2010surgicom MedihelpCPTBILLINGGUIDES

CCSA 2010
SURGICOM-MEDIHELP BILLING GUIDES
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CTP based on CCSA 2010 Prepared for exclusive use by Surgicom
CCSA 2010
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Surgicom Billing Tables Medihelp 2010
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Surgicom Correct Coding Help Desk Medihelp CPT contract

From 1st January 2010 the latest version of CPT in South Africa (CCSA2010) came into operation. This resulted in major changes to the relative value units (RVU) of the codes. In addition a correction to the rand conversion factor has been implemented to effect a 9.5% increase overall above last years remuneration status. An electronic version can be downloaded from the Surgicom website http://www.surgicom.co.za Medihelp CPT Payout (guaranteed to the surgeon) is significantly above the current base rate paid by most Schemes. Medihelp will advise the surgeon if an account is rendered below guaranteed rate so that a revised account can be submitted; if an overcharge exists on the account the guaranteed amount as per contract will be paid direct to the surgeon and the excess must be discounted and not claimed from the patient. Please do not hesitate to contact us for advice on any billing or coding matter. Surgicom Office: PO Box 1105 Cramerview 2060 Telephone : 011-706 4815 Telefax : 011-463 1041 Email : surgicom@worldonline.co.za Website : http://www.surgicom.co.za
Stephen Grobler 051-4442878 / 051-4442889 / fax 051-4440267 or 0866-412178 / sgrobler@global.co.za
Any Physicians Current Procedural Terminology (CPT) five digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright of the American Medical Association (AMA). All rights reserved. Complete CPT for SA is the subject of copyright owned by the SA Medical Association exclusive of CPT and any derivative work of CPT which is the subject of copyright owned by the American Medical Association. No fee schedules, basic unit values, relative value guides, related lists, conversion factors or scales are included in CPT. AMA and SAMA assume no responsibility for the consequences attributable to or related to any use or interpretation of any information contained in or not contained in CPT. AMA and SAMA do not directly or indirectly practise medicine or dispense medical services. AMA and SAMA assume no liability for data contained herein.
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CCSA2010 COPYRIGHT NOTICE
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CONFIDENTIAL
Introduction to CPT Coding

Surgicom - Medihelp contract. Surgicom surgeons contracted to Medihelp may only bill in CPT and are not allowed to combine the SAMA Doctors Billing Manual (DBM) or other coding systems. The rand conversion factor (RCF) is negotiated annually with Medihelp. The contract specifically prohibits balance billing charges in excess of the agreed amounts and no claims may be made directly from the client, even in the event of disagreement. The only exception is for Evaluation and Management Services (E/M) where available funds have been exhausted the client will have to pay out-of-pocket for these services for non-PMB conditions. Accurate ICD10 coding is a prerequisite and the appropriateness of the ICD10 codes in respect of the CPT code undergoes a validation process. Your claim may be rejected if a line-for-line appropriate ICD10 code is not supplied. Surgicom and contracted partners provide this guide for the purpose of information and as a general billing guide. The final decisions on reimbursement rest with Medihelp. The Surgicom Office Assistant application evolved from the EasyCode programme. It includes CPT coding and billing (units and rand values), ICD10, surgical procedure guidelines, patient information sheets, medical scheme benefit designs and many other useful tips and references for practice management. An updated disk will not be supplied this year. The Browser may still be used to look up codes, but the unit and rand values will be incorrect. A web-based application may become available later. Any information on items not included in the Guide or Browser, comments or disagreement with interpretation &/or reimbursement must be reported to: Surgicom Office, P.O. Box 1105, Cramerview 2060. Telephone: 011 706 4815; Fax: 011 463 1041; email: surgicom@worldonline.co.za; Web: http://www.surgicom.co.za. Stephen Grobler 051 4442878; 083 251 8727; fax: 0866 412 178 / 051 4440267; email: sgrobler@global.co.za. The coding utilised in the Surgicom - Medihelp contract follows the rules in the Current Procedural Terminology (CPT) of the American Medical Association (AMA) and Medicare RBRVS, but includes local adaptations. The South African Medical Association (SAMA) has contracted the rights to these publications and from time to time publishes a South African version, the Complete CPT for South Africa (CCSA). Their current publication is the CCSA 2010 based on the CPT up to 2008 and comes into effect on 1 st January 2010 for use in the Surgicom Medihelp contract. CCSA 2010 Copyright Notice. Any CPT five digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright of the AMA. The CCSA is the subject of the copyright owned by SAMA exclusive of CPT and any derivative work of CPT which is the subject of copyright owned by the AMA. No fee schedules, basic unit values, relative value guides, related lists, conversion factors or scales are included in CPT . AMA and SAMA assume no responsibility for the consequences attributable to or related to any use or interpretation of any information contained in or not contained in CPT . AMA and SAMA do not directly or indirectly practise medicine or dispense medical services. AMA and SAMA assume no liability for data contained herein. CCSA 2010 is a set of codes, descriptions and guidelines intended to describe procedures and services performed by surgeons and other health care providers. The main body of the material is listed in six sections. Each section is divided into subsections with anatomic, procedural, condition, or descriptor subheadings. Evaluation and Management .......................................... 99201-99499 Anaesthesiology ............................................................... 00100-01999, 99100-99140 Surgery ............................................................................. 10021-69990 Radiology (including ultrasound)................................... 70010-79999 Pathology and Laboratory .............................................. 80048-89356 Medicine (including diagnostic procedures) ................. 90281-99199, 99500-99602
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CCSA 2010
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CPT General Modifiers

21 Prolonged E&M Services When the face-to-face or floor/unit service(s) provided is prolonged or greater than usually required for the highest level of E/M service within a given category, it may be identified by adding modifier -21 to the E/M code. A report may also be appropriate. Unusual Procedural Services. Service(s) provided is greater than usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure number. A report may also be appropriate. Unrelated E&M Service by the Same Surgeon Indicate that an E&M service was performed during a postoperative period for a reason(s) unrelated to the During a Postoperative Period: different ICD 10 original procedure (different ICD code). This circumstance may be reported by adding the modifier -24 to code required the appropriate level of E/M service. Significant, Separately Identifiable E&M Service by The Surgeon may need to indicate that on the day a procedure or service was performed, the patients the Same Surgeon on the Same Day of a Procedure or condition required a significant, separately identifiable E&M service above and beyond the other service Other Service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier -57. Mandated services Services related to mandated consultation and/or related services e.g. E&M services mandated by a medical scheme, may be identified by adding the modifier -32 to the appropriate level of E&M service. Anaesthesia by surgeon Regional or general anaesthesia provided by the surgeon may be reported by adding the modifier -47 to the basic service. (This does not include local anaesthesia.) Note: Modifier -47 would not be used as a modifier for the anaesthesia procedures. Bilateral Procedure, unless otherwise identified in the Unless otherwise identified in the listings, bilateral procedures that are performed at the same session listings. The fee is 150% of the global amount. identified by adding modifier -50 to the appropriate five digit code. The fee for a bilateral procedure (if not otherwise indicated) is 150% of the global amount when the bilateral modifier is applicable. If additional procedures are performed under the same anaesthetic, they should be reported with modifier -51. The multiple rules apply with the bilateral procedure considered the first highest valued procedure. Multiple Procedures, additional procedure(s) or Additional procedures identified by modifier -51; 2nd - 5th procedures charged for at 50%, additional service(s) identified by modifier 51. Not applicable procedures >5th for negotiation with funder on a by-report basis. This modifier not applicable if 2 in poli-trauma where 100% of fee charged for all surgeons of different specialities each performs distinctly different procedures at the same time. Not procedures applicable in poli-trauma where 100% of the fee for all procedures is to be charged. Should not be appended to designated add-on codes. Reduced Services: Under certain circumstances a Under certain circumstances a service or procedure is partially reduced or eliminated at the Surgeons service or procedure is partially reduced or discretion - add modifier -52. For procedure/service that is partially reduced or cancelled as a result of eliminated at the Surgeons discretion. extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anaesthesia, see modifiers -73 and -74. Discontinued Procedure: Under certain Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to circumstances, the Surgeon may elect to terminate a indicate that a surgical or diagnostic procedure was started but discontinued. For outpatient hospital/day surgical or diagnostic procedure. clinic reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well -being of the patient prior to or after administration of anaesthesia, see modifiers -73 and -74.
22 24
32 47
50
51
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54 55 56 Surgical Care Only. Postoperative Management Only Pre-operative Management Only When one Surgeon performs a surgical procedure and another provides pre-operative and/or post-operative management, surgical services may be identified by adding the modifier -54. When one Surgeon performs the postoperative management and another Surgeon has performed the surgical procedure, the postoperative component may be identified by adding the modifier '-55. When one Surgeon performs the pre-operative care and evaluation and another Surgeon performs the surgical procedure, the pre-operative component may be identified by adding the modifier -56 to the usual procedure number and charge using a percentage of the global amount that is service specific. An E&M service that resulted in the initial decision to perform the surgery, may be identified by adding the modifier -57 to the appropriate level of E/M service. The treating Surgeon may indicate that the performance of a procedure or service during the post-operative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier -58 to the staged or related procedure. Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier -78.
57 58
Decision for Surgery Staged or Related Procedure or Service by Same Surgeon
59
Distinct Procedural Service.
62
Under certain circumstances the Surgeon may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedure services that are not normally reported together but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same Surgeon. However, when another already established modifier is appropriate, it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used. Two Surgeons working together as primary surgeons When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each performing distinct part(s) of procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 at 62.5% to the procedure surgeon should report his/her distinct operative work code and any associated add-on code(s) for that procedure as long as both surgeons continue to work to by adding modifier -62 to the procedure code and any together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure associated add-on code(s) for that procedure as long code. If additional procedure(s) (including add-on procedure(s)) are performed during the same surgical as both surgeons continue to work to together as session, separate code(s) may also be reported with the modifier -62 added. Note: If a co-surgeon acts as an primary surgeons. assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier -80 or modifier -82 added, as appropriate.
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Procedures Performed on Infants less than 4 kg
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Modifiers
Procedures performed on neonates and infants 4 kg may involve significantly increased complexity and Surgeon work. Reported by adding modifier -63.
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66 Surgical Team Under some circumstances, highly complex procedures (with several Surgeons, often of different specialities, plus other specially trained personnel, complex equipment) are carried out under the surgical team concept. Each participating Surgeon to use modifier -66. Repeat Procedure by Same Surgeon The Surgeon may need to indicate that a procedure or service was repeated subsequent to the original procedure or service by adding the modifier -76 to the repeated procedure/service. The Surgeon may need to indicate that a basic procedure or service performed by another Surgeon had to be Repeat Procedure by Another Surgeon repeated by adding modifier -77 to the repeated procedure/service. Return to the Operating Theatre for a Related The Surgeon may need to indicate that another procedure was performed during the post-operative period. Procedure During the Post-operative Period When this subsequent procedure is related to the first and requires the use of the operating theatre, it may be reported by adding the modifier -78 to the related procedure. (For repeat procedures on the same day, see 76). If complications require the patients return to operating theatre, modifier -78 would be applicable. Charges for re-operations must be for intra-operative services only. Separate full payment is allowed for treatment for complications requiring expertise of another surgeon Unrelated Procedure or Service by the Same Surgeon The Surgeon may need to indicate that the performance of a procedure or service during the post-operative during the Post-operative Period period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. (For repeat procedures on the same day, see -76). Multiple modifiers Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations modifier -99 should be added to the basic procedure and other applicable modifiers may be listed as part of the description of the service.
76 77 78
79
99
Anatomic Modifiers
LT Left side RT Right side E1 Upper left, eyelid E2 Lower left, eyelid E3Upper right, eyelid E4 Lower right, eyelid F1 Left hand, second digit F2 Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit F5 Right hand, thumb F6 Right hand, second digit F7 Right hand, third digit F8 Right hand, fourth digit F9 Right hand, fifth digit FA Left hand, thumb
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T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, fourth digit T4 Left foot, fifth digit T5 Right foot, great toe T6 Right foot, second digit T8 Right foot, third digit T8 Right foot, fourth digit T9 Right foot, fifth digit TA Left foot, great toe
LC Left circumflex coronary artery LD Left anterior descending coronary artery RC Right coronary artery
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Billing Component Modifiers

