Lesson

There is a lot to cover this week from the surgery section of the CPT Manual. Before we start, make sure you have your medical dictionaries and your anatomy and physiology textbooks handy as you may need to reference them 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 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.

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 digestive system is a subsection in the CPT Manual that includes the code range of 40490–49999. This section is divided first by anatomic site then by the procedure. The following are some parts of the digestive system; oral cavity, tongue, esophagus, liver, pancreas, gallbladder, cecum, transverse colon, sigmoid colon, and rectum.

There are some common surgeries such as tonsillectomy and adenoidectomy that we are familiar with, but there are others that we may not be so familiar with, like pharyngostomy. (This is a surgery that prepares an opening for the insertion of a long-term feeding tube.)

This week, we will continue to learn how the common approaches used in surgery cross over to all of the body systems. The digestive system uses the following surgical approaches:

• Excision
• Repair
• Removal
• Resection
• Incision and drainage

There are a lot of procedures that involve the use of surgery scope to perform the procedure. There are four frequently performed rectal endoscopic procedures; esophagoscopy, gastroscopy, proctosigmoidoscopy, sigmoidoscopy, and colonoscopy. In order to determine the correct code, you must understand the route through which the endoscope is inserted. It is common to see removal of polyps, biopsies, brushing, or washings during these procedures, so pay careful attention to the CPT code descriptions when coding these types of procedures. The multiple procedure reduction rule applies to these endoscopic procedures, so only use modifiers when appropriate. Remember what we have learned in previous weeks; the diagnostic endoscopy procedure is included with the surgical endoscopy procedure when performed at the same surgery encounter.

There are other procedures involving the digestive tract such as; hernia repair, bariatric, hemorrhoidectomy, anoscopy, laparoscopy, and esophagogastroduodenoscopy, to name just a few more that may involve similar surgical approaches to what we have learned in previous weeks.

Some questions to ask when coding procedures in the digestive system:

• What section of the digestive system is involved in the procedure?
• Did the physician use an endoscope to perform the procedure?
• What approach did the physician use to perform the procedure? (incisional, excision, repair, removal, etc.)
• Was a biopsy performed?
• Was the procedure complete? If not, is there information in the documentation to inform as to which modifier should be used?
• Were there multiple procedures performed and, if so, do they fall under the multiple procedure rule?

The urinary system can be found in the subsection 50010–53899. The codes are located anatomically by these categories; kidney, ureter, bladder, and urethra. Like the systems we have discussed so far, there are common surgical procedures involving the urinary system such as incision, excision, introduction, and repair. There are procedures similar to the digestive system that use an endoscope. The difference is where the endoscope enters the body. In some cases, this can be through a stoma or an incision.

An important fact when coding for transplants is to determine what type of transplant is being performed. There are two types of transplants; allotransplantation, which is when a transplant is performed with two people who are not related, and autotransplantation, which is a tissue transfer from one area of a patient's body to another. There is usually backbench work performed before the transplant can occur. The services involved in backbench work will typically involve open organ retrieval, preparation of the organ, and the transplant. The CPT codes for backbench will have modifier 51 appended to define these as an addition to the transplant surgery.

There is a service in the bladder section that involves the study of the motion and flow of urine. The urodynamics services are procedures performed on patients that are showing signs of urine obstruction. These services are not included in the surgery to correct the problem which could be caused by cysts, stricture, or calculi. If the physician only performs the professional component of the urodynamic procedures remember to append modifier 26 to those codes.

The male genital subsection contains the codes 54000–55899 and is separated by the anatomical areas; penis, testis, epididymis, tunica vaginalis, scrotum, vas deferens, spermatic cord, seminal vesicles, and prostate. This subsection of surgery contains many of the same types of procedures – incision, excision, repair, destructions, and introductions – as the other systems we have discussed so far.

