Transcript Slide 1

CHAPTER 10
GENERAL SURGERY II
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1
Hemic and Lymphatic Systems
Subsection
• Divisions
– Spleen
– General
– Lymph Nodes and Lymphatic Channels
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Spleen (38100-38200)
• Spleen easily ruptured, causes massive
hemorrhage
• May require splenectomy
• Splenectomy: total or partial
(Cont’d…)
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Spleen (38100-38200)
(…Cont’d)
• Often done as part of more major
procedure
• Bundled into major procedure
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General (38204-38242)
• Codes divided based on
– Aspiration
– Biopsy
– Harvesting
– Transplantation
• Stem cells
– Immature blood cells originating in bone marrow
– Used in leukemia treatment
(Cont’d…)
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General (38204-38242)
(…Cont’d)
• Types of stem cells:
– Allogenic: Close relative
– Autologous: Patient’s own
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Lymph Nodes and Lymphatic
Channels (38300-38999)
• Two types of lymphadenectomies:
– Limited: Lymph nodes only
– Radical: Lymph nodes, submandibular gland, and
surrounding tissue
• Term “complete” same as radical neck
dissection
• Lymph nodes in all 5 regions are resected
(Cont’d…)
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Lymph Nodes and Lymphatic
Channels (38300-38999)
(…Cont’d)
• Region I—Submental & submandibular group
• Region II—Upper jugular group
• Region III—Middle jugular group
• Region IV—Lower jugular group
• Region V—Posterior triangle group
• 38720- is unilateral code
(Cont’d…)
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Lymph Nodes and Lymphatic
Channels (38300-38999)
(…Cont’d)
• “Modified” radical neck: Removal of all
lymph nodes routinely removed by
radical neck dissection, while
preserving internal jugular vein, spinal
accessory nerve, and/or
sternocleidomastoid muscle
• This is unilateral procedure
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Lymphadenectomies
• Often bundled into more major
procedure (e.g., prostatectomy)
– Do not unbundle and report
lymphadenectomy separately
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Endocrine System Subsection
• 9 glands in
endocrine system;
only 4 included in
subsection
– Thyroid
– Parathyroid
– Thymus
• Pituitary and pineal:
See Nervous System
• Pancreas: Digestive
System
• Ovaries and testes:
Respective genital
system
– Adrenal
(Cont’d…)
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Endocrine System (60000-60699)
(…Cont’d)
• Divided into 2 subheadings
– Thyroid Gland
– Parathyroid, Thymus, Adrenal Glands,
and Carotid Body
(Cont’d…)
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Endocrine System (60000-60699)
(…Cont’d)
• Carotid body refers to area adjacent
to carotid artery
– Can be site of tumors
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Thyroid Gland, Excision (60100-60281)
• 2 lobes
• Code descriptions often refer to
– Partial or subtotal: Something less than total
• Removes problem side of gland, isthmus, and majority of
opposite lobe
– Total: All
– Lobectomy (Partial)
– Total thyroid lobectomy (solitary nodules, follicular
adenomas, hot or cold nodules, goiters)
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Nervous System
• Divided anatomically
– Skull, Meninges, and Brain
– Spine and Spinal Cord
– Extracranial Nerves, Peripheral Nerves,
and Autonomic Nervous System
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Skull, Meninges, and Brain
(61000-62258)
• Categories
– Injection, Drainage, or Aspiration
– Twist Drills, Burr Hole(s), or Trephine
• Meninges—3 layers of connective
tissue membranes that surround brain
& spinal cord
(Cont’d…)
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Skull, Meninges, and Brain
(61000-62258)
(…Cont’d)
• Conditions that require openings into
brain to:
– Relieve pressure
– Insert monitoring devices
– Place tubing
– Inject contrast material
(Cont’d…)
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Skull, Meninges, and Brain
(61000-62258)
(…Cont’d)
• Craniectomy or Craniotomy category
(61304-61576)
– Removal of portion of skull, usually as
operative site
– Codes divided by site and condition
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Surgery of Skull Base Category
• Skull base: Area at base of cranium
– Lesion removal from this area very
complex
• Extensive category notes
• Surgical management of lesions in
skull base
• Often involve surgeons from different
specialties working during same
operative session
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Surgery of Skull Base Terminology
• Approach procedure: Used to gain
exposure of lesion
• Definitive procedure: What is done
to lesion
• Repair/reconstructive procedure:
Reported separately only if extensive
repair
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Surgery of Skull Base (61580-61619)
