Lesson

The surgery section is the largest section in the Current Procedural Terminology (CPT) manual. The range of codes is 10021 to 69990. This code range is divided into subsections that cover the following areas: Integumentary, Musculoskelatal, Respiratory, Cardiovascular, Digestive, Urinary, Male and Female Genital and Nervous, Ocular/Auditory. This week we will be focusing on the Surgery Guidelines and the Integumentary and Musculoskeletal systems.

It will be important before we start this week that you review the introductory section to surgery in the CPT coding manual. This will help you understand the criteria that is included in a surgical package, follow-up care, separate procedures, and unlisted procedures.

As a coder, it is important to remember not to code what is not documented and not to document what you do not understand. As a coder, it will be important for you to perform research that will provide clarification on procedures that are new technology or that may be difficult to understand. The best resource to have for clarification is the provider of the service.

Understanding the global surgical package is a key factor in coding the pre and post services of a surgery. The global surgical package includes the following: preoperative visits, intraoperative services, complications following surgery, post-operative visits, supplies, and miscellaneous services (dressing or bandage changes, catheter or IV removal, suture removal, etc.) These services are part of the global surgical package when they fall within the global surgery period. Most major surgeries will have a global period of 90 days, and minor surgery could have around 10 days. So when the global surgical package services are performed in the time period as the global period, they are at all times considered a part of the surgery fee.

As a coder, it will be important to understand when to use modifiers for services performed within a global surgical period. The use of modifiers or lack of appending the correct modifier on both surgery and the evaluation management service related to a pre- or post-op service can directly influence the reimbursement process. All modifier descriptions can be found in either the CPT or Healthcare Common Procedure Coding System (HCPCS) manuals.

There are specific modifiers that are used to account for payable services during the global period of a surgery, and these can be found in Appendix A of the Professional CPT Manual:

• 24 – Unrelated E/M Services by the Same Physician/Provider during a post-operative period. The reason for the E/M service should be documented in the patient's medical record/chart to reflect the reason for the added service and why it was not related to the surgical procedure.
• 25 – Significant Separately Identifiable E/M service by the same physician/provider on the same day of another procedure or other service. The medical record documentation should clearly define the need for the separate service.
• 57 – Decision for Surgery modifier is used for an E/M service when the outcome/decision was to perform surgery.
  • The modifiers 24, 25, and 57 are specifically for use with evaluation and management CPT codes.
• 58 – Staged or related procedure or service performed during a postoperative period by the same physician/provider. The use of modifier 58 is specifically for planned procedure(s) that were more extensive than the original procedure(s) which follows another procedure.
• 78 – The unplanned return to the operating/surgical treatment room by the same physician/provider following the first procedure/surgery for a related surgery/procedure during a patient's postoperative period.
• 79 – Unrelated procedure or service performed during the post-operative period by the same physician. Modifier 79 is appended to the unrelated procedures by the same physician/provider during the patient's post-operative period. Typically the unrelated procedures/service is identified by reporting a different ICD-9-CM diagnosis code.

The integumentary system includes the following subsection: skin, nails, pilonidal cyst, introduction, repair (closure), destruction, and breast. The procedures involved in this section of the CPT manual can be defined further by the following different categories: excision of benign or malignant lesions; biopsy, paring or cutting, removal/destruction of skin tags, incision and drainage (I & D), debridement and shaving of epidermal or dermal lesions.

A key fact in coding multiple excisions and destructions of lesions is that you should always code the most complex or involved procedure first and follow the other, less extensive procedures by appending modifier 51 to them (except for procedures exempt from modifier 51 or when third-party payers request you not to use modifier 51 and they apply the hierarchy for each procedure).

There are three types of wound closures: simple, intermediate, and complex. The closure of excisions is included in the procedure, with the exception of intermediate or complex closures, which can be reported separately.

All biopsies and lesions specimens should be sent to the laboratory for a diagnosis.

There are a few key facts to remember when coding for the integumentary system:

• Review how to bill add-on codes and understand when to append modifier 51.
• Wound repairs are grouped by complexity and site location.
• A biopsy takes a portion of the lesion for a pathological assessment, and the excision removes the whole lesion.
• Local anesthesia is usually included in the excision of the lesion.

The musculoskeletal system is divided into the following categories; general, head, spine, abdomen, shoulder, humerus, hand/fingers, forearm/wrist, femur/knee, pelvis/hip, leg/ankle and foot/toes. The main categories contain the following subsections: repair/reconstruction/revision, fracture and/or dislocation, incision, excision, removal, arthrodesis, and amputation.

A key factor to remember when coding for fractures is that there is a difference between open treatment and closed treatment. An open treatment of a fracture is when the fracture is exposed and surgery is needed to repair the fracture. A closed treatment of a fracture is when the fracture is repaired and there is no actual visualization of the fracture. This type of repair can be with or without manipulation or with or without traction of the fracture. As a coder, it will be important for the documentation to indicate if the type of fracture is open or closed.

There are a few key facts to remember when coding for the musculoskeletal system:

• Understand the difference between a fracture and a dislocation of a bone.
• The application or removal of the initial cast or splint is included in the initial procedure.
• Casting and strapping services are coded for the initial treatment of fracture when no other fracture treatment is provided at the time of service.

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