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Chapter 25
CPT Surgery Section
| Question | Answer |
|---|---|
| Allotransplantation | The relocation of tissue from one individual to another (both of the same species) without an identical genetic match. |
| Arthrodesis | The immobilization of a joint using a surgical technique. |
| Closed Treatment | The treatment of a fracture without surgically opening the affected area. |
| Complex Closure | A method of sealing an opening in the skin involving a multilayered closure and a reconstructive procedure such as scar revision, debridement, or retention sutures. |
| Donor Area (Site) | The area or part of the body from which skin or tissue is removed with the intention of placing that skin or tissue in another area or body. |
| Excision | The full-thickness removal of a lesion, including margins; includes (for coding purposes) a simple closure. |
| Fornix | The conjunctival fornix is the area between the eyelid and the eyeball. The superior fornix is between the upper lid and eyeball; the inferior fornix is between the lower lid and the eyeball [plural: fornices]. |
| Full-Thickness | A measure that extends from the epidermis to the connective tissue layer of the skin. |
| Global Period | The length of time allotted for postoperative care included in the surgical package, which is generally accepted to be 90 days for major surgical procedures and up to 10 days for minor procedures. |
| Harvesting | The process of taking skin or tissue (on the same body or another). |
| Intermediate Closure | A multilevel method of sealing an opening in the skin involving 1+ of the deeper layers of the skin. Singlelayer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter also constitutes intermediate closure |
| Laminectomy | The surgical removal of a vertebral posterior arch. |
| Manipulation | The attempted return of a fracture or dislocation to its normal alignment manually by the physician. |
| Open Treatment | Surgically opening the fracture site, or another site in the body nearby, in order to treat the fractured bone. |
| Percutaneous Skeletal Fixation | The insertion of fixation instruments (such as pins) placed across the fracture site. It may be done under x-ray imaging for guidance purposes. |
| Recipient Area | The area, or site, of the body receiving a graft of skin or tissue. |
| Saphenous Vein | Either of the two major veins in the leg that run from the foot to the thigh near the surface of the skin. |
| Simple Closure | A method of sealing an opening in the skin (epidermis or dermis), involving only one layer. It includes the administration of local anesthesia and/or chemical or electrocauterization of a wound not closed. |
| Standard of Care | The accepted principles of conduct, services, or treatments that are established as the expected behavior. |
| Surgical Approach | The methodology or technique used by the physician to perform the procedure, service, or treatment. |
| Transplantation | The transfer of tissue from one site to another. |
| The global surgical package includes all except | general anesthesia. |
| When a surgeon does not provide preoperative or postoperative care to the patient upon whom he or she operates, the procedure code should be appended with modifier | 54 |
| Excision of lesions is reported | with each lesion coded separately. |
| If multiple wounds located on the same anatomical site are repaired with the same complexity, report this procedure by | adding all the lengths together and coding the total. |
| When a procedure is planned as a series of procedures, each service after the first should be appended with the modifier | 58 |
| Backbench work during a transplant process is | the preparation of the organ. |
| A laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy of 145 cm would be coded | 43644 |
| Thoracotomy, with biopsy of pleura, would be coded | 32098 |
| Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy would be coded | 56631 |
| A physician who only interprets the results of a urodynamic procedure must append the code with | modifier 26 |
| Codes within the musculoskeletal subsection include | cast |
| Prophylactic Treatment | performed to prevent a condition from developing. This may be a surgical procedure, a series of injections, or a prescription. |
| Diagnostic Procedure | performed to gather more details about a condition or concern at issue. In other words, the reason for performing the test or procedure is to get closer to an accurate diagnosis. |
| Therapeutic Procedure | provided to correct or fix a problem. |
| Noninvasive/External Procedure | does not enter the patient's body |
| Minimally Invasive Procedure | becoming more and more available as health-care researchers continue to find methods to diagnose and correct problems with the least amount of trauma to the patient. |
| Percutaneous Approach | uses instruments inserted into the body by way of a puncture or small incision to access the intended anatomical site. |
| Percutaneous Endoscopic Approach | uses instruments inserted into the body by way of a puncture or small incision to access and visualize the intended anatomical site. |
| Via Natural or Artificial Opening | instrumentation entered into the body through a natural or an artificial opening (such as a stoma) to visualize the intended anatomical site |
| Via Natural or Artificial Opening Endoscopic Approach | insertion of a scope through a natural or artificial opening to visualize and aid in the performance of a procedure on the intended anatomical site. |
| Open Approach Procedures | fully invasive, as the surgeon cuts the body open to enable access to internal tissues and organs. These procedures involve using a scalpel or laser to cut through the skin, membranes, and body layers to access the intended anatomical site. |
| Surgical Package Services Included | 1. evaluation/management 2. local infiltration 3. operation 4. immediate post op care 5. follow-up care 6. supplies |
| Surgical Package Services NOT Included | 1. diagnostic tests 2. postoperative therapies 3. more comprehensive version of original procedure 4. staged/ multipart procedures 5. management of postop complications that require additional surgery 6. unrelated surgical procedure 7. supplies |
