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Surgery Guidelines and General Surgery – Study Guide Chapter Introduction and Learning Objectives Introduction: This chapter covers the guidelines for surgery procedures and provides an overview of general surgery. It helps you understand how surgery is categorized and billed in the medical coding system (CPT codes). Learning Objectives:
- Understand the different surgery sections and subsections in the CPT manual.
- Learn how surgery codes are organized by medical specialty and body systems.
- Recognize the importance of accurate coding for surgical procedures. Voices of Experience These sections include real-life experiences from professionals in the medical field, sharing insights on how surgery coding is used and its challenges. Using the Chapter Outline The chapter is broken into several sections that help guide you through the different surgical codes, how they are categorized, and the rules for using them. Surgery Guidelines and General Surgery Lesson Introduction This lesson introduces you to the surgery section of the CPT manual, which is one of the largest sections and is used by surgeons and many other healthcare professionals. Learning Objectives:
- Understand the surgery section's importance in the CPT manual.
- Learn about the different subsections in the surgery section.
- Recognize the coding systems for body systems and medical specialties. Surgery Section: Overview
The Surgery Section in the CPT manual is the largest section, covering a wide range of medical procedures. It is used by surgeons as well as other medical professionals who perform surgery-related procedures. The Surgery Section Includes: o 19 subsections, ranging from code numbers 10004 to 69990. o These subsections are categorized by: Medical specialty (what type of doctor performs the surgery) Body systems (the parts of the body involved in the surgery) 19 Surgery Subsections The surgery section is divided into 19 subsections, each based on medical specialties or body systems. These subsections help categorize different surgical procedures based on the type of surgery being done or the area of the body affected. Here are the main subsections:
- General Surgery : o Includes a wide variety of surgeries that don't fit into a specific body system category.
- Integumentary System : o Covers surgeries involving skin, hair, nails, and sweat glands.
- Musculoskeletal System : o Includes surgeries involving bones, muscles, joints, tendons, and ligaments.
- Respiratory System : o Covers surgeries involving the lungs, throat, and other parts of the respiratory system.
- Cardiovascular System : o Includes surgeries involving the heart and blood vessels.
- Hemic and Lymphatic Systems : o Covers surgeries related to blood and lymph nodes, which help the body fight infections.
- Mediastinum and Diaphragm : o Includes surgeries involving the area between the lungs and the diaphragm.
- Digestive System : o Covers surgeries involving the stomach, intestines, liver, and other parts of the digestive system.
- Urinary System : o Includes surgeries involving the kidneys, bladder, and other parts of the urinary system.
- Male Genital System :
1. Notes and Guidelines: Notes and guidelines are provided throughout the Surgery Section to give you more information about how to use the codes correctly. Where Notes Are Found: o Notes are located throughout the sections in the CPT manual. They provide additional information or instructions for using specific codes. o Guidelines are found at the beginning of the Surgery Section and provide general rules for how to use the codes in that section. 2. Types of Notes: There are different types of notes in the CPT manual, each with a specific purpose. Here are the main types of notes you will encounter: a. New and Revised Text Notes: Purpose: These notes indicate when a CPT code or description has been updated or changed. Symbol: A special symbol (usually a triangle) is used to show new or revised text. Where It Applies: This note applies to the CPT manual overall and informs coders about updates in coding rules or descriptions.
b. Subsection Notes: Purpose: These notes provide guidance for the entire subsection of codes within the Surgery Section. Where It Applies: It applies to the entire subsection (for example, a subsection for surgeries related to the respiratory system ). c. Subheading Notes: Purpose: These notes apply to all the codes listed under a specific subheading. Where It Applies: The note applies to all codes under a subheading (for example, codes related to specific types of surgeries in a subsection).
Where It Is Found: o Parenthetical Information is placed within parentheses right after the CPT code. o This extra information is often found next to the code in the CPT manual. Why It’s Helpful: o Refers to Additional Codes: Parenthetical notes often tell you about other related codes you might need to use along with the code you are working on. o Helps Avoid Mistakes: These notes help you make sure you're coding everything correctly, especially when there are special circumstances or additional procedures involved.
4. Examples of How Notes Work in Coding: Example 1: If a parenthetical note mentions "Use in conjunction with CPT code 12345," it means that the code you are working with may require a second code to be reported together. Example 2: A subheading note could tell you, "This category includes only open surgeries," which would guide you in choosing the correct code when a procedure is performed in a particular way. Why These Notes Matter:
Accuracy: The notes and guidelines are there to help you understand how to use the codes correctly. Without these instructions, you could easily misinterpret how to apply a code, leading to mistakes in billing and documentation. Efficiency: By following the notes, you’ll be able to quickly find the right codes, especially when dealing with complicated procedures that might involve multiple codes. Comprehensive Coding: The additional codes and instructions ensure that you are coding all relevant aspects of a surgical procedure, not leaving anything out. Key Takeaways: Notes and Guidelines in the Surgery Section help you apply codes accurately. Different Types of Notes apply to different levels in the CPT manual, including codes, subsections, and categories. Parenthetical Notes are particularly useful because they provide extra information and references to other codes. These guidelines help make sure that the correct codes are used for all aspects of a procedure. Unlisted Procedure Codes, Special Reports, and Separate Procedures This study guide will help you understand some key concepts in coding for surgeries, including unlisted procedure codes , special reports , and separate procedures. Let's break down each section in a way that is easier to understand.
