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CHAPTER 13

SURGERY GUIDELINES AND GENERAL SURGERY

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Surgery Section

Largest CPT Section

Section format:

10004-69990

Divided by subspecialty

Integumentary

Cardiovascular

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How many subsections are included in the Surgery section of the CPT manual? (It has 19 subsections, with codes ranging from 10004 to 69990. Within the Surgery section, the Integumentary and Cardiovascular are among the more complex subsections.)

Notes and Guidelines

Throughout section

Information varied and extensive

“Must” reading

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Guidelines are provided at the start of each section of the CPT. The information they contain allows the coder to appropriately interpret and report on the procedures and services included in that section.

Can subsections have their own notes with special instructions? (In addition to the general guidelines, each subsection, subheading, category, and subcategory of information included in the CPT is likely to have its own set of notes, including special instructions for use of the codes contained in that part of the CPT. These instructions must be followed for coding to be accurate.)

CPT Manual Text Changes

Figure 13.1

►◄ Indicates text changes from previous edition

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Why is it important to note any changes in the CPT guidelines accompanying a revision of the CPT? (Revisions to the CPT are periodically released. New or revised text included in the CPT guidelines is indicated by arrows placed at the start and end of the changed information, as shown here in Fig. 13.1.)

Subsection Notes

Figure 13.2

Subsection notes apply to entire subsection

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As an example, consider the following notes from the Musculoskeletal System subsection shown in Fig. 13.2. Because this note is provided at the start of the subsection, it applies to the entire subsection.

Three critical pieces of information are provided:

Location of cast and strapping procedures—knowing this may speed up the process of locating a code.

If more than one cast or traction device is applied, an additional listing may be required. Failure to follow this note could result in underpayment for services rendered.

Definitions are provided for key terms that will be used throughout the section.

Subheading Notes

Figure 13.3

Subheading notes apply to entire subheading

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On what basis are subheadings clustered within a subsection? (Subsections of the CPT may include subheadings to cluster together a group of related procedures or services. As with notes that appear under subsections, notes placed under a subheading will apply to all procedures and services within that portion of the CPT. The note listed in this example [Fig. 13.3] provides guidelines for coding bone grafting procedures within the Spine section and indicates that these instructions apply solely to this section.)

Category Notes

Figure 13.4

Category notes apply to entire category

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Notes may also be placed at the start of a category of procedures or services, in which case they apply to all procedures and services within the category. Consider the example from the Grafts (Implants) category shown in Fig. 13.4. The note restricts use of certain codes to situations in which the graft has not already been used as part of the procedure.

Subcategory Notes

Figure 13.5

Subcategory notes apply to entire subcategory

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The CPT also includes notes for subcategories of procedures and services, as shown in Fig. 13.5.

These notes apply to the entire subcategory.

Additional Helpful Notes

Figure 13.6

Parenthetical information

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Parenthetical notes provide additional information that will aid the coder in making correct coding decisions (as shown in Fig. 13.6).

Unlisted Procedure Codes

Used only when more specific Category I or Category III code not found

Written report accompanies submission

Each unlisted code service paid on case-by-case basis

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Are there any circumstances for which one cannot assign a listed procedure code to a procedure or service? (Yes, when the procedure is not listed in the CPT, you would use an unlisted procedure code.)

What documentation is required for an unlisted procedure code? (A Special Report describing the procedure)

Category III codes may exist for procedures that lack a specific code within the CPT. In this case, the Category III code, and not the unlisted procedure code, must be used.

Separate Procedure

“Separate procedure” follows code description

Incidental to more major related procedure

Breast biopsy

Before radical mastectomy, same operative session, would not be coded, as only procedure performed, would be coded

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Under what circumstances are minor procedures coded as separate procedures? (When they are the only services performed, or when they are performed along with other procedures that affect other body sites. When performed with another procedure, they are incidental to that procedure. For example, a breast biopsy performed prior to a radical mastectomy would NOT be coded as a separate procedure because it has material significance to the mastectomy and affects the same body area. However, if the biopsy were the only procedure performed, it would be coded with use of the separate procedure code.)

Separate Procedure Reported When

Only procedure performed

With another procedure

On different site

Unrelated to major procedure

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Remember, “separate procedure” doesn’t mean that it was the only one performed. It only indicates how the code can be used.

