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Abstracting Documentation (p. 33-36: Exercises**)Visualize what is being done to be able to know if what is happening is part of a bigger procedure or is its own procedure separate from others. 1) Scan rpt for procedures performed; action type words (excision, incision, aspiration, endoscopy, etc). 2)?Resection/Excision don't have different definitions in CPT. They are interchangeable. No -LT or -RT modifiers for skin Ex: Resection of a Bladder Tumor Operative approach: Natural opening -- Endoscopy Specimen sent tissue to lab: Path ReportFluid: Cytology ReportIndex: Resection, Tumor, Bladder52234-5, 52240 (size is only difference)Using a scope is built into the codes.Index: Biopsy, Bladder, Cystourethroscopy52204, 52224, 52250Bcs that is the approach used for biopsy.Solution: 52235, 52204 Reminder: Use Coder's Desk Reference if you need help understanding procedures and terminologies. Access current edition on Encoders (3M-CPT Lay Descriptions; Quadrimed-Quantim- )Surgical Procedure: Any single, separate, systemic process upon or within the body that is complete in itself.Surgical Operation: One or more surgical procedures performed at one time for one pt via a common approach or for a common purpose.Surgical Packages: (CPT def'n CMS def'n) CPT: refers to a combination of services & procedures provided during one surgical operation. 1 single service for reimbursement purposes. Includes:The actual surgical procedure(s)Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesiaAfter the decision to perform surgery has been made, one related E/M encounter on the date of, or immediately prior to, the date of the procedure (incl. H&P)Immediate post-op care, incl. dictation of op notes and talking w/family and other physiciansPreparation of ordersEvaluation of pt in the post-anesthesia recovery areaTypical post-op follow-up care. (Open-ended time frame... defaults to whether it relates to the procedure) No # of daysGlobal Surgical Payment = Surgical Package . This concept applies for the physicians who are doing the procedures, doing the op notes, checking pt in recovery, etc. If pt has to go back into the out-pt area, the hospital may report it using std billing procedures.Follow-up visit: Would not be billed separately. Included under the code(s) for the surgical procedure(s) performed during the first encounter, and both encounters would be submitted as a single reimbursement claim. (Some payers will require submission of an E/M code just for tracking purposes -- Zero balance due -- May need to check with payer to clarify if this is needed or not).Follow-up visit for Tx of Complications: resulting from surgical procedure would be reported with codes for the appropriate E/M level of service, along with appropriate ICD-9/10-CM code, to describe the complication.ICD Dx code + E/M service code (Physician)CMS: Guidelines may be referenced in manuals published by CMS (Medicare Claims Processing Manual) on website. Surgical Pkg or Global surgical concept does not apply in the out-pt setting (Lab Rpt, X-ray). Hospitals may report post-op visits (technical component) that occur on subsequent days by using std billing procedures, such as assigning the approp. ICD-9/10-CM Dx code to describe the reason for the visit. (Pkgs apply to physicians, not hospitals)Medicare: Services may vary depending on individual 3rd-party payer requirements. Post-op period for M'care claims IS NOT open-ended. M'care assigns post-op global periods of 90 days for major surgeries and 0-10 days for minor surgeries and endoscopies.M'care global surgery def'n for major surgeries includes:The actual surgical procedurePre-op services after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures. Except when modifier -57 (decision for surgery) or -25 (more than 1 E/M level on the same day) applies.Follow-up visits during the post-op period of the surgery that are related to recovery from the surgeryComplications following surgery: All add'l medical or surgical services required of the surgeon during the post-op period of the surgery bcs of complications that do not require add'l trips to the operating room. (CMS says if there are complications they are considered part of the surgical global package -- the physical must treat the pt and will not expect to receive any more payment for the treatment of the complication)Postsurgical pain mgmt provided by the surgeonInsignificant surgical procedures not performed in the operating room, incl. dressing changes, removal of operative packs, care of the operative incision site; removal of sutures, staples, wires, lines, tubes, drains, casts, and