1. Unlisted Procedure Codes Unlisted procedure codes are used when there is no more specific code available for a surgical procedure or service. What Are Unlisted Codes? Unlisted Procedure Codes are used when a specific code doesn’t exist for the procedure being performed. These codes are only used as a last resort if no other code fits.
What Does "Separate Procedure" Mean? Minor Procedures : When the term “separate procedure” is listed with a code, it means the procedure is usually minor. These are procedures that are incidental or part of a bigger surgery. Bundling : If a "separate procedure" is done during a larger surgery, it is usually bundled into the major surgery, meaning it is not billed separately. Example of Separate Procedure: If a breast biopsy is done right before a radical mastectomy , the breast biopsy is considered part of the mastectomy and should not be coded separately. It’s bundled with the mastectomy procedure. However, if the breast biopsy is the only procedure done, it should be coded separately. Exceptions to the Rule: There are times when a "separate procedure" can be coded even if it's part of a larger surgery, especially when it happens at different times. For example: o If a unilateral ovarian biopsy is done, and later the same day a total oophorectomy (removal of the ovaries) is done, you can use modifier -58 (which indicates a staged or related procedure performed by the same doctor during the postoperative period).
4. Self-Comprehension Questions Questions on Unlisted Codes:
- Which of these codes are used when a more specific code cannot be found? o a) Level III o b) National o c) Unlisted o d) Both A and C o Answer : c) Unlisted. Unlisted codes are used when a specific code cannot be found.
- What must always accompany the submission of an unlisted procedure code? o a) History and physical report o b) Pathology report o c) Copy of patient file o d) Special report o Answer : d) Special report. A special report is required to explain the procedure when an unlisted code is used. Questions on Separate Procedures:
- A “separate procedure” is: o a) Coded when it is the only procedure performed. o b) Not coded when it is part of a more involved surgery at the same site. o c) May be coded along with another procedure depending on the circumstances. o d) All of the above. o Answer : d) All of the above. A separate procedure may be coded when it is the only procedure, but it is usually not coded if part of a larger surgery at the same site. It depends on the situation. Key Takeaways:
- Unlisted Codes are used when no specific code exists for the procedure. Always include a special report to explain why the unlisted code is being used.
- Special Reports should describe the procedure, including its need, extent, and the equipment used.
- Separate Procedures are minor procedures that are usually bundled with a larger surgery unless they are the only procedure done. Always check if there is an exception to the rule, like when the procedure happens at a different time.
o Answer : d) A, B, and C. Major surgeries generally include preoperative, intraoperative, and postoperative services.
- What is another name for the period of time after a major surgery? o a) Global o b) Major o c) Preoperative o d) Intraoperative o Answer : a) Global. The period after a major surgery is known as the global period. Medical Terminology Review Curettage : Scraping of a cavity using a spoon-shaped instrument. Endoscopy : Inspection of body organs or cavities by the use of a light scope. Injection : Forcing fluid into a vessel, cavity, or tissue. Suture : To unite parts by stitching them together. Learning Activity
- Is a written order part of the surgical package? o a) Yes o b) No o Answer : b) No. A written order is not typically part of the surgical package.
- What type of postoperative follow-up care is included in the surgical package? o a) Common o b) Unusual o c) Complex o d) Immediate
o Answer : d) Immediate. Immediate follow-up care after surgery is typically included in the surgical package. Quiz
- How many days do most payers specify for the postoperative period following a major surgery? o a) 90 o b) 60 o c) 30 o d) 10 o Answer : a) 90. Most payers include postoperative services for 90 days after a major surgery.
- If a needle biopsy is performed in the office, would all third- party payers pay separately for the necessary supplies used during the biopsy? o a) Yes o b) No o Answer : a) Yes. Some payers require supplies like surgical trays to be reported separately when a needle biopsy is performed in the office. Surgical Package, Part II - Study Guide Key Concepts Major Surgical Procedures typically include three phases:
- Preoperative Service : Services provided before the surgery.
- The Procedure : The actual surgery.
- Postoperative Service : Services provided after the surgery. Minor Surgical Procedures : o Preoperative and postoperative services can be variable. o These services are usually reported separately for minor procedures.
Medical Terminology Review
- Biopsy : Removal of a small piece of living tissue for diagnostic purposes.
- -centesis : Suffix meaning puncture of a cavity.
- -ectomy : Suffix meaning removal of part or all of an organ of the body.
- -rrhaphy : Suffix meaning suturing. Learning Activity
- Would the surgery package include the postanesthesia recovery area visit by the surgeon? o a) Yes o b) No
- Is a digital block performed by the surgeon part of the surgery package? o a) Yes o b) No Quiz
- When a minor procedure is provided to a new or established patient, and that procedure is the major service, do you report both the E/M service and the procedure? o a) Yes o b) No