26; PC Professional Component (PC) Professional Component
TC
Technical component (TC)
Technical component: equipment, facility and staff costs
Place of Service Modifiers (identify each line item by the appropriate POS modifier)
POS-11 POS-21 Office & Out-patient facility Inpatient hospital e.g. theatre
Office (includes out-patient facility e.g. endoscopy suite) Inpatient hospital e.g. theatre
Assistant Modifiers (See categories of assistants assigned to individual procedures)

80; 09980 Assistant Surgeon: 20% of the surgeons fee with a minimum of R377.79 (3 RVUs). Specialist Surgeon Acting as Assistant Surgeon in procedures of a specialised nature: 40%
82; 09982
1 non-specialist assistant
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1 non-specialist assistant AND 1 specialist assistant
2 specialist assistants
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Modifiers
See categories of assistants assigned to individual procedures
Note: for most major surgical procedures reimbursement will be limited to one specialist surgeon or 2 general practitioners. A report is required if the circumstances warrant a different arrangement of assistants.
Assistant code A allows reimbursement of 1 non-specialist assistant at operation
Assistant code B allows reimbursement of 2 non-specialist assistants OR 1 specialist assistant at the operation
Assistant code C allows reimbursement of 1 non-specialist assistant AND 1 specialist assistant
Assistant code D allows reimbursement of 2 specialist assistants
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EVALUATION & MANAGEMENT (E/M) 2010 MEDIHELP

OFFICE SERVICES (POS 11)
New patient visit Established patient visit
99211 99212 99213 99214 99215 Seen during last 12 months 0.52 R 65.48 5 min 1.03 R 129.71 10 min 1.7 R 214.08 15 min 2.56 R 322.38 25 min 3.46 R 435.71 40 min Not seen during last 12 months 1.02 R 128.45 10 min 1.76 R 221.64 20 min 2.55 R 321.12 30 min 3.93 R 494.90 45 min 4.96 R 624.61 60 min
RCF =
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Consultation "Second opinion"

(Only if Dr does not take over care/treatment) 99241 1.35 R 170.00 15 min 99242 2.52 R 317.34 30 min 99243 3.46 R 435.71 40 min 99244 5.11 R 643.50 60 min 99245 6.28 R 790.83 80 min
99201 99202 99203 99204 99205
HOSPITAL INPATIENT SERVICES (POS 21)

Initial Visit
99221 99222 99223 2.49 3.4 5 R 313.56 R 428.16 R 629.65 30 min 50 min 70 min 99231 99232 99233
Subsequent Visit
Hospital discharge day management

15 min 25 min 35 min 99238 99239 1.84 2.67 R 231.71 R 336.23 30 min > 30 min
1.03 1.85 2.65
R 129.71 R 232.97 R 333.71
99218 99219 99220
1.74 2.88 4.04
R 219.12 Low severity R 362.68 Moderate severity R 508.75 High severity
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Per day
Hospital Observation Services Discharge day
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Admission and discharge on same day

3.53 4.63 5.75 R 444.53 R 583.05 R 724.09 Low severity Moderate severity High severity
99235 99235 99236
Emergency Department Services

99281 99282 99283 99284 99285
Critical Care Services

(Depends on diagnosis & not only because patient is in ICU) 99232, 99233 <30 min 99291 5.88 R 740.46 30 74 min 2.94 R 370.23 > 74 min; per 30 min 99292* * add to code 99291 for services >74 minutes; Specify exact times of ICU care e.g. 08:15 - 08:55; 16:30 - 17:45
4.72
R 594.38
Comprehensive examination, high complexity
Consultation in hospital Second opinion

(Only if Dr does not take over care/treatment) Initial Inpatient Consultation R 170.00 20 min R 264.45 40 min R 400.45 55 min R 578.01 80 min R 705.20 110 min
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NEW and ESTABLISHED PATIENT 0.56 R 70.52 Problem focused, straightforward 1.09 R 137.26 Expanded problem, low complexity 1.7 R 214.08 Expanded problem, moderate complexity 3.17 R 399.19 Detailed examination, moderate
After hours Services