A common procedure that a coder will see working in pediatrics or family practice specialties is circumcision. This procedure is usually performed on a newborn under 28 days old with an excision not involving a clamp, device, or dorsal slit. There have been two codes established: 54160 for under 28 days old and 54161 for over 28 days old. So when selecting the correct code, make sure you have the patient's age.

There are procedures in the male genital system that are considered unilateral, so when they are performed bilaterally make sure you append the correct modifier. Some payers require LT/RT and others require modifier 50. An example of this can be seen with CPT code 54550 (Exploration for undescended testis) or 54640 (Orchiopexy, inguinal approach with or without hernia repair).

The prostate is one of the areas in the male genital system that involves the use of a laser to remove the prostate gland, correct an obstruction, or remove a tumor. These procedures can be performed with a laser or by an open surgical approach, so determine the type of approach and the extent of the procedure in order to assign the correct CPT code.

Some questions to ask when coding procedures in the urinary and male genital systems:

• What section of the urinary or male genital system is involved in the procedure?
• Did the physician use an endoscope to perform the procedure?
• What approach did the physician use to perform the procedure? (incision, excision, repair, removal, laser, etc.)
• Was an exploratory procedure performed at the same time a corrective procedure was performed?
• Was the procedure complete? If not, is there information in the documentation to inform as to which modifier should be used?
• Was the procedure unilateral or bilateral?

The Reproductive and Intersex are subsections in the CPT Manual that include the code range of 55920–55980. These two sections are relatively small compared to other subsections in the CPT Manual and follow the same rules that apply to the other subsections of the surgery section.

The Female Genital System

The female genital system contains the code range of 56405–58999 and divides the codes into the following anatomical sites; vulva, vagina, cervix, corpus uteri, oviduct, ovary, and in-vitro fertilization. This subsection of the CPT Manual includes many procedures that are considered minor and performed in a physician's office. There are some codes that are not included in the female genital system that are located in other sections of the CPT Manual. These include cervical pap smears, pelvic examinations, and cervical smears for other sexual transmitted diseases.

This subsection of surgery contains the same types of approaches to procedures as we have seen in other areas of the surgery sections, such as incision, excision, repair, destructions, and introductions. When the destruction of a lesion occurs there is not a pathology sample sent for diagnosis since the lesion was destroyed. If an excision of a lesion is performed there is a sample sent for a pathology interpretation.

There are quite a few minor procedures that can be provided in a physician's office and are typically performed under local anesthesia. These can include the following types of procedures: excisions, biopsies, and destructions. When the procedure is more involved, such as a radical removal for a malignancy, the simple closure is included in the procedure, but if there is a plastic repair with skin graft performed this is coded separately.

Maternity and Delivery Care

Maternity and delivery care can be found in the subsection 59000 – 59899 of the CPT Manual. The procedures for delivery include vaginal, cesarean, vaginal delivery after a previous cesarean, and cesarean delivery following an attempted vaginal delivery after a previous cesarean. The use of modifier 51 is appended when twins or multiple births are delivered vaginally. This modifier would not be used with twins delivered by cesarean since only one cesarean was performed.

There are other procedures related to maternity that may be performed either before the delivery, such as amniocentesis, or after the delivery, such as postpartum curettage or episiotomy. The surgical approach for these procedures is very similar to what we have covered so far in the other subsections of surgery.

There are many types of procedures for abortion, but there are four categories of abortions. These include the following:

• Spontaneous abortion, which may not require surgical intervention.
• Incomplete abortion, which is when a spontaneous abortion requires surgical intervention due to remaining fetal tissue.
• Missed abortion is when the fetus has died at some point during the pregnancy but remains in the uterus – this requires surgical intervention.
• Septic abortion: has the attributes of a missed abortion, but the complication of an infection has occurred.

Some questions to ask when coding maternity and delivery:

• Did the physician perform a vaginal or cesarean birth?
• How many pregnancies has the patient carried to term and delivered? What was the method of delivery of the previous births?
• Did the physician perform the entire antepartum and postpartum care?

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