spints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines; removal of nasogastric tubes and rectal tubes; care of the tracheostomy tubes.M'care global surgery def'n for minor and endoscopic surgeries include: The actual surgical procedurePre-op services after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures. Except when modifier -57 (decision for surgery) or -25 (more than 1 E/M level on the same day) applies.Post-op services within 0-10 daysFollow-up Care for Diagnositic and therapeutic ProceduresIncludes only that care related to recovery of the diagnostic procedure (imaging proc.)When follow-up care involves the initiation of Tx for the cond. that has been diagnosed or for a complication, the Tx should be coded and reported separately. Complication, exacerbation, or recurrence, or the presence of other diseases or injuries requiring add'l services should be reported with the approp. code for that procedure.Separate Procedures: (Modifier -59) 2 diff't situations and need to modify one as a separate procedure. The lesser of the 2 gets the -59. Ex: 58720 Fallopian tube(s) and ovary(s), unilateral or bilateral (separate procedure)(Separate procedure) is an indication that this is a lesser code that may be encompassed in a combination code -- look for the combination code to rule out that it should not be used before using this one. The combination code here would be 58150.Ex: Do this procedure (44180). Then later the same day, go back in, do another laparaoscopy while doing something else. 44180 Laparaoscopy, surgical, ... (separate procedure)This claim will look like you are trying to unbundle codes. If it is actually a separate trip to the OR, put on -59 to show it is distinct and separate surgery.If only a diagnostic exam is being done, it may have the notation (separate procedure). If the intention is to do a diagnostic exam and it turns into a biopsy or a surgery, code the biopsy or surgery, not the diagnostic exam.Integumentary System -- SKIN (p. 58)Skin, subcutaneous structures, incl. excision of skin lesions, wound closue, skin grafting, burn Tx, Mohs' chemosurgery, incision and drainage, and debridementNails, incl. debridement, excision, and reconstruction of nail bedBreasts, incl. needle, incisional, and excisional biopsies, and all types of mastectomiesAdded Code:10030 -- Image-guided fluid collection drainage by catheter, soft tissue, ... percutaneousCompare with 10021 -- Fine needle aspiration; without guidance (no site given here)10022 -- with imaging guidanceIncision & DrainageStraightforward... Be sure there is documentation there was an incision being done.10060 Use only if 1 abscess and it is simple10061 Use if > 1 or if documentation makes it clear the 1 abscess was complicated.Debridement(11000) Infected skin & exzema (% of body surface)(11004-11006) Muscle and fascia for necrotizing soft tissue infection(11008) Add-on code. For removal of prosthetic material (mesh) assoc. w/abdom. wall infection(11010-11012) Debridement assoc w/open fxTIPDebridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. Out-pt debridement does not need to know if it is an excisional debridement or a non-excisional debridement. Only need to know the difference for in-pt ICD-9 procedure coding. (PCS not an issue)Sequence the most resource intensive code first.LesionsTissue suffering damage thru injury or disease (moles, cysts, keloids, warts, or skin tags). See Tbl 4.1: Methods & Documentation (p. 61)ParingDx of benign hyperkeratotic lesion # of lesions removedRemoval-Skin TagsDx of S. Tags# of tags removedShaving of epidermal and dermal lesionsDx of epidermal or dermal lesionLocation of lesion (per lesion)Diameter of lesionExcision of benign lesion(s)Dx of benign skin lesionLocation of lesions Excised diameter (per lesion) (Include margins)Excision of malignant lesion(s)Dx of malignant skin lesionLocation of lesions Excised diameter (per lesion) (Including margins)If frozen section done and Path Rpt says they still see malignant cells, go back for more. Code for the largest dimension excised. If Pt leaves OR and needs to come back (probably Out-Pt encounter) code separately even if on the same day = a subsequent operative episode, may use -58 modfier (works for both Physician & Hospital)If on 2nd encounter shows Pathology benign, still code malignant bcs original code showed malignancy.Destruction of benign or premalignant lesionsDx of benign or premalignant Skin lesionLesion removed by methods such as electro-, cryosurgery, laser, or chemical Tx# of lesions removedDestruction of malignant lesionsDx of malignant skin lesionLesion removed by destructionDiameter of lesionLocation of lesionMay code