17:00 - 08:00 weekdays, >12:00 Saturdays and all public holidays 0.68 R 85.63 After hours E/M Services After hours irrespective of time spent Charge only once per day. R 85.63 After hours Surgical Services per 15 minutes Specify exact times of the service.
99251 99252 99253 99254 99255
1.35 2.10 3.18 4.59 5.6
0.68
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Refer to detailed tabulation and notes for accurate billing
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SURGICOM-MEDIHELP BILLING GUIDES Evaluation and Management (E/M) Services Guidelines
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The E/M section is divided into broad categories such as office visits, hospital visits and consultations. The place &/or type of service is specified. The content of the service is defined e.g. comprehensive history & examination. The nature of the presenting problem(s) usually associated with a given level and the time typically spent providing the service is described. New and Established Patient A new patient is one who has not received any professional services from the surgeon or another surgeon of the same specialty, within the past year. An established patient is one who has received professional services from the surgeon or another surgeon of the same specialty, within the past year. No distinction is made between new and established patients in the emergency department. Levels of E/M Services. Within each category of E/M service, there are three to five levels. Levels are not interchangeable among the different categories e.g. the first level in the subcategory office visit, new patient, does not have the same definition as the first level in the subcategory of office visit, established patient. The descriptors recognise seven components: History, Examination, Medical decision making, Counselling, Coordination of care, Nature of presenting problem, Time.
The history, examination and medical decision making should be considered the three key components in selecting the level of E/M services. Determine the Extent of History Obtained: Problem focused: chief complaint; brief history of present illness or problem. Expanded problem focused: chief complaint; brief history of present illness; problem pertinent system review. Detailed: chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, &/or social history directly related to the patient's problems. Comprehensive: chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family and social history. Determine the Extent of Examination Performed: Problem focused: a limited examination of affected body area or organ system. Expanded problem focused: a limited examination of affected body area or organ system and other symptomatic or related organ system(s). Detailed: an extended examination of affected body area(s) and other symptomatic or related organ system(s). Comprehensive: a general multi-system examination or a complete examination of a single organ system. Determine the Complexity of Medical Decision Making in establishing a diagnosis &/or selecting a management option as measured by: The number of possible diagnoses &/or the number of management options that must be considered. The amount &/or complexity of medical records, diagnostic tests, &/or other information that must be obtained, reviewed and analysed. The risk of significant complications, morbidity &/or mortality, as well as comorbidities, associated with presenting problem(s), diagnostic procedure(s) &/or management options. No. of Diagnoses or Management Options Minimal Limited Multiple Extensive Table 2. Complexity of Medical Decision Making Amount &/or Complexity of Data Reviewed Risk of Complications, Morbidity/Mortality minimal or none Minimal Limited Low Moderate Moderate Extensive High Surgicom Coding CPT Guide: E & M Services Ver. 01/2010 p. 1/3
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Time. Included to assist surgeons in selecting the most appropriate level of services. The specific times are averages and represent a range of times depending on actual clinical circumstances.
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The E/M codes recognise five types of presenting problems that are defined as follows: Minimal: a problem that may not require the presence of the surgeon, but is provided under the surgeon's supervision. Self-limited/minor: a problem that runs a definite and prescribed course, transient in nature and is unlikely to permanently alter health status OR has a good prognosis with management. Low severity: a problem where the risk of morbidity and mortality without treatment is low; full recovery expected. Moderate: a problem where the risk of morbidity and mortality without treatment is moderate; uncertain prognosis OR increased probability of prolonged functional impairment. High severity: a problem where the risk of morbidity and mortality without treatment is high to extreme; high probability of severe, prolonged functional impairment.
Type of Decision Making Straightforward low complexity moderate complexity high complexity
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Office or Other Outpatient Services. E/M provided in the surgeon's office or outpatient or other ambulatory facility. To report services provided to a patient who is admitted to a hospital or nursing facility in the course of an encounter in the office or other ambulatory facility, the initial hospital care codes are used to report the E/M. E/M Hospital Observation Services. E/M services provided to patients designated/admitted as "observation status" in a hospital. Observation care discharge of a patient from
"observation status" includes final examination of the patient, discussion of the hospital stay, instructions for continuing care and preparation of discharge records. For observation or inpatient hospital care including the admission and discharge of the patient on the same date, see codes 99234 99235 -99236 as appropriate.
E/M Hospital Inpatient Services. E/M services provided to hospital inpatients. When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site
of service (e.g. hospital emergency department, observation status in a hospital, surgeon's office) all E/M services provided by that surgeon in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.
Hospital Discharge Services (99238-99239) discharge day management codes are to be used to report the total duration of time spent by a surgeon for final hospital discharge of a E/M Consultations (Second opinion). A consultation is a type of service provided by a surgeon whose opinion or advice regarding evaluation &/or management of a specific
problem is requested by another doctor or appropriate source. A surgeon consultant may initiate diagnostic &/or therapeutic services at the same or subsequent visit. (For follow-up inpatient consultation, see 99261-99263.) Emergency Department, see Critical Care notes and 99291, 99292.
E/M Prolonged Services with Direct (Face-to-Face) Patient Contact (99354-99359).
Standby Services (99360) Used to report standby service that is requested by another physician and that involves prolonged attendance without direct (face-to-face) patient contact. The surgeon may not be providing care or services to other patients during this period. This code is not used to report time spent proctoring another surgeon. It is also not used if the period of standby ends with the performance of a procedure subject to a "surgical package" by the surgeon who was on standby. It is always helpful to provide a motivating letter with the account; Medihelp will usually request clinical motivations. E/M Critical Care Services (99291-99292)
Critical care is the direct delivery by a surgeon of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. Critical care involves high complexity decision making to assess, manipulate and support vital system functions to treat single or multiple vital organ system failure &/or to prevent further life threatening deterioration of the patient's condition. Providing medical care to a critically ill, injured or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements. Critical care is usually, but not always, given in a critical care area, such as ICU or the emergency care facility. Critical care by the same surgeon in the postoperative global period of a procedure often requires motivation and distinctly separate ICD codes. Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes. Critical care and other E/M services may be provided to the same patient on the same date by the same surgeon. The following services are included in reporting critical care when performed during the critical period by the surgeon(s) providing critical care: interpretation of cardiac output measurements, chest x-rays, oximetry, blood gases and information data stored in computers (e.g. ECGs, blood pressures, haematologic data; gastric intubation; ventilator management; and vascular access procedures (36000, 36410, 36415, 36540, and 36600). Any services performed which are not listed above should be reported separately.
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E/M Emergency Department Services. No distinction is made between new and established patients in the emergency department. For critical care services provided in the
E & M Services Ver. 01/2010
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patient. The codes include final examination of the patient, discussion of the hospital stay, even if the time spent by the surgeon on that date is not continuous, instructions for continuing care to all relevant caregivers and preparation of discharge records, prescriptions and referral forms.
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The critical care codes 99291 and 99292 are used to report the total duration of time spent by a surgeon providing critical care services to critically ill or critically injured patient, even if the time spent by the surgeon on that date is not continuous. Time spent in activities that occur outside of the unit or off the floor (e.g. telephone calls, whether taken at home, in the office or elsewhere in the hospital) may not be reported as critical care since the surgeon is not immediately available to the patient. Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care. Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time. Critical care of <30 min total duration on a given date should be reported with the appropriate E/M code. Code 99291 is used to report the first 30 - 74 min of critical care on a given date. It should be used only once per date even if the time spent by the surgeon is not continuous on that date. Code 99292 is used to report additional block(s) of time, of up to 30 min each, beyond the first 74 min Note the exact times of the service on the accounts The following examples illustrate the correct reporting of critical care services: Total Duration of Critical Care Less than 30 min (less than 1/2 hour) 30-74 min (1/2 hr. - 1 hr. 14 min.) 75-104 min (1 hr. 15 min. - 1 hr. 44 min.) 105-134 min (1 hr. 45 min. - 2 hr. 14 min.) 135-164 min (2 hr. 15 min. - 2 hr. 44 min.) 165-194 min (2 hr. 45 min. - 3 hr. 14 min.) 194 min or longer (3 hr. 14 min. - etc.) Codes appropriate E/M codes 99291 X 1 99291 X 1 AND 99292 X 1 99291 X 1 AND 99292 X 2 99291 X 1 AND 99292 X 3
99291 X 1 AND 99292 X 4
99291 and 99292 as appropriate
E/M Inpatient Neonatal and Paediatric Critical Care Services. Codes 99293-99296 are used to report services provided by a surgeon directing the inpatient care of a critically
ill neonate/infant. The same definitions for critical care services apply for the adult, child and neonate.
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Surgery CPT Coding - Introduction