• Approach procedure and definitive
procedure coded separately
(Cont’d…)
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Surgery of Skull Base (61580-61619)
(…Cont’d)
• Example:
– Removal of an intradural lesion using
middle cranial fossa approach
– 61590 Pre-auricular approach procedure,
middle cranial fossa and
– 61608 Definitive procedure of intradural
resection of lesion
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Cerebrospinal Fluid (CSF)
Shunt (62180-62258)
• Used to drain fluid
• Codes describe placement of
– Devices
– Repair
– Replacement
– Removal of shunting devices
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Spine and Spinal Cord
(62263-63746)
• Codes divided on condition and
approach
• Other important coding considerations
– Unilateral or bilateral procedures (-50)
– Multiple procedures (-51)
– Radiologic supervision and
fluoroguidance reported separately
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Spine and Spinal Cord
(62263-63746)
• Many codes in the nervous system
involve conditions responsible for
procedure
– Example: abscess, cyst, hematoma,
foreign body, tumor, etc., as well as
technique used for operation
• Review CCI edits
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Introduction/Injection of Anesthetic Agent,
Diagnostic or Therapeutic (64400-64530)
• Includes codes for:
– Nerve blocks 64400-64530
– Facet joint injections 64470-64476
– Epidural injections 64479-64484
• Used to provide pain relief
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Eye and Ocular Adnexa
(65091-68899)
• Terminology extremely important
– Code descriptions often vary only slightly
(Cont’d…)
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Eye and Ocular Adnexa
(65091-68890)
(…Cont’d)
• Codes divided anatomically, examples:
– Eyeball
– Conjunctiva
– Anterior Segment
– Posterior Segment
• Some codes specifically for patients
previously operated on
(Cont’d…)
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Eye and Ocular Adnexa
(65091-68890)
(…Cont’d)
• Much bundling
– Example: Subheading Posterior Segment,
Prophylaxis category notes indicate
• “The following descriptors intended to include
all sessions in defined treatment period.”
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Eyeball (65091-65290)
• Removal of the Eye report:
– Evisceration (65091, 65093)
• Removal of contents of globe
– Enucleation (65101-65105)
• Removal of eye, leaving orbital structures intact
– Exenteration (65110-65114)
• Removal of eye, adnexa, part of bony orbit
• Associated skin grafting reported separately
(15120/15121, 15260/15261)
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Removal of Foreign Body
(65205-65265)
• Extensive notes
• Removal from external or intraocular
• Slit lamp
– Microscope with high-intensity light source
– Focuses long narrow beam of light
– Different codes for with/without slit lamp
– Example:
• 65220, foreign body removal without slit lamp; 65222,
foreign body removal with slit lamp
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Anterior Segment
(65400-66999)
• Includes:
–
–
–
–
–
–
–
Cornea
Anterior Chamber
Anterior Sclera
Iris, Ciliary Body
Lens
Other Procedures
Posterior segment—vitreous procedures for
removal of vitreous humor from eye
– If performed from core of vitreous, it is a posterior
vitrectomy
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Cornea
• Keratoplasty: Repair of cornea
• 65710-65756
• Penetrating keratoplasty: Full thickness
of cornea removed
– Replaced with donor cornea
• Aphakia: Absence of lens of eye
• Pseudophakia: Presence of artificial
lens after cataract surgery
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Anterior Chamber
(65800-66030)
• Paracentesis: Removal of fluid
– Needle inserted into anterior chamber and fluid
withdrawn
• Diagnostic (65800)
• Therapeutic (65805-65815)
• Goniotomy: Surgical procedure using
goniolens to view eye (65820)
– Usually for congenital glaucoma
• Synechiae (adhesions)
– Posterior synechiae: Adhesions iris to lens
– Anterior synechiae: Adhesions iris to cornea
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Anterior Sclera
(66130-66250)
• Trabeculectomy ab externo
(e.g., 65850)
– Involves trabecular meshwork
• Iris-scleral junction, drains aqueous humor
– Surgery reshapes or punctures the
meshwork as a treatment for glaucoma
or trauma
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Iris, Ciliary Body
(66500-66770)
• Iridotomy performed for removal of:
– Lesion (66600)
– Treatment of glaucoma (66625, 66630)
– Laser iridotomy (66761)
– Photocoagulation (66762)
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Lens (66820-66940)
• Cataracts
– Nuclear cataract: Most common
• Center of lens (nucleus)
• Due to aging process
– Cortical cataract: Forms in lens of cortex and extends
outward
• Common in diabetics
– Subcapsular cataract: Forms at back of lens
• Assigned based on type of procedure performed