from Pathology Report on Out-Pt encounter.May not code from Path Rpt on In-pt encounter. Need Physician confirmation.Know there are 2.54 cm in an inch4 cm x 2 cm lesion: Start with 4 cm measurement + 1/2 cm margin: Plus 1 cm = 5 cm Excision ClosureExcision (lesion) codes include simple closure.Separate codes for more complicated closures (intermediate, complex)Excision of Lesion followed by Adjacent Tissue TransferRearranging tissue: 1) Know the site, 2) know the sq. cm. Does not cut blood supply to tissue.Ex: W-plasty, V-Y plasty, Z-plasty, Rotation Flap, Pedicle Flap, Random island Flap, Advancement Flap are different techniques.Lesion excision is included in the transfer code.Excision of LipomasFatty Tumor usually found in soft tissue (code as skin lesion). If excision of a lipoma extends into muscle, code from musculoskeletal section.Wound Repair/Closure (p. 67)Simple = epidermis + dermis + subq tissue without involvement of deeper structures. Typically, suturing of 1 layer of skin. Can do a layered closure in dermis and epidermis (this is not intermed and not a layered closure).Intermediate = superficial repair requiring 1 + deeper layers of subq tissues and superficial fascia, + skin (epi- and dermal) be closed in layers. Complex: goes beyond a layer closure. Requires extensive debridement, cleaning, undermining, stents, or retension sutures. Angular, jagged, irregular, or stellate closures too. Coding of Wound Repairs/Closures (add/same type/same body group)What type of repair? Simple, Intermed, ComplexWhat site or body part and extend of woundWhat is the length of the repair (in cm)Wound repair codes include simple ligation of blood vessels and simple exploration of the nerves, vessels, or tendons -- no extra code.Also included: Steri-Strips, bandages (part of E/M level)Tissue Adhesive: (Dermabond) use same code as suture or staple. Look for code that uses suture or staple, not a separate code. CMS Pt: Use Level II HCPCS G-code instead of CPT code for wound repair with tissue adhesive.If the laceration requires repair of the nerves, vessels, or tendons, code separately.Add cm(s) together wound repairs when same type of closure and in same category of body part.Sequence the most complicated repair first. Use modifier -51 (for physician) to ID performance of more than one procedure.Code debridement separately only when gross contamination requires prolonged cleansing, considerable amts of tissue removed, or that which is carried out separately w/out immed. primary closure.Penetrating Wound: gun shot or stabbing is found in musculoskeletal section.Wound required:SEnlargementExtension of dissectionDebridementRemoval of 1+ foreign bodiesLigation or coagulation of minor subq and/or muscular blood vesselsSkin Grafting (p. 72)Adjacent Skin Graft: Do not code lesion removal separately.Code by the size of the defect (in sq. cm) where they picked it up from, not the size of the lesion.Skin Replacement Surgery: Surgical Preparation of the recipient site (ready to receive a graft) by excision of open wounds, eschar, or scar, incl. subq tissue. Also incl. incisional/excisional release of scar contracture. Measured in 100 sq cm or by body surface percentages for children < 10 yrs.If donor site needs repair, will need additional code.--Surg. Prep site code (recipient)--Skin graft code (1st site)--Repair of 1st site with graft (if needed) Autograft: Same indiv. pick skin up, cut free, & moving somewhere else.Allograft: comes from another person.Skin Substitute Grafts: not autologous. Biobrane is a nylon mesh (dermis) and silicone membrane (epidermis) Alloder: cadaveric dermis.Free Skin Grafts: Cut away from blood supply. Need to know full- or partial-thickness.Removal of skin lesion w/skin Replacement/Substitute Graft (Code removal of lesion separately). Then fix the area w/split-thickness gaft.Mohs Micrographic Surgery (p. 78)Delicate area (face) to minimalize scarring. Take very small pieces (layers) of tissue at a time (frozen section) to find out where the skin comes out clear of disease. Surgical Procedures of the BreastUse -LT or -RT or -50 (bilateral)Is it an asperation, biopsy, or excision?Is it open or percutaneous?Using any imaging guidance?IntroductionJust the placement of the device by different techniques (19281-19288) No biopsy or removing any tissue.Mastectomy ProceduresModified Radical Mastectomy: taking out axillary lymph nodes (may or may not take out pectoralis muscle). Trying to preserve that muscle structure.A prosthesis (silicone implant or tissue expander) put in at the time of breast removal, code this separately. ................
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