Instructions for Use of the CPT Codes. Select the name of the procedure or service that most accurately identifies the service performed. When necessary, any modifying or extenuating circumstances are added. Any service or procedure should be adequately documented in the medical record. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service to Medihelp and Surgicom to adjudicate on the appropriate action. CPT Global Surgical Package Definition Services provided by the surgeon to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-byprocedure basis, a variety of services. In defining the specific services "included" in a given CPT surgical code, the following services are always included in addition to the operation per se: local infiltration, metacarpal/metatarsal/digital block or topical anaesthesia; subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical); immediate postoperative care, including making operative notes, talking to family and other surgeons, writing orders; evaluating the patient in the post-anaesthesia recovery area; typical postoperative follow-up care. Postoperative services by the surgeon: the global surgery package includes a standard postoperative period of 90 days for major procedures (less for some minor procedures) when no separate payment is made for visits or services. Postoperative services specifically included as part of the global package include: dressing changes, local incisional care removal of operative packs, sutures, staples, lines, wires, tubes, drains, casts and splints insertion, removal and irrigation of urinary catheters routine peripheral intravenous lines, nasogastric and rectal tubes changes and removal of tracheostomy tubes. Follow-up Care for Diagnostic Procedures includes only care related to recovery from the diagnostic procedure itself (e.g. endoscopy). Care of the condition for which the diagnostic procedure was performed or other concomitant conditions not included & may be listed separately. Follow-up Care for Therapeutic Surgical Procedures includes only that care which is usually a part of the surgical service and is included for a specified number of days referred to as the global period. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported, specifically identified by unique ICD codes and specific modifiers. If the complication requires the patient return to theatre, these services will be paid separately from the global surgery allocation. The theatre or operating room includes cardiac catheterisation suite, radiological interventional suite and endoscopy suite. It does not include the patient room, minor treatment room, recovery room or ICU (unless the patients condition was so critical that there would be insufficient time or logistic reasons precluding transportation to an operating room). Surgicom Coding CPT Guide: Surgery Introduction Ver. 01/2010 p. 1/3
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CODING SERVICES SUPPLEMENTAL TO A PRINCIPAL PROCEDURE (ADD-ON CODES). The CPT system identifies certain codes that are to be submitted in addition to other codes. Generally, these are identified with the statement "list separately in addition to code for primary procedure" in parentheses, and other times the supplemental code is to be used only with certain primary codes that are parenthetically identified. Incidental services that are necessary to accomplish the primary procedure (e.g. lysis of adhesions in the course of an open cholecystectomy) are not separately reported. Certain complications with an inherent potential to occur in an invasive procedure are, likewise, not separately reported unless resulting in the necessity for a significant separate procedure to be performed. For example, control of bleeding during a procedure is considered part of the procedure and is not separately reported. Surgical Assistants. Considerable leniency has been allowed by Medihelp in relaxing the strict provisions of Medicare e.g. laparoscopic procedures and more complex procedures. It is recognised that the quality of surgery and operation times may be improved by better assistance. Medihelp will not pay for the inappropriate use of assistants. If special circumstances required the presence of an assistant(s) other than sanctioned by the contract, these circumstances must be motivated in writing to Medihelp for consideration by the Medihelp-Surgicom coding panel. A 1 non-specialist assistant B 2 non-specialist assistants OR 1 specialist assistant C 1 non-specialist assistant AND 1 specialist assistant D 2 specialist assistants
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Separate Procedure. Some of the procedures or services that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term "separate procedure." When such a procedure or service is carried out independently or considered to be unrelated or distinct from other procedures/services provided, it may be reported by itself, or in addition to other procedures/services by appending the modifier 59 to the specific "separate procedure" code to indicate that it is a distinct, independent procedure. This may be a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. Exceptions to the postoperative period when separate payment is allowed include E/M services that are unrelated to the diagnosis for which the surgery was performed. These services are indicated by appending modifier 24 to the appropriate E/M service and submitting appropriate documentation if requested. Services provided by the surgeon for treating the underlying condition and for a subsequent course of treatment that is not part of the normal recovery from the surgery are reported separately by modifier 79. Full payment for the procedure (not just the Intraoperative services) is allowed for situations when distinctly separate but related procedures are performed during the global period of another surgery (e.g. reconstructive and burn surgery) in which the patient is admitted to the hospital for treatment, discharged and then readmitted for further treatment. When the decision is made prospectively or at the time of the first surgery to perform a second procedure (i.e. to stage a procedure), modifier 58 (staged or related procedure or service by the same surgeon during the postoperative period) should be reported.
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Reporting More Than One Procedure/Service. When a surgeon performs more than one procedure/service on the same date, same session or during a post-operative period (subject to the "surgical package" concept), several CPT modifiers may apply. 27 Multiple Outpatient Hospital E/M Encounters on the Same Date For hospital outpatient reporting purposes, utilisation of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding the modifier 27 to each appropriate level outpatient &/or emergency department E/M code(s). 51 Multiple Procedures: when multiple procedures/services (other than E/M) are performed at the same session, report the most significant procedure first, with all other procedures listed with the 51 modifier appended. A reduction of fees or 50% applies for the subsequent procedures, including diagnostic procedures, but not for trauma. 58 Staged or Related Procedure or Service by the Same Surgeon During Postoperative Period When a procedure(s) is prospectively planned as a staged procedure, or when the secondary and subsequent procedure(s) is more extensive, or to indicate therapy following a diagnostic surgical procedure, use the 58 modifier with the staged procedure(s). 59 Distinct Procedural Service: for procedure(s)/service(s) not ordinarily performed or encountered on the same day by the same surgeon, but appropriate under certain circumstances (e.g. different site or organ system, separate excision or lesion), use '59'. 76 Repeat Procedure by Same Surgeon: when a procedure or service is repeated by the same surgeon subsequent to the original service, use the '76' modifier. 77 Repeat Procedure by Another Surgeon subsequent to original service, use '77' modifier. 78 Return to the Operating Room for a Related Procedure During the Postoperative Period When a procedure, related to the initial procedure, requires a return to the operating room during the postoperative period of that initial procedure, use the '78' modifier. 79 Unrelated Procedure or Service by the Same Surgeon During the Postoperative Period When a procedure, unrelated to the initial procedure, is performed by the same surgeon during the postoperative period of the initial procedure, use the '79' modifier.
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Materials Supplied by Surgeon. Supplies and materials provided by the surgeon (e.g. sterile trays/drugs), over and above those usually included with the procedure(s) rendered are reported separately. Identify as 99070 or specific supply code plus NAPPI code. A 10% mark-up is allowed, but proof of purchase and price must be supplied to Medihelp. Subsection Information: Skin, soft tissue, breast & musculoskeletal: Biopsy ......................................................................................... 11100-11101 Excision-Benign & Malignant Lesions .................................... 11400-11471, 11600-11646 Repair (Closure) ........................................................................ 12001-13160, 14000-14350 Skin Grafts................................................................................. 15000-15431 Flaps (Skin &/or Deep Tissue) ................................................. 15570-15999 Burns, Local Treatment ........................................................... 16000-16036 Breast ......................................................................................... 19100-19272 Endocrine ................................................................................... 60650-60659 Musculoskeletal ......................................................................... 20000-29999 Arteries and Veins .................................................................... 34001-35907 EVAR ......................................................................................... 34800-34900 Bypass Grafts ............................................................................ 35500-35572, 35681-35683, 35685-35686 Intravenous, Central Venous Access Procedures ................... 36000-36015, 36555-36597 Haemic, Lymphatic Spleen ...................................................... 38300-38999 Endoscopy/Laparoscopy........................................................... 43200-49659 Hernia ........................................................................................ 49491-49611 Urinary....................................................................................... 50541-50545, 50945-50980, 51990-52648 Male Genital .............................................................................. 54690-54699, 55550-55559, 55866 Female Genital .......................................................................... 58545-58579, 58660-58679 Nervous System ......................................................................... 61000-
Unlisted Service or Procedure. A service or procedure may be provided that is not listed in this edition of CPT/CCSA. When providing and reporting such a service, you are requested to negotiate the specific situation directly with Medihelp and Surgicom and provide a "Special Report" as discussed below. The annotation of "Unlisted Procedures" codes for Surgery has not been adopted in South Africa but the general reference can be added to your report: Unusual Procedural Services. Modifier 22 is used to indicate that a service(s) provided is greater than usually required for the listed procedure e.g. repeat laparotomy with dense adhesions. Use Modifier -22, rather than try to list the extra work as separate codes. CPT uses strict coding rules to prevent the unbundling and listing of multiple procedures. When an unusual or extensive service if provided, it is more appropriate to use modifier 22. Additional remuneration may be negotiated e.g. +30% and listed on your account using the modifier -22. A special report is usually required (see below). Special Report. A service that is rarely provided, unusual, variable or new may require a special report in determining medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Additional items which may be included are: Complexity of symptoms, final diagnosis Pertinent physical findings (such as size, locations, and number of lesion(s), if appropriate) Diagnostic and therapeutic procedures (including major and supplementary surgical procedures) Concurrent problems Follow-up care Surgicom Coding CPT Guide: Surgery Introduction Ver. 01/2010 p. 3/3
