Step by Step Lesson 13 - Surgery Guidelines and General Surgery

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Feb 20, 2024

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Chapter 13: Surgery Guidelines and General Surgery Chapter Introduction and Learning Objectives Chapter Introduction Chapter Learning Objectives Voices of Experience Using the Chapter Outline Lesson 13-1: Surgery Guidelines and General Surgery Lesson Introduction Lesson 13-1 Learning Objectives Introduction to the Surgery Section 1. Surgery Section : a. The largest in the CPT manual b. Used by surgeons and also numerous other physicians 2. 19 subsections within the code range 10004-69990 a. The subsections are divided based according to: i. Medical specialty ii. Body systems 1. Integumentary 2. Cardiovascular 3. Surgery Subsections: a. General b. Integumentary System c. Musculoskeletal System d. Respiratory System e. Cardiovascular System f. Hemic and Lymphatic Systems g. Mediastinum and Diaphragm h. Digestive System i. Urinary System j. Male Genital System k. Reproductive System Procedures l. Intersex Surgery m. Female Genital System n. Maternity Care and Delivery o. Endocrine System p. Eye and Ocular Adnexa q. Auditory System r. Operating Microscope Notes and Guidelines 1. Notes and Guidelines : a. Provide additional information about use of the codes b. Notes are located throughout the sections c. Guidelines are located at the beginning of the Surgery Section. 2. Examples of Notes: a. New and Revised text symbol i. Apply to CPT manual
b. Subsection notes i. Apply to the entire subsection c. Subheading notes i. Apply to the entire subheading d. Category notes i. Apply to the entire category e. Subcategory notes i. Apply to the entire subcategory Additional Helpful Information
1. Additional Information is located within the parentheses following the CPT codes: 2. The parenthetical information is very helpful because: a. It refers you to Additional codes that may apply to what you are coding: Self-Comprehension Questions 3. Information that is applicable to the entire section is in: a. Notes b. Guidelines c. Parenthetical Information d. Appendices 4. Guidelines contain information that is applicable to the entire section Medical Terminology Review 1. Drainage a. Free flow or withdrawal of fluids from a wound or cavity 2. Excision a. Cutting or taking away 3. Repair a. To remedy, replace, or heal 4. -plasty a. Suffix meaning technique involving molding or surgical formation Unlisted Procedure Codes 1. Unlisted Procedure Codes a. Are only used when a more specific code cannot be found b. A written report must always accompany the submission of a service reported with an unlisted code 2. The Surgery Guidelines contain unlisted procedure codes, by anatomic site 3. Unlisted codes are used to identify: a. Procedures and services within the Surgery Section in which there is not CPT code 4. If there is a Category III code to identify the procedure or service: a. You must use the Category III code b. Not the unlisted procedure code Special Reports 1. Special Reports must accompany the claim when reporting an unlisted procedure code 2. According to the CPT manual: a. “Pertinent information [in the special report] should include the description of the nature , extent , and need for the procedure and the time , effort , and equipment necessary to provide the service.”
Self-Comprehension Questions 1. Which of these codes are used when a more specific code cannot be found? a. Level III b. National c. Unlisted d. Both A and C 2. Unlisted codes and Level III codes are used when no more specific codes can be found Self-Comprehension Questions 1. This must always accompany the submission of an unlisted code: a. History and physical report b. Pathology report c. Copy of patient file d. Special report 2. A special report must always accompany the submission of an unlisted code Separate Procedure 1. When the parenthetical expression “(separate procedure)” follows a code description: a. The procedure is usually a minor procedure b. Minor procedures are considered incidental to a more major procedure 2. Example: a. A breast biopsy (19100, separate procedure) performed immediately before a radical mastectomy would be bundled into the mastectomy procedure and not be reported separately i. However, a breast biopsy was performed as the only procedure would be reported 3. Exception: a. As an example, a patient has a unilateral ovarian biopsy (58900) performed and is then brought back to the operation room for a total oophorectomy (58940) the same day b. The second procedure performed should have modifier -58 appended to the CPT code. i. (Staged or related procedure or service by the same physician during the postoperative period) ii. 58940-58 Self-Comprehension Questions 1. A “separate procedure” is: a. Coded when it is the only procedure performed b. Not coded when it is part of a more involved surgery at the same site c. May be coded along with another procedure depending on the circumstances d. All of the above 2. The separate procedure is “all of the above” Lesson 13-1 Learning Activity 1. How many subsections are there in the Surgery section of the CPT manual? a. 15 b. 16 c. 17 d. 19 2. What code range represents those in the Surgery section? a. 10000-80000 b. 12000-70000 c. 10000-60000 d. 10004-69990
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