Lesson

There are a few more subsections of the surgery section left to cover this week as well as radiology and HCPCS Level II codes. Remember to have your medical dictionaries and your anatomy and physiology textbooks handy, as you may need to reference these with this week's chapters. As with previous chapters, it is important that you use the index in the CPT Manual as a guide to locate the correct CPT code. Remember – never code from the index. The descriptions in the CPT Manual will provide tips regarding the procedure, such as whether the procedure includes contrast, if the code is an add-on code, or the approach used for the procedure. Remember that the surgical global period applies to all areas of the surgery section of the CPT Manual. It will be important for you to have access to the most recent CMS HCPCS code sets for this week. These can be found on the CMS website: https://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp

As a reminder, if you do not understand the documentation in the medical record, do not code what you do not understand. Always research and ask questions. As a coder, it is your responsibility to clarify documentation. This can be done by improving your resource lists and research skills, and most of all by becoming comfortable with asking questions.

The endocrine system subsection is represented in the CPT Manual under the code range of 60000–60699. The four glands contained in this code range are as follows: thyroid, parathyroid, thymus, and adrenal (the other five glands are included elsewhere in the CPT Manual). The endocrine system consists of glands that regulate most body functions through the secretion of hormones.

The surgeries included in the endocrine system involve many of the same types of approaches that we have learned in the previous weeks. An example would be a thyroidectomy. This is the removal of part or all of the thyroid gland. This type of surgery requires an incision to remove the affected portion of the gland. A few more examples of surgeries that you will find in the endocrine system are the aspiration or the injection of cysts and excision/biopsy of tumors. As you finish this week learning about surgery, you will find that these types of approaches to surgeries are common throughout each surgery subsection.

The nervous system can be found in the surgery subsection 61000–64999. This code range involves both the central and peripheral nervous systems. The brain and spinal cord are located in the central nervous system. The peripheral nervous system involves 12 sets of cranial nerves and 31 pairs of spinal nerves. The surgical approaches are very similar to what we have previously discussed over the past few weeks.

There are some key facts that you should know to assist you with locating the CPT codes for surgeries of the brain:

• The largest part of the brain is the cerebrum, which is divided by two hemispheres.
• There are four major lobes of each of the hemispheres – frontal, occipital, temporal, parietal.
• The cerebellum is the area of the brain that manages the voluntary muscle movements and assists with balance.

The surgical codes are separated by the type of procedure, so it will be important for a coder to know the location of, reason for, and type of procedure in order to accurately code it. Some of the procedures that can be performed in the nervous system are as follows: shunt, craniotomy, incision and drainage, and lumbar puncture. A common approach to incision and drainage is performing a burr hole or twist into the skull. This is better for the patient because the skull is left intact and only small openings are made to perform the procedure.

Some questions to ask when coding procedures from the nervous system:

• What body area is involved in the procedure?
• What is the approach to the surgery? (anterior, posterior, costovertebral)
• Was a shunt inserted?
• What nerve(s) were involved in the procedure?
• Was the procedure for a nerve block? If so, was this the only procedure performed?
• If the procedure was for a nerve block, was it unilateral or bilateral?

The eye and ocular adnexa systems can be found in the surgery subsection 65091–68899. It will be very important when coding this subsection that you understand the procedure that was performed. There is a difference between the removal of an eyeball and the removal of a foreign body, so do not confuse the two types of procedures. There are specific HCPCS modifiers (E1–E4) to use that further define which eyelid was involved in the procedure. There are similar types of surgical approaches that we have previously discussed, such as incision, excision, repair, and destruction. The most common procedure performed is removal of cataracts. It will be important to know if the cataract procedure was a partial or total removal of the lens because there is a difference in the CPT code that would be used.

Some facts to know before coding surgeries related to the eye or adnexa:

• Was the procedure unilateral or bilateral?
• Did the procedure involve removal of the eyeball?
• Was a slit lamp used during the foreign body removal?
• Did the cataract procedure involve a partial or total lens removal?
• If the procedure involved repair of the extraocular muscles, were they the horizontal or vertical muscles?
• Was a laser used in the procedure?
• Did the procedure involve the eyelid? If so which modifier should be used?