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SURGICOM-MEDIHELP BILLING GUIDES GENERAL CORRECT CODING POLICIES
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CODING BASED ON STANDARD OF SURGICAL PRACTICE For this system to be effective, it is essential that the coding description accurately describe what actually transpired at the patient encounter. Because many surgeons activities are so integral to a procedure, it is impractical and unnecessary to list every event common to all procedures of a similar nature as part of the narrative description for a code. Many of these common activities reflect simply normal principles of medical/surgical care. These "generic" activities are assumed to be included as acceptable medical/surgical practice and, while they could be performed separately, they should not be considered as such when a code descriptor is defined. Accordingly, all services integral to accomplishing a procedure will be considered included in that procedure. Many of these generic activities are common to virtually all procedures. On other occasions, some are integral to only a certain group of procedures but are still essential to accomplish these particular procedures. Accordingly, it would be inappropriate to separately code these services based on standard medical and surgical principles. Some examples of generic services integral to standard medical/surgical services would include: - Cleanings, shaving and prepping of skin. - Draping of patient, positioning of patient. - Insertion of intravenous access for medication. - Sedative administration by the surgeon performing the procedure. - Local, topical, or regional anaesthetic administered by surgeon performing procedure. - Surgical approach, incl. ID anatomical landmarks, incision, evaluation of surgical field, simple debridement, lysis of simple adhesions, isolation neurovascular, muscular or other structures. - Surgical cultures. - Wound irrigation. - Insertion and removal of drains, suction devices, dressings, pumps into same site. - Surgical closure. - Application, management, and removal of postoperative dressings including analgesic devices. - Preop, intraop & postoperative documentation, incl. photographs, dictation and transcriptions... - Surgical supplies. In the case of individual services, there are numerous specific services that may typically be involved to perform a procedure. Generally, performance of these services represents the standard of practice for a more comprehensive procedure and the services are therefore to be included in that service.
MEDICAL/SURGICAL PACKAGE. In general, most services have pre-procedure and post-procedure work associated with them, when performed at a single patient encounter; the preprocedure and post-procedure work does not change proportionately when multiple services are performed. Additionally, the nature of the pre-procedure and post-procedure work is reasonably consistent across the spectrum of procedures. In keeping with the policy that the work typically associated with a standard surgical of medical service is included in the CPT code description of the service; some general guidelines can be developed. With few exceptions these guidelines transcend a majority of CPT descriptions, whether or not the service is limited or comprehensive. Furthermore, CPT codes describing services to gain visualisation of tract (endoscopy) were created for the purpose of coding a diagnostic of therapeutic service and are not to be reported as a part of a major surgical procedure. When vascular access is obtained, the access generally requires maintenance of an infusion or use of an anticoagulant (heparin lock injection). These services are necessary for maintaining the access and are not to be separately reported. In some situations, more invasive access services (central venous access) are performed with a specific type of procedure. Because this is not typically the case, the codes referable to these services may be separately reported. Surgicom Coding CPT Guide: General correct Coding Policy Ver. 01/2010 p. 1/5
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Lysis of adhesions and exploratory laparotomy reported with colon resection or other abdominal surgery. These procedures involve gaining access to the organ system of interest and are not separately reported.
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Placement of central access devices (central lines, pulmonary artery catheters, involve passage of catheters through central vessels and in the case of PA catheters, through the right ventricle, additionally these services often require the use of fluoroscopic support. Separate reporting of CPT codes for right heart catheterisation, first order venous catheter placement, or other services that represents a separate procedure, is not appropriate when the CPT code that describes the access is reported. General fluoroscopic services necessary to accomplish routine central vascular access or endoscopy cannot be separately reported unless a specific CPT code has been defined for this service. When anaesthesia is provided by the surgeon performing the primary service, the anaesthesia services are included in the primary procedure (anaesthesia rules). If it is medically necessary for a separate provider (anaesthesiologist/anaesthetist) to provide the anaesthesia services (e.g. monitored anaesthesia care), a separate service may be reported. Most procedures require cardiopulmonary monitoring, either by the surgeon performing the procedure or an anaesthesiologist. Because these services are integral and routine, they are not to be separately reported. This may include cardiac monitoring, intermittent ECG procurement, oximetry, or ventilation management. These services when integral to the monitoring service, are not to be separately reported. When, in the course of a procedure, a non-diagnostic biopsy is obtained and subsequently excision, removal, destruction, or other elimination of the biopsied lesion is performed, a separate service cannot be reported for the biopsy procurement as this represents part of the removal. When a single lesion biopsied multiple times, only one biopsy removal service should be reported. When multiple distinct lesions are non-endoscopically biopsied, a biopsy removal service may be reported for each lesion separately with a modifier, indicating a different service was performed or a different site was biopsied. The medical record (e.g. operative report) should indicate the distinct nature of this service. However, for endoscopic biopsies of lesions, multiple biopsies of multiple lesions are reported with one unit of service regardless of how many biopsies are taken. If separate biopsy removal services are performed on separate lesions and it is felt to be medically necessary to submit pathologic specimens separately, the medical record should identify the precise location of each biopsy site. It the decision to perform a more comprehensive procedure is based on the biopsy result, the biopsy is diagnostic and the biopsy service may be separately reported. In the performance of a surgical procedure, it is routine to explore the surgical field to determine the anatomic nature of the field and evaluate anomalies. Accordingly, codes describing exploratory procedures e.g. CPT code 49000) cannot be separately reported. If a finding requires extension of the surgical field and it is followed by another unrelated to the primary procedure, this service may be separately reported using the appropriate CPT code and modifiers. When a definitive surgical procedure requires access through abnormal tissue (e.g. diseased skin, abscess, hematoma, seroma etc.), separate services for this access (e.g. debridement, incision and drainage) are not reported. For example, if a patient presents with a pilonidal cyst and it is determined that it is medically necessary to excise this cyst, it would be appropriate to submit a bill for CPT code 11770 (Excision of pilonidal cyst), it would not, however, be appropriate to also report code 10080 (Incision and drainage of pilonidal cyst), as it was necessary to perform the latter to accomplish the primary procedure. When an excision and removal is performed ("-ectomy" code), the approach generally involves incision and opening of the organ ("-otomy" code). The incision and opening of the organ or lesion cannot be separately reported when primary service is the removal of the organ or lesion. There are frequently multiple approaches to various procedures & there are often clusters of CPT codes describing various approaches (e.g. vaginal hysterectomy as opposed to abdominal hysterectomy). These approaches generally mutually exclusive of one another and, therefore, not to be reported together for a given encounter. Only the definitive, or most comprehensive, service performed can be reported. Endoscopic procedures are often performed as a prelude to, or as a part of, open surgical procedures. When an endoscopy represents a distinct diagnostic service prior to an open surgical service & the decision to perform surgery is made on the basis of the endoscopy, a separate service for the endoscopy may be reported. Modifier 58 may be used to indicate that the diagnostic endoscopy & the open surgical service are staged or planned procedures. When an endoscopic service is performed to establish the location of a lesion, confirm the presence of a lesion, establish anatomic landmarks, or define extent of a lesion, the endoscopic service is not separately reported as it is a medically necessary part of the overall surgical service. Additionally, when an endoscopic service is attempted and fails and another surgical service is necessary, only the successful service is reported. For example, if a laparoscopic cholecystectomy is attempted and fails and an open cholecystectomy is preformed, only the open cholecystectomy can be reported, if appropriate, modifier 22 may be added to indicate unusual procedural services. Surgicom Coding CPT Guide: General correct Coding Policy Ver. 01/2010 p. 2/5
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A number of CPT codes describe services necessary to address the treatment of complications of the primary procedure (e.g. bleeding or haemorrhage). When the services described by CPT codes as complication of primary procedure require a return to the operating room, they may be separately reported with modified 78 indicating that the service necessary to treat the complication required a return to operating room during the postoperative period. When a complication described by codes defining complication arises during an operative session, however, a separate service for treating the complication is not to be reported. An operative session ends upon release from the operating or procedure suite. EVALUATION AND MANAGEMENT SERVICES. All CPT codes have a global surgery indicator. The separate payment of E/M services provided on the same day of service as procedures with a global surgery indicator of 000, 010, or 090 are covered by global surgery rules. The surgeon may, however, perform a significant and separately identifiable E/M service on the same day of service; this may be reported by appending the modifier 25 to the E/M code. CODING SERVICES SUPPLEMENTAL TO A PRINCIPAL PROCEDURE (ADD-ON CODES). The CPT system identifies certain codes that are to be submitted in addition to other codes. Generally, these are identified with the statement "list separately in addition to code for primary procedure" in parentheses, and other times the supplemental code is to be used only with certain primary codes that are parenthetically identified. The basis for these CPT codes is to enable providers to separately identify a service that is performed in certain situations as an additional service or a commonly performed supplemental service complementary to the primary procedure. Incidental services that are necessary to accomplish the primary procedure (e.g. lysis of adhesions in the course of an open cholecystectomy) are not separately reported. Certain complications with an inherent potential to occur in an invasive procedure are, likewise, not separately reported unless resulting in the necessity for a significant separate procedure to be performed. For example, control of bleeding during a procedure is considered part of the procedure and is not separately reported. Supplemental codes frequently specify codes or ranges of codes with which they are to be used. It would be inappropriate to use these with codes other than those specified. On occasion, a procedure described by a CPT code is modified or enhanced, either due to the unique nature of the clinical situation or due to advances in technology since the code was first published. When CPT codes are not labelled as supplemental in the manner described above, they are not to be reported unless the actual procedure is, in fact, performed. It is inappropriate to use non-supplemental codes that approximate part of a more comprehensive procedure but do not describe a separately identifiable service. MODIFIERS. Used to expand the information provided by CPT codes. 