

CPT Surgery V General Guidelines

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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 • 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 • 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 • 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

More Related