Minor Procedures

Often on service-by-service basis

Often do not have bundle of services

Third-party payer decides what is in a surgical bundle

Minor procedure for Medicare has 0 or 10-day global period

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Minor procedures are often provided on a service-by-service basis because they lack significant elements of preoperative and postoperative follow-up and tend to be straightforward and limited in scope. Major surgical procedures, on the other hand, are often coded as a bundle of services that reflects the standard care the surgical patient can be expected to receive in connection with the procedure.

Third-Party Payers

Decide what is in a surgical bundle

Medicare has the “Correct Coding Initiative” edits

Specify what is in bundle

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Third-party payers vary in definitions of what is included in a surgical package.

This will vary what you can and cannot submit separately for reimbursement.

Major Guideline of Surgical Packages (1 of 2)

Major surgical procedures usually include:

Preoperative (before)

Intraoperative (during)

Postoperative (after—also known as global period)

Minor complications

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The surgical package includes a global package that consists of the preoperative examination, the surgical procedure, and the postoperative period.

When a patient is hospitalized and it is determined that he or she needs surgery, he or she would have a preoperative exam, and no E/M charges after this day can be billed if they are due to the reason the patient is having surgery.

The insurance companies set the postoperative (global) days period. Typically it is 10 or 90 days.

Major Guideline of Surgical Packages (2 of 2)

One bundle—one price

Minor procedure may have no bundle

Varies by payer

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How are individual components of a complex procedure billed as a surgical bundle? (The package of services is billed, rather than the individual components. These include the operation itself, local anesthesia, and typical follow-up care, one related E/M encounter prior to the procedure, and immediate follow-up care, including written orders.)

Which party determines the components of a specific surgical package? (Each third-party payer may define the package differently. It is important to be clear on the definitions the third-party payer has applied to these procedures when determining how to bill for them.)

Major Guideline Example

Most payers specify 90 days after major surgery

All services related to surgery are in package

Including preop, intraop, and postop

Separate reporting = Unbundling

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What procedures or services that are related to surgery are billed separately from the surgical package?

When bundled services are delivered, all services provided during the standard postoperative period are included in the surgical package price. For major surgery, this period typically covers the 90 days following surgery.

When minor surgical procedures are delivered, preoperative and postoperative care are not typically bundled into a surgical package. Instead, all services are reported separately. The global period for minor procedures is 10 days following surgery.

General anesthesia is typically not bundled but rather is billed separately by the anesthesiologist.

Never in Bundle

General anesthesia services

Reported separately by anesthesiologist

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General anesthesia is a separate specialty and performed by an anesthesiologist. This is always separately reportable.

Surgical Package

Minor procedure: preop and postop services are sometimes reported separately

Same day may be included in performance of the procedure

Can be reported separately if specified by payer

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Many minor procedures have zero global days assigned to them. This allows for separate charges to be billed for preoperative and postoperative services.

This varies by payers.

Minor Surgery Example

Needle biopsy in office

Report

Procedure (biopsy)

Supplies (surgical tray)

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If there are no global days assigned to a minor procedure, could you bill for the postoperative visit 3 days following the minor procedure? (Yes)

Surgical Tray

Needles, suture materials, wipes, drugs

Report surgical tray with

99070 CPT, Medicine section (Medicare bundles into procedure)

A4550 HCPCS (not separately reported to Medicare)

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Is a surgical tray billable as a separate item? (The surgical tray is commonly included in minor surgical procedures. It is billable as a separate line item because it contains items not typically required for an office visit.)

Reporting Surgery

Outpatient coders: Physician payment (professional)

Inpatient coders: Hospital payment (facility)

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What set of codes is used for inpatient services and procedures, and what set of codes is used for outpatient services and procedures? (Outpatient coders address physician payments with use of the CPT codes; inpatient coders address hospital or facilities payments with use of the ICD codes.)

General Subsection (10004-10021)

Fine needle aspiration biopsies with or without (w/wo) imaging guidance

Pathology 88172, 88173, and 88177 for aspirate evaluation

From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

Figure 13.9

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What is a fine-needle biopsy? (A fine-needle biopsy is used to withdraw fluid that contains individual cells. The needle is inserted into the area and moved several times to take multiple samples without withdrawing the needle.)

Note that fine needle aspiration biopsy is different from needle core biopsy. In the latter case, the biopsy site is exposed to the physician, who then removes a portion of the lesion for examination.

Conclusion CHAPTER 13

SURGERY GUIDELINES AND GENERAL SURGERY

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