1. Modifier 22: "Unusual procedural services" - it is more appropriate to use modifier 22 when unusual or extensive service provided than to report a separate code that does not accurately describe the service provided. 2. Modifier 25: "Significant, separately identifiable evaluation and management service by same surgeon on the same day of the procedure or other service", this modifier may be appended to an evaluation and management (E/M) code reported with another procedure on the same day of service. If in addition to the procedure the surgeon performs a significant and separately identifiable E/M service beyond the usual preprocedure, intraprocedure, and postprocedure surgeon work, the E/M may be reported with modifier 25 appended. The E/M and procedure(s) may be related to the same or different diagnoses. 3. Modifier 58: "Staged or related procedure or service by the same surgeon during the postoperative period". It indicates that a procedure was followed by another procedure or service during the postoperative period. This may be because it was planned prospectively, because it was more extensive than the original procedure, or because it represents therapy after a diagnostic procedural service. When an endoscopic procedure is performed for diagnostic purposes at the time of a more comprehensive therapeutic procedure, and the endoscopic procedure does not represent a scout endoscopy, modifier 58 may be appropriately used to signify that the endoscopic procedure and the more comprehensive procedure are staged or planned procedures. 4. Modifier 59: has been established for use when several procedures are performed on different anatomical sites or at different sessions (on the same day) - "Distinct procedural service: Under certain circumstances, the surgeon may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same surgeon". When certain services are reported together on a patient by the same surgeon on the same date of service, there may be a perception of unbundling when, in fact, the services were performed under circumstances that did not involve this practice at all. Because Funders cannot identify this based simply on CPT coding on either electronic or paper claims, modifier 59 was established to permit services of such a nature to bypass correct coding edits. This modifier indicates that the procedure represents a distinct service from others reported on the same ate of service. This may represent a different session, different surgery, different site, different lesion, or different injury of area of injury (in extensive injuries). Frequently another, already established, modifier has been defined that describes this situation more specifically. In the event that a more descriptive modifier is available, it should be used in preference to modifier 59. Surgicom Coding
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Example: If a patient requires placement of a pulmonary artery catheter for hemodynamic monitoring via the subclavian vein, it would be appropriate to submit the CPT code 93505 (Insertion and placement of flow directed, e.g. Swan-Ganz for monitoring purposes) for the service. If, later in the day, the catheter is to be removed and a central venous catheter is inserted through the femoral vein, the appropriate code for this service would be 36010 (Introduction of catheter, sup or inferior vena cava). Because the pulmonary artery (PA) catheter requires passage through the vena cava, it may appear that the service for the PA catheter was being unbundled if both services were reported on the same day. Accordingly, the central venous catheter code should be reported with modifier 59 (CPT code 36010 59), Indicating that this catheter was placed in a different site as a different service on the same day. Note that modifier 59 is often misused. The two codes in a code pair edit often by definition represent different procedures. The provider cannot use 59 for such an edit bases on the two codes being different procedures. However, if the two procedures are performed at separate sites or at separate patient encounters on the same date of service, modifier 59 may be appended. Additionally, 59 cannot be used with E/M services (CPT codes 99201-99499) or radiation treatment management (code 77427). SEPARATE PROCEDURE. The narrative for many CPT codes includes a parenthetical statement that the procedure represents a "separate procedure". The inclusion of this statement indicates that the procedure can be performed separately but should not be reported when a related service is performed. The "separate procedure" designation is used with codes in the surgery (codes 10000 through 69999), radiology (70000 through 799999) and medicine (90000 through 99199) sections. When a related procedure is performed, a code with the designation of "separate procedure" is not to be reported with the primary procedure. When a "separate procedure" is performed on the same day but at a different session or at an anatomically unrelated site, the "separate procedure" code may be reported in addition to a code for a procedure that would be related if performed at the same patient encounter or at an anatomically related site. Modifier 59 should be included to indicate that this service was, in fact, a separate service. In other sections of the CPT book, the word "separate" is used in phrase identified as "separate or multiple procedures" with a different meaning.
1. 2. 3. 4. 5. 6. 7.
"Simple" and "complex" CPT codes are reported, the simple procedure is included in the complex procedure on the same site. "Limited" and "complete" CPT codes are reported, the limited procedure is included in the complete procedure on the same site. "Simple" and "complicated" CPT codes are reported, the simple procedure is included in the complicated procedure on the same site. "Superficial" and "deep" CPT codes are reported, the superficial procedure is included in the deep procedure on the same site. "Intermediate" and "comprehensive" CPT codes are reported, the intermediate procedure is included in the comprehensive procedure on the same site.
"External" and "internal" CPT codes are reported, the external procedure is included the internal procedure on the same site.
SEQUENTIAL PROCEDURE. An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT codes describing each service. The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service; these procedures are considered "sequential procedures". Only the CPT code for one of the services, generally the more invasive service, should be reported. An example of this situation is a failed laparoscopic cholecystectomy, followed by an open cholecystectomy at the same session. Only the code for the successful procedure, in this case the open cholecystectomy, should be reported. MISUSE. In general, CPT codes have been written as precisely as possible to not only describe a specific service or procedure but also to avoid describing similar services or procedures that are already defined by other CPT codes. When a CPT code is reported, the surgeon must have performed all of the services noted in the description unless the description states otherwise. (Frequently, a CPT description identifies certain services that may or may not be included, usually stating "with or without" a service). A provider should not report a CPT code out of the context for which it was intended. Providers who are familiar with procedures or services described in areas or sections of CPT will understand the specific language of the description as well as the intent for which the code was developed. On the other hand, a provider who, for example, is unfamiliar with an area of CPT may fail to understand the intent of certain codes. Either intentionally or unintentionally, a provider may report a service or procedure using a CPT code that may be construed to describe the service/procedure but in no way was intended to be used in fashion. Surgicom Coding CPT Guide: General correct Coding Policy Ver. 01/2010 p. 4/5
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"Incomplete" and "complete" CPT codes are reported, the incomplete procedure is included in the complete procedure on the same site.
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MOST EXTENSIVE PROCEDURE. When procedures that are basically the same are performed together or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is included in the more extensive procedure. In the following situations, the procedure viewed as the most complex would be reported:
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MUTUALLY EXCLUSIVE PROCEDURE. There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes describe procedures that cannot reasonably be done in the same session. An example of a mutually exclusive situation is when the repair of the organ can be performed by two different methods. One repair must be chosen and reported. A second example is the reporting of an "initial" service and a "subsequent" service. It is contradictory for a service to be classified as an initial and a subsequent service at the same time. GENDER-SPECIFIC PROCEDURE (FORMERLY DESIGNATION OF SEX). Many procedure codes have a gender-specific classification within their narratives. These codes are not reported with codes having the opposite gender designation because this would reflect a conflict in gender classification either by the definition of the code descriptions themselves (as they appear in the CPT book) or by the fact that the performance of these procedures on the same patient would be anatomically impossible. The sections that this policy pertains to are the male and female genital procedures. Other codes indicate in their definitions that a particular gender classification is required for the use of that particular code. An example of this situation would be CPT codes 53210 for total urethrectomy including cystostomy in a female as opposed to code 53215 for the male. Both of these procedures are not to be reported together. Some other examples of these code pairs are: 53210/53250/52275/52270 and 57260-53620. These specific edits have been included in the "Mutually Exclusive Table" because both procedures of a code pair edit cannot be performed on a patient. (See section Q in this chapter for more explanation of mutually exclusive codes). UNLISTED SERVICE OR PROCEDURE. Because of advance in technology or surgeon expertise with new procedures, a code may not be assigned to a procedure when the procedure is first introduced as accepted treatment. Every effort should be made to find the appropriate code to describe the service. Contact Medihelp and/or Surgicom for assistance in determining correct codes or allocating a special arrangement. We have access to the latest CPT code and new codes with appropriate unit values may be assigned for individual cases.
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Introduction to CPT Coding: Surgery Breast Instructions for Use of the CPT Codes. Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code. When necessary, any modifying or extenuating circumstances are added. Any service or procedure should be adequately documented in the medical record. 10021 Fine needle aspiration; without imaging guidance 10022 Fine needle aspiration; with imaging guidance (For percutaneous needle biopsy see 20206 muscle, 32400 pleura, 32405 lung / mediastinum, 42400 salivary gland, 47000, 47001 liver, 48102 pancreas, 49180 abdominal/retroperitoneal mass, 60100 thyroid) 19000 Puncture aspiration of cyst of breast; +19001 Puncture aspiration of cyst of breast; each additional cyst (Use with code 19000) 19020 Mastotomy with exploration or drainage of abscess, deep 19030 Injection procedure only for mammary ductogram or galactogram Breast biopsies: 19100 Biopsy breast; percutaneous, needle core, no imaging guidance (separate procedure) 19101 Biopsy of breast; open, incisional 19102 Biopsy of breast; percutaneous, needle core, using imaging guidance 19103 Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance 19105 Ablation cryosurgical of fibroadenoma, including ultrasound guidance, each fibroadenoma (Use 19295 for placement of percutaneous localisation clip) Open excision of breast lesions (e.g. lesions of breast ducts, cysts, benign or malignant tumours), without specific attention to adequate surgical margins preop radiological markers: 19110 Nipple exploration, with or without excision of a solitary lactiferous duct or papilloma 19112 Excision of lactiferous duct fistula 19120 Excision of cyst, fibroadenoma or other benign or malignant tumour, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions 19125 Excision breast lesion identified by preoperative radiological marker, open; single lesion +19126 Excision breast lesion identified by preoperative marker, open; each additional lesion separately identified by a preoperative radiological marker (Use with code 19125) 19300 Mastectomy for gynaecomastia Partial mastectomy (e.g. lumpectomy, tylectomy, quadrantectomy or segmentectomy) denotes open excisions of breast tissue with specific attention to and documentation of removal of the breast mass or lesion with adequate surrounding surgical margins: 19301 Mastectomy, partial 19302 Mastectomy, partial; with axillary lymphadenectomy (For placement of radiotherapy afterloading balloon/brachytherapy catheters, see 19296-19298) Total mastectomy: 19303 Mastectomy, simple, complete 19304 Mastectomy, subcutaneous 19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes 19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) 19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle
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Excisions or resections of chest wall tumours including ribs reconstruction mediastinal lymphadenectomy (not restricted to breast tumours; use to report resections of chest wall tumours originating from any chest wall component. (For excision of lung or pleura, see 32310 et seq.) 19260 Excision of chest wall tumour including ribs 19271 Excision of chest wall tumour involving ribs, with plastic reconstruction 19272 Excision of chest wall tumour involving ribs, with plastic reconstruction; with mediastinal lymphadenectomy (Do not report 19260, 19271, 19272 in conjunction with 32002, 32020, 32100, 32503, 32504) Introduction needle, device 19290 Preoperative placement of needle localisation wire, breast; +19291 Preoperative placement of needle localisation wire, breast; each additional lesion (List separately in addition to code for primary procedure) (Use with code 19290) +19295 Image guided placement, metallic localisation clip, percutaneous, during breast biopsy (Use in conjunction with code 19102, 19103) 19296 Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy +19297 Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (Use with 19160 or 19162) 19298 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance (Use code 99141 for attendant conscious sedation) Repair &/or Reconstruction 19316 Mastopexy 19318 Reduction mammaplasty 19324 Mammaplasty, augmentation; without prosthetic implant 19325 Mammaplasty, augmentation; with prosthetic implant 19328 Removal of intact mammary implant 19330 Removal of mammary implant material 19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction (For supply of implant, use 99070) (For preparation of custom breast implant, see 19396) 19350 Nipple/areola reconstruction 19355 Correction of inverted nipples 19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19361 Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant 19364 Breast reconstruction with free flap (Do not report code 69990 in addition to code 19364; 19364 includes harvesting of the flap, microvascular transfer, closure of the donor site and shaping the flap into a breast) 19366 Breast reconstruction with other technique (For operating microscope, use 69990) (For insertion of prosthesis, use also 19340 or 19342) 19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; 19368 Breast reconstruction with TRAM flap, single pedicle, including closure of donor site; with microvascular anastomosis (supercharging) (Do not report code 69990 in addition to code 19368) 19369 Breast reconstruction with TRAM flap, double pedicle, including closure of donor site 19370 Open periprosthetic capsulotomy, breast 19371 Periprosthetic capsulectomy, breast 19380 Revision of reconstructed breast 19396 Preparation of moulage for custom breast implant
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Introduction to CPT Coding: Surgery Skin, soft tissue Instructions for Use of the CPT Codes. Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code. When necessary, any modifying or extenuating circumstances are added. Any service or procedure should be adequately documented in the medical record. 10021 Fine needle aspiration (FNA); without imaging guidance 10022 Fine needle aspiration; with imaging guidance (For percutaneous needle biopsy see 20206 muscle, 32400 pleura, 32405 lung / mediastinum, 42400 salivary gland, 47000, 47001 liver, 48102 pancreas, 49180 abdominal/retroperitoneal mass, 60100 thyroid) Integumentary System: Skin, Subcutaneous and Accessory Structures Incision and Drainage (10040-10180) (For excision, see 11400, et. seq.) 10040 Acne surgery (e.g. marsupialisation, opening milia, comedones, cysts, pustules) 10060 Incision and drainage of abscess (e.g. carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia); simple or single 10061 Incision and drainage of abscess (e.g. carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia); complicated or multiple 10080 Incision and drainage of pilonidal cyst; simple 10081 Incision and drainage of pilonidal cyst; complicated (For excision of pilonidal cyst, see 11770, 11771 -11772) 10120 Incision and removal of foreign body, subcutaneous tissues; simple 10121 Incision and removal of foreign body, subcutaneous tissues; complicated (Wound exploration in penetrating trauma without laparotomy or thoracotomy, use 20100-20103) (For debridement associated with open fracture(s) &/or dislocation(s), use 11010-11012) 10140 Incision and drainage of haematoma, seroma or fluid collection 10160 Puncture aspiration of abscess, haematoma, bulla or cyst 10180 Incision and drainage, complex, postoperative wound infection (For secondary closure of surgical wound, see 12020, 12021, 13160) Excision - Debridement (11000-11044) (For burn(s), see 16000-16035) 11004 Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum 11005 Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure 11006 Debridement of skin, subcutaneous tissue, muscle & fascia for necrotizing soft tissue infection; external genitalia, perineum & abdominal wall, with or without fascial closure 11008 Removal of prosthetic material or mesh, abdominal wall for necrotizing soft tissue infection (Use in conjunction with 11004, 11005-11006) (Do not report 11008 with 11000-11001, 11010, 11011, 11012, 11040, 11041, 11042, 11043-11044) (Report skin grafts or flaps separately when performed at the same session as 11004, 11005, 11006-11008) (When insertion of mesh is used for closure, use 49568) (If orchiectomy is performed, use 54520); (If testicular transplantation is performed, use 54680)
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11201
Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in addition to code for primary procedure; use with 11200) Measuring and Coding the Removal of a Lesion
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Biopsy of skin, subcutaneous tissue &/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); each separate/additional lesion (List separately in addition to 11100) Removal of Skin Tags (11200-11201) Removal by scissoring or any sharp method, ligature strangulation, electrosurgical destruction or combination of treatment modalities including chemical or electrocauterisation of wound, with or without local anaesthesia. 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11101
OM
11010 Debridement including removal of foreign material associated with open fracture(s) &/or dislocation(s); skin and subcutaneous tissues 11011 Debridement including removal of foreign material associated with open fracture(s) &/or dislocation(s); skin, subcutaneous tissue, muscle fascia and muscle 11012 Debridement including removal of foreign material associated with open fracture(s) &/or dislocation(s); skin, subcutaneous tissue, muscle fascia, muscle and bone 11040 Debridement; skin, partial thickness 11041 Debridement; skin, full thickness 11042 Debridement; skin and subcutaneous tissue 11043 Debridement; skin, subcutaneous tissue and muscle 11044 Debridement; skin, subcutaneous tissue, muscle and bone Biopsy (11100-11101) During certain surgical procedures in the integumentary system, such as excision, destruction or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported. The use of a biopsy procedure code (e.g. 11100, 11101) indicates that the procedure to obtain tissue for pathologic examination was performed independently or was unrelated or distinct from other procedures/services provided at that time. Such biopsies are not considered components of other procedures when performed on different lesions or different sites on the same date and are to be reported separately. (For biopsy of conjunctiva, use 68100; eyelid, see 67810) 11100 Biopsy of skin, subcutaneous tissue &/or mucous membrane (including simple closure), unless otherwise listed; single lesion
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Excision - Benign Lesions (11400-11471) Excision (including simple closure) of benign skin lesions includes local anaesthesia. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins and includes simple (non-layered) closure. Report separately each benign lesion excised. Measure the greatest clinical diameter of the apparent lesion plus margin required for complete excision. The margins refer to the narrowest margin required to adequately excise the lesion, based on the surgeon's judgment. The measurement of lesion plus margin is made prior to excision. The excised diameter is the same whether the surgical defect is repaired in a linear fashion or reconstructed (e.g. with a skin graft). Excision of benign lesions requiring more than simple closure are reported as 11400-11446 plus appropriate intermediate closure (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, use 14000-14300, 15000-15261, 15570-15770. For unusual or complicated excision, add modifier 22. Copy of histology report to accompany account for lesions >2.0cm in diameter Excision benign lesions, excised diameter: Trunk, arms or legs: 11400 0.5 cm 11401 0.6 - 1.0 cm 11402 1.1 - 2.0 cm 11403 2.1 - 3.0 cm 11404 3.1 - 4.0 cm 11406 >4.0 cm (For eyelids involving more than skin, see also 67800-) Scalp, neck, hands, feet, genitalia: 11420 0.5 cm 11421 0.6 - 1.0 cm 11422 1.1 - 2.0 cm 11423 2.1 - 3.0 cm 11424 3.1 - 4.0 cm 11426 >4.0 cm Face, ears, eyelids, nose, lips, mucous membrane: 11440 0.5 cm 11441 0.6 - 1.0 cm 11442 1.1 - 2.0 cm 11443 2.1 - 3.0 cm 11444 3.1 - 4.0 cm 11446 >4.0 cm
Excision of skin and subcutaneous tissue for hidradenitis 11450 axillary, with simple or intermediate repair 11451 axillary; with complex repair 11462 inguinal; with simple or intermediate repair 11463 inguinal; with complex repair 11470 perianal, perineal or umbilical; with simple or intermediate repair 11471 perianal, perineal or umbilical; with complex repair (When skin graft or flap is used for closure, use appropriate procedure code in addition) (For bilateral procedure, add modifier 50). For unusual or complicated excision, add modifier 22. Excision - Malignant Lesions (11600-11646) Excision (including simple closure) of malignant lesions of skin includes local anaesthesia. Excision is defined as full-thickness (through the dermis) removal of a lesion including margins and includes simple (non-layered) closure. Report separately each malignant lesion excised. Measure the greatest clinical diameter of the lesion plus margin required for complete excision.. Copy of histology report to accompany account for malignant lesions Excision of malignant lesions requiring more than simple closure are reported as 11600-11646 plus appropriate intermediate closure (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, use 14000-14300, 15000-15261, 15570-15770. When frozen section pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumour removal. Use only one code to report the additional excision and re-excision(s) based on the final widest excised diameter required for complete tumour removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Append the modifier 58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure. For unusual or complicated excision, add modifier 22.
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Excision, malignant lesion, excised diameter: Trunk, arms or legs: 11600 0.5 cm 11601 0.6 - 1.0 cm 11602 1.1 - 2.0 cm 11603 2.1 - 3.0 cm 11604 3.1 - 4.0 cm 11606 >4.0 cm (For eyelids involving more than skin, see also 67800 et seq)