| Zero-Day Postoperative Period | For procedures such as endoscopies and some minor procedures: • No preoperative period. • No postoperative days. • Visit on day of procedure is generally not payable as a separate service |
| 10-Day Postoperative Period | For other minor procedures, the day of the surgery + 10 days following the day of the surgery. • No preoperative period. • Visit on day of the procedure is generally not payable as a separate service. |
| 90-Day Postoperative Period | For major procedures, 1 day before the day of the surgery + the day of surgery + 90 days immediately following the day of surgery. • One day preoperative included. • Day of the procedure is generally not payable as a separate service |
| 54 Surgical Care Only | You must add this modifier to the correct CPT surgical procedure code when your physician is only going to perform the procedure itself, and not provide or be involved in any preoperative or postoperative care of the patient. |
| 55 Postoperative Management Only | This modifier is added to the CPT code for the surgical procedure included on a claim from the physician who only cares for the patient after the operation |
| 56 Preoperative Management Only | When a physician, other than the surgeon who performed the procedure, cares for the patient from the decision to have surgery up to but not including the operation itself, modifier 56 is appended to the CPT code for the procedure. |
| 22 Increased Procedural Services | When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work |
| Fine-needle aspiration biopsy | The physician uses a thin needle to draw out—or drain—a specimen. |
| Core-needle biopsy | The physician uses a hollow needle, a bit larger than the needle used during a fine-needle biopsy, to extract a cylindrical section of tissue |
| Excisional biopsies and incisional biopsies | A sampling of tissue of the abnormal area; an entire organ or tumor is taken |
| Endoscopic biopsy | During a percutaneous endoscopy or via a natural or artificial opening endoscopic procedure, a specimen of an abnormal or suspicious tissue is obtained |
| Anatomical site | The anatomical location of the primary defect—the skin opening that needs to be repaired—as well as the location of the secondary defect—the skin area from where the surgeon took the skin being transferred. |
| Size of the defect | Add together the sizes of the primary defect and the secondary defect |
| The codes for skin grafts are determined by: | 1. The size of the recipient area (the size of the wound to be grafted). 2. The location of the recipient area (the anatomical site). 3. The type of graft (pinch graft, split graft, full-thickness graft, etc.) |
| Cauterization | the process of destroying tissue with the use of a chemical or electricity to seal a wound and stop bleeding. |
| Cryosurgical or cryotherapy | Use liquid nitrogen or freezing carbon dioxide to destroy the tissue of concern |
| Curettage | the method of using a special surgical tool, called a curette, to scrape an organ, a muscle, or other site. |
| Electrosurgical | use high-frequency electrical current instead of a scalpel to separate and destroy tissue. |
| Laser surgery | uses light to cut, separate, or destroy tissue. The term laser is actually an acronym for “light amplification by stimulated emission of radiation. |
| Manipulation | The attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the application of manually applied forces. |
| Penetrating trauma wounds require: | Surgery to explore wound. Determination of depth and complexity of the wound. Identification of any damage created by the penetrating object Debridement of the wound Ligation or coagulation of minor subcutaneous tissue, muscle fascia, and/or muscle |
| Laminotomy | A partial laminectomy used to treat lumbar disc herniation. |
| Arthrodesis | The immobilization of a joint using a surgical technique |
| Laminectomy | The surgical removal of a vertebral posterior arch |
| Percutaneous skeletal fixation | The insertion of fixation instruments (such as pins) placed across the fracture site; may be done under X-ray imaging for guidance purposes |
| Lumbar puncture (spinal tap) | A needle is inserted into the spinal canal between two lumbar vertebrae to collect cerebrospinal fluid (CSF) |
| Sinus Endoscopy | The standard for a nasal/sinus endoscopic procedure, performed for diagnostic purposes, includes assessment of the: • Interior nasal cavity. • Middle and superior meatus. • Turbinates. • Sphenoethmoid recess |
| Percutaneous Needle Biopsy | a hollow needle is inserted through a tiny incision and directed toward the internal area, typically with the support of imaging guidance. |
| Thoracotomy | the patient’s chest is surgically opened (an open procedure rather than a percutaneous approach). |
| Endoscope | used to visually examine and/or obtain a specimen for pathologic testing of the interior of an organ, such as the throat, stomach, or bladder, in order to make a more accurate diagnosis |
| Simple | The removal of skin and superficial subcutaneous tissues |
| Radical | The removal of skin and deep subcutaneous tissues |
| Partial | The removal of less than 80% of the vulvar area |
| Complete | The removal of more than 80% of the vulvar area |
| Approach | the tactic of the procedure, such as craniofacial, orbitocranial, or transcochlear |
| Definitive | the procedure itself, such as resection, excision, repair, biopsy, or transection. |
| Electrical reprocessing | Includes transcutaneous electrical modulation pain reprocessing (TEMPR), which administers electrical impulses designed to interrupt pain signals |
| Epidural/intrathecal medication administration | Medication administered intrathecally (directly into the cerebrospinal fluid via the subarachnoid space in the spinal cord) |
| Intravenous therapy | If the condition is chronic, a peripherally inserted central catheter (PICC) line may be inserted and used for the administration of the medication for the duration of the therapy. |
| Glaucoma surgery | Treats glaucoma with an incision into the trabecular tissue of the eye to drain the excess fluid that has accumulated; in some cases, a tube is inserted |
| Vitrectomy | The surgical removal of vitreous gel from the center of the eye, may be necessary |
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