– Intracapsular (ICCE)
– Extracapsular (ECCE)
(Cont’d…)
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Lens (66820-66940)
(…Cont’d)
• Removal and lens placement (66830-66990)
– Extracapsular cataract extraction (ECCE), partial removal
• Removes hard nucleus in 1 piece and soft cortex in
multiple pieces
– Intracapsular cataract extraction (ICCE), total removal
• Removes lens and capsule in 1 piece
– Phacoemulsification
• Small incision into eye, introduction of probe
• High frequency waves fragment cataract
• Lens placed through same small incision
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Eyelid (67700-67999)
• Blepharotomy (67700)
– Incision into eyelid for drainage of abscess
• Blepharoplasty
– Repair of eyelid
– Codes in Integumentary System (15820-15823)
– Codes in Eye and Ocular Adnexa (67916, 67917,
67923, 67924)
• Selection of code depends on technique used for repair
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Eyelid Modifiers
• E1-E4
• E1—upper left eyelid
• E2—lower left eyelid
• E3—upper right eyelid
• E4—lower right eyelid
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Auditory System (69000-69990)
• Codes divided by
– External Ear (69000-69399)
– Middle Ear (69400-69799)
– Internal Ear (69801-69949)
– Temporal Bone, Middle Fossa Approach (69950-69979)
– Operating Microscope (69990)
• Outer and middle ear function is conduction of sound
waves through ear
• Inner ear contains structures that receive auditory waves
and relay to brain
– Right ear—AD
– Left ear—AS
– Both ears—AU
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Divisions of Auditory System
Figure: 10.14
• External, middle, and internal ear
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Auditory System
• Further divisions on procedure:
– Incision
– Excision
– Removal, ex. foreign body
– Repair
– Other
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External Ear (69000-69399)
• Incision: Drainage of abscess or hematoma
– Simple, 69000
– Complicated, 69005
• Excision: Biopsy
– External ear, 69100
– External auditory canal, 69105
– Excision of external ear, partial/complete, 69110,
69120
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Removal of Foreign Body
• Based on with/without general
anesthesia
– 69200, 69205
• Impacted cerumen
– One or both ears
– 69210
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Repair
• Otoplasty
– For protruding ears
– May or may not decrease external ear size
– Add -50 for both ears
• Canalplasty
– Reconstruction of external auditory canal
– Codes based on stenosis or congenital defect
– Caution: Canalplasty bundled into some middle
ear repair codes
• For example 69631-69646
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Middle Ear (69400-69799)
• Eustachian tube connects middle ear to back of
throat for drainage
– Fluid collects in middle ear when tube malfunctions
– Prevents air from entering middle ear and pressure builds
• Surgical intervention
– Myringotomy (incision into tympanic membrane) relieves
pressure and drains pus
– Tympanostomy (incision and placement of PE tube
(pressure equalization) repair of eardrum and hearing
mechanism
• Myringotomy included in tympanostomy (tubes)
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Inner Ear, Incision and/or
Destruction (69801-69840)
• Labyrinthotomy: Surgical incision into the
cavelike structure (labyrinth) of inner ear
• If pressure builds within labyrinth, may result
in:
– Vertigo
– Ringing
– Hearing loss, etc.
• 69801, 69802 = with/without mastoidectomy
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Excision (69905-69915)
• Labyrinthectomy
• Incus and stapes are removed
• Codes are based on approach as:
– Transcanal 69905
– Postauricular (behind ear) 69910
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Introduction (69930)
• Cochlear device Implant
• Computerized device
• Restores partial hearing
• Receiver on outside of skin, behind ear, over
the site of transmitter
• Transmitter implanted under skin
• Sound processor connected to an electrode
implanted in cochlea
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Temporal Bone, Middle Fossa
Approach (69950-69979)
• Surgical approach used with:
• Repair vestibular labyrinth nerves
(69950)
• Decompress facial nerve (69955)
• Decompress internal auditory canal
(69960)
• Removal of neoplasm from temporal
bone (69970)
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Operating Microscope
(+69990)
• Used with procedures using microsurgical
techniques
• Code in addition to primary procedure
performed
– Unless primary procedure description includes
microsurgical techniques
– Example: 15758 Free fascial flap with
microvascular anastomosis
– Note that following 15758 is the statement:
• “(Do not report code 69990 in addition to code 15758)”
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Conclusion
CHAPTER 10
GENERAL SURGERY II
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