Neck, hands, feet, genitalia: 11620 0.5 cm 11621 0.6 - 1.0 cm 11622 1.1 - 2.0 cm 11623 2.1 - 3.0 cm 11624 3.1 - 4.0 cm 11626 >4.0 cm
CONFIDENTIAL
Face, ears, eyelids, nose: 11640 0.5 cm 11641 0.6 - 1.0 cm 11642 1.1 - 2.0 cm 11643 2.1 - 3.0 cm 11644 3.1 - 4.0 cm 11646 > 4.0 cm
Integumentary System: Repair (Closure) Codes in this section designate wound closure with sutures, staples or tissue adhesives, either singly or in combination. Closure with adhesive strips only is coded by appropriate E/M code. Classification:
Simple repair denotes superficial wounds e.g. epidermis, dermis or subcutaneous tissues requiring simple one layer closure. This includes local anaesthesia and chemical or electrocauterisation of wounds not closed. Intermediate repair includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia. Single-layer closure of heavily contaminated wounds that required extensive cleaning also constitutes intermediate repair. Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement, (e.g. traumatic lacerations or avulsions), extensive undermining or retention sutures.
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11732 Avulsion of nail plate, partial or complete, simple; each additional nail plate 11740 Evacuation of subungual haematoma 11750 Excision of nail and nail matrix, partial or complete, for permanent removal; 11752 Excision of nail and nail matrix, partial or complete, with amputation of tuft of distal phalanx (For skin graft, if used, see 15050) 11755 Biopsy nail unit (plate, bed, matrix, hyponychium or nail folds) (separate procedure) 11760 Repair of nail bed 11762 Reconstruction of nail bed with graft 11765 Wedge excision of skin of nail fold (e.g. for ingrown toenail) Pilonidal Cyst (For incision of pilonidal cyst, see 10080, 10081) 11770 Excision of pilonidal cyst or sinus; simple 11771 Excision of pilonidal cyst or sinus; extensive 11772 Excision of pilonidal cyst or sinus; complicated
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Nails (11719-11765) (For drainage of paronychia or onychia, see 10060, 10061) 11720 Debridement of nail(s) by any method(s); one to five 11721 Debridement of nail(s) by any method(s); six or more 11730 Avulsion of nail plate, partial or complete, simple; single
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12011 12013 12014 12015 12016 12017 12018
Repair Simple, superficial wounds (12001-12021) (Sum of lengths of repairs for each group of anatomic sites) Scalp, neck, axilla, external genitalia, trunk &/or extremities (incl. hands & feet): 12001 2.5 cm 12002 2.6 cm to 7.5 cm 12004 7.6 cm to 12.5 cm 12005 12.6 cm to 20.0 cm 12006 20.1 cm to 30.0 cm 12007 >30.0 cm Face, ears, eyelids, nose, lips, mucous membranes: 12020 Treatment of superficial wound dehiscence; simple closure 12021 Treatment of superficial wound dehiscence; with packing (For extensive or complicated secondary wound closure, see 13160)
Repair Intermediate, layer closure (12031-12057) (Sum of lengths of repairs for each group of anatomic sites) Scalp, axilla, trunk, extremity (excl. hand, foot): 12031 2.5 cm 12032 2.6 - 7.5 cm 12034 7.6 - 12.5 cm 12035 12.6 - 20.0 cm 12036 20.1 - 30.0 cm 12037 >30.0 cm Neck, hands, feet &/or external genitalia: 12041 2.5 cm 12042 2.6 - 7.5 cm 12044 7.6 - 12.5 cm 12045 12.6 - 20.0 cm 12046 20.1 - 30.0 cm 12047 >30.0 cm Face, ear, eyelid, nose, lips, mucous membrane: 12051 2.5 cm 12052 2.6 - 5.0 cm 12053 5.1 - 7.5 cm 12054 7.6 - 12.5 cm 12055 12.6 - 20.0 cm 12056 20.1 - 30.0 cm 12057 >30.0 cm
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Instructions for listing services at time of wound repair: Complex repair does not include excision of benign or malignant lesions. The repaired wound(s) should be measured in centimetres, whether curved, angular or stellate. When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and from all anatomic sites that are grouped together into the same code descriptor (e.g. add the lengths of intermediate repairs to trunk and extremities; do not add lengths of repairs from different groupings of anatomic sites e.g. face and extremities; also, do not add together lengths of different classifications e.g. intermediate and complex repairs. When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 51. Decontamination &/or debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed or when debridement is carried out separately without immediate primary closure. (For extensive debridement of soft tissue &/or bone, not associated with open fracture(s) and /or dislocations(s), see 11040 11041 11042 11043-11044.) (For extensive debridement of subcutaneous tissue, muscle fascia, muscle and /or bone associated with open fracture(s) &/or dislocations(s), see 11010, 11011-11012.) Involvement of nerves, blood vessels & tendons: report under appropriate system (Nervous, Cardiovascular, Musculoskeletal) for repair. The repair of these associated wounds is included in the primary procedure unless it qualifies as a complex wound, in which case either modifier 51 applies. Simple ligation of vessels in an open wound is considered as part of any wound closure. Simple "exploration" of nerves, blood vessels or tendons exposed in an open wound is also considered part of the essential treatment of the wound and is not a separate procedure unless appreciable dissection is required. If the wound requires enlargement, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous &/or muscular blood vessel(s), of the subcutaneous tissue, muscle, fascia, &/or muscle, not requiring thoracotomy or laparotomy, use codes 20100 20101 2010220103, as appropriate.
2.5 cm 2.6 cm to 5.0 cm 5.1 cm to 7.5 cm 7.6 cm to 12.5 cm 12.6 cm to 20.0 cm 20.1 cm to 30.0 cm >30.0 cm
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Repair Complex, reconstructive procedures, complicated wound closure (For full thickness repair of lip or eyelid, see respective anatomical subsections - 40650 40652 -40654, 67961 67966 67971 67973 67974 -67975) Trunk: Scalp, arms, &/or legs: Forehead, cheek, chin, mouth, neck, axilla, genitalia, hands &/or feet (1.0 cm, see simple or intermediate repairs) 13100 1.1-2.5 cm 13120 1.1-2.5 cm 13131 1.1-2.5 cm 13101 2.6-7.5 cm 13121 2.6-7.5 cm 13132 2.6-7.5 cm 13102 per 5 cm 13122 per 5 cm 13133 per 5 cm
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Eyelids, nose, ears &/or lips 13150 13151 13152 1.0 cm 1.1-2.5 cm 2.6-7.5 cm
13153 per 5 cm
Figure A. Rotation flap
13160 Secondary closure of surgical wound or dehiscence, extensive or complicated (For packing or simple secondary wound closure, see 12020, 12021) Adjacent Tissue Transfer or Rearrangement (14000-14350) For full thickness repair of lip or eyelid, see respective anatomical subsections. Excision (including lesion) &/or repair by adjacent tissue transfer or rearrangement (Z-, W-, V-Y plasty, rotation-, advancement- or double pedicle flap). The "defect" includes the primary defect resulting from the excision and the secondary defect resulting from flap design to perform the reconstruction; measure together to determine the code. Assign code based upon repair location and approximate description of area repaired.
Anatomic site Trunk Scalp, arms &/or legs Forehead, cheek, chin, mouth, neck, axilla, genitalia, hand, foot Eyelids, nose, ears, lips Eyelids, full thickness Any area, unusual or complicated
RG IC
Defect cm2 10 14000 14020 14040 14060 see 67961-
Defect cm2 10.1-30.0 14001 14021 14041 14061
OM
Defect cm2 >30.0 14300 14300 14300 14300
14300
14350
Filleted finger or toe flap, including preparation of recipient site
Skin graft necessary to close secondary defect is considered an additional procedure.
SU
Figure B. Advancement flap
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Skin Grafting and Skin Substitutes Identify by size and location of the defect (recipient area) and the type of graft or skin substitute; includes simple debridement of granulation tissue. The measurement of 100 cm2 is applicable to adults and children age 10 and over, percentages of body surface area apply to infants and children under 10. Use modifier 58 for staged application procedure(s). When a primary procedure such as orbitectomy, radical mastectomy or deep tumour removal requires skin graft for definitive closure, see appropriate anatomical subsection for primary procedure and this section for skin graft or skin substitute. Repair of donor site requiring skin graft or local flaps is to be added as an additional procedure. Surgical Preparation For excision of benign and malignant lesions, see appropriate section. For appropriate skin grafts or replacements, see 15050 15100 15101 15120 15121 15200 15201 15220 15221 15240 15241 15260 -15261, 15330-15336. List the graft or replacement separately by its procedure number when the graft, immediate or delayed, is applied For excision with immediate skin grafting use 15000, 15001 in conjunction with 15050 15100 15101 15120 15121 15200 15201 15220 15221 15240 15241 15260 -15261 For excision with immediate allograft skin placement use 15000, 15001 in conjunction with 15300-15366 Grafts 15050
Pinch graft, single or multiple, to cover small ulcer, tip of digit or other minimal open area (except on face), up to defect size 2 cm diameter. 1st 100cm2 or 1% BSA infants/child 15100 15120 Per additional 100cm2 or 1% BSA infants/child +15101 +15121
Alternate sources of skin and substitutes (15300-15431). Application of a non-autologous human skin graft or acellular dermal graft from a donor or tissue cultured allogeneic dermal substitute (homograft) or xenograft to a part of the recipient's body to for temporary wound closure or resurfacing of an area damaged by burns, traumatic injury, soft tissue infection &/or tissue necrosis or surgery. Other types of cultured and skin substitute grafts refer to Electronic Office Assistant or coding help line Full thickness graft, free, including direct closure of donor site see15200 15261. (For finger tip graft, see 15050) (For eyelids, see also 67961 et seq) (Repair of donor site requiring skin graft or local flaps, to be added as additional separate procedure) Flaps (Skin &/or Deep Tissues) (15570-15738). Regions listed refer to recipient area (not donor site) when flap is being attached in transfer or to final site. Regions listed refer to donor site when tube is formed for later or when "delay" of flap is prior to transfer. Procedures do not include extensive immobilization (e.g. large plaster casts and other immobilizing devices are considered additional separate procedures). Repair of donor site requiring skin graft or local flaps is considered an additional separate procedure. For microvascular flaps, see 15756 15757 15758. Formation of direct or tubed pedicle, with or without transfer; 15570 trunk 15572 scalp, arms or legs 15574 forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet 15576 eyelids, nose, ears, lips or intraoral Delay of flap or sectioning of flap (division and inset): 15600 at trunk 15610 at scalp, arms or legs 15620 forehead, cheeks, chin, neck, axillae, genitalia, hands or feet 15630 at eyelids, nose, ears or lips
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Split-thickness autograft Trunk, arms, legs Face, scalp, eyelid, mouth, neck, ear, orbit, genital, hand, foot, multiple digits (For eyelids, see also 67961 et seq)
OM
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Pressure Ulcers (Decubitus Ulcers) (15920-15999) Excision With Primary With skin pressure ulcer primary suture with flap suture ostectomy closure
SU
Skin flap closure with ostectomy 15934 15944 15952 15935 15945 15953
Coccygeal Sacral Ischial Trochanteric
15920 15931 15940 15950
15922 15933 15941 15951
(For repair of defect using muscle or myocutaneous flap, use code(s) 15734 &/or 15738, for repair of defect using split skin graft, use codes 15100 &/or 15101 in addition to 15936, 15937, 15946, 15947, 15956, 15958) (For free skin graft to close ulcer or donor site, see 15000 et seq)
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RG IC
in preparation for muscle or myocutaneous flap or skin graft closure 15936 15946 15956 in preparation for flap or skin graft closure; with ostectomy 15937 15947 15958
15650 Transfer, intermediate, of any pedicle flap (e.g. abdomen to wrist, Walking tube), any location (For eyelids, nose, ears or lips, see also anatomical area) 15732 Muscle, myocutaneous or fasciocutaneous flap; head and neck (e.g. temporalis, masseter muscle, sternocleidomastoid, levator scapulae) 15734 Muscle, myocutaneous or fasciocutaneous flap; trunk 15736 Muscle, myocutaneous or fasciocutaneous flap; upper extremity 15738 Muscle, myocutaneous or fasciocutaneous flap; lower extremity Other Flaps and Grafts (15740-15776) Repair of donor site requiring skin graft or local flaps should be reported as an additional procedure. 15740 Flap; island pedicle 15750 Flap; neurovascular pedicle 15756 Free muscle or myocutaneous flap with microvascular anastomosis (Do not report code 69990 in addition to code 15756) 15757 Free skin flap with microvascular anastomosis (Do not report code 69990 in addition to code 15757) 15758 Free fascial flap with microvascular anastomosis (Do not report code 69990 in addition to code 15758) 15760 Graft; composite (e.g. full thickness of external ear or nasal ala), including primary closure, donor area 15770 Graft; derma-fat-fascia 15831 Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) 15840 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) (For bilateral procedure, add modifier 50) 15841 Graft for facial nerve paralysis; free muscle graft (including obtaining graft) 15842 Graft for facial nerve paralysis; free muscle flap by microsurgical technique (Do not report code 69990 in addition to code 15842) 15845 Graft for facial nerve paralysis; regional muscle transfer (For nerve transfers, decompression or repair, see 64831 64832 64834 64835 64836 64837 64840 64856 64857 64858 64859 64861 64862 64864 64865 64866 64868 64870 64872 64874 64876, 64905, 64907, 69720, 69725, 69740, 69745, 69955) Dressings 15850 Removal of sutures under anaesthesia (other than local), same surgeon 15851 Removal of sutures under anaesthesia (other than local), other surgeon 15852 Dressing change (for other than burns) under anaesthesia (other than local)
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Destruction, Benign or Premalignant Lesions 17000 Destruction, all benign or premalignant lesions (e.g. actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; first lesion +17003 ; second through 14 lesions, each (use with 17000) 17004 ; 15 or more lesions (Do not report 17004 in conjunction with codes 17000-17003) 17106 Destruction of cutaneous vascular proliferative lesions (e.g. laser technique); less than 10 cm2 17107 Destruction of cutaneous vascular proliferative lesions (e.g. laser technique); 10.0 to 50.0 cm2 17108 Destruction of cutaneous vascular proliferative lesions (e.g. laser technique); over 50.0 cm2 17110 Destruction (e.g. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of flat warts, molluscum contagiosum or milia; up to 14 lesions 17111 Destruction 15 or more lesions (For destruction of common or plantar warts, see 17000, 17003, 17004) 17250 Chemical cauterisation of granulation tissue (proud flesh, sinus or fistula) (17250 is not to be used with removal or excision codes for the same lesion) Destruction, Malignant Lesions, Any Method (e.g. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) (17260-17286) Trunk, arms or legs Scalp, neck, hands, feet, genitalia Face, ears, eyelids, nose, lips, mucous membrane 17260 0.5 cm 17270 0.5 cm 17280 0.5 cm 17261 0.6 - 1.0 cm 17271 0.6 - 1.0 cm 17281 0.6 - 1.0 cm 17262 1.1 - 2.0 cm 17272 1.1 - 2.0 cm 17282 1.1 - 2.0 cm 17263 2.1 - 3.0 cm 17273 2.1 - 3.0 cm 17283 2.1 - 3.0 cm 17264 3.1 - 4.0 cm 17274 3.1 - 4.0 cm 17284 3.1 - 4.0 cm 17266 >4.0 cm 17276 >4.0 cm 17286 >4.0 cm
CCSA 2010
Surgicom CPT Coding
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Burns, Local Treatment (16000-16036) Procedures 16000 16020 16025 16030 16035 -16036 refer to local treatment of burned surface only. Codes 16020-16030 include the application of materials (e.g. Biobrane, other dressings) not described in 15100-15431. List percentage of body surface involved and depth of burn. Calculation of Total Body Surface Area (TBSA) Burn is achieved by dividing the total body surface area into 9% or multiples of 9% segments. In the infant or child, the "rule" deviates because of the large surface area of the child's head. For necessary related medical services (e.g. hospital visits) in management of burned pts, see appropriate services in E/M sections 16000 Initial treatment, first degree burn, when no more than local treatment is required 16020 Dressings &/or debridement of partial-thickness burns, initial or subsequent; small (<5% TBSA) 16025 Dressings &/or debridement of partial-thickness burns, initial or subsequent; medium (e.g. whole face or whole extremity or 5% to 10% total body surface area) 16030 Dressings &/or debridement of partial-thickness burns, initial or subsequent; large (e.g. more than one extremity or greater than 10% total body surface area) 16035 Escharotomy; initial incision +16036 Escharotomy; each additional incision (List separately in addition to code for primary procedure; use with 16035) For debridement, curettement of burn wound, see 16020 16025 -16030. For the application of skin grafts or skin substitutes, see 15100-15650. Surgery Integumentary System: Destruction Destruction means the ablation of benign, premalignant or malignant tissues by any method, with or without curettement, including local anaesthesia and not usually requiring closure. Any method includes electrosurgery, cryosurgery, laser and chemical treatment. Lesions include condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (i.e. common, plantar, flat), milia or other benign, pre-malignant (e.g. actinic keratoses) or malignant lesions. For destruction of lesion(s) in specific anatomic sites, see 40820, 46900 46910 46916 -46917, 46924, 54050 54055 54056 -54057, 54065, 56501, 56515, 57061, 57065, 67850, 68135. For paring or cutting of benign hyperkeratotic lesions (e.g. corns or calluses), see 11055 11056 -11057. For sharp removal or electrosurgical destruction of skin tags and fibrocutaneous tags, see codes 11200, 11201
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SURGICOM-MEDIHELP