The auditory system can be found in the subsection 69000–69990 of the CPT Manual. These procedure codes are then further divided by the following categories: external ear, middle ear, inner ear, temporal bone, and middle fossa. The surgical approaches that we have discussed with previous chapters can also be found in the auditory system. The most common surgical approaches in the auditory system are incisions, excisions, removal of foreign body, implant, and repairs. Because many of these surgeries require magnification of the area, the physician may use an operating microscope. This is billed separately unless the use of the microscope is included in the definition of the surgical CPT code.

Some important questions to ask before coding auditory system surgeries are as follows:

• Was a microscope used with the procedure, and is it included in the definition for the surgical code?
• Did the excision involve a simple, modified radical, or radical approach?
• Was the procedure performed unilaterally or bilaterally?
• Did the documentation indicate if the incision and drainage was simple or complicated?
• Was anesthesia used for the procedure?

Radiology is a section in the CPT Manual that uses radiant energy in order to diagnose and treat patients. The specialists in radiology are radiologists. The CPT code range for the radiology subsection is 70010–79999.

There are seven radiology subsections:

• diagnostic radiology
• diagnostic ultrasound
• radiologic guidance
• breast – mammography
• bone and joint studies
• radiation oncology
• nuclear medicine procedures

• Fluoroscopy is a procedure that views the inside of the body and provides real-time video imaging instead of using films.
• MRI uses magnetic energy/radio waves to view soft tissue structures.
• Tomography is used to view a two-dimensional image of a section of the area.
• Biometry is the application of statistical methods to biologic facts.
• Position is the way in which the patient is placed.
• Projection is the path the X-ray beam travels.
• Prone is the position in which the patient is lying on their anterior.
• Lateral is the side position.
• Anteroposterior is the front to back position.
• Posteranterior is the back to front.
• Recumbent is lying down.

Radiology uses component coding. There are three component terms: professional, technical, and global. The professional component is sometimes called the physician portion of the service. It includes supervision of the technician and interpretation of the results, including a written report. The technical component includes the technologist's services, equipment, film, and supplies. The global component describes a procedure in which both the professional and technical portions of the radiology service were provided. If both the professional and technical components are provided, use no modifier. If only the professional component of the radiology service was provided, add modifier –26 to the code. If only the technical component of the radiology service was provided, add modifier –TC to the code. The modifier – TC is an HCPCS modifier but is used with both CPT and HCPCS codes.

In the radiology code descriptions, the statement "with contrast" implies that the injection has been built into the code. Guidelines within parentheses will instruct the coder when to refer to the surgical section of the CPT to code an additional procedure for the injection in order to describe the complete procedure. Oral or rectal contrast does not qualify for with contrast.

An interventional radiologist is a physician who is skilled in both the surgical procedure and the radiology portion of the procedure. For example, with a liver biopsy (surgical procedure) with CT guidance (radiology portion) for location of a lesion, the interventional radiologist would perform both the biopsy and the CT guidance. Interventional radiology services are reported with both the surgery code and the radiology code.

• diagnostic radiology
• diagnostic ultrasound
• radiation oncology
• nuclear medicine

In the diagnostic radiology section, codes are often divided based on whether or not contrast material was used. Codes are further divided based on number of views. This section is used to diagnose a disease or monitor disease process – progression or remission. It includes both therapeutic procedures and diagnostic procedures (e.g. X-ray, computerized axial tomography [CAT or CT scan], magnetic resonance imaging [MRI], and angiography).

Diagnostic ultrasound uses high frequency sound waves to image anatomic structures. The nine subheadings of diagnostic ultrasound are primarily based on anatomy. Complete ultrasounds scan the entire body; limited ultrasounds scan part of the body, for example, one organ; and follow-up/repeat ultrasounds are limited studies of a part of the body that was scanned previously.

Radiation oncology is the therapeutic use of radiation. It deals with both professional and technical services. The subheadings are divided based on the treatment. The technical component is the actual delivery of the radiation.

Nuclear medicine is the placement of radioactive material into the body and measurement of emissions. It is used both for diagnosis and treatment. The codes are divided primarily based on organ system.

The following activity provides you with an opportunity to test your knowledge about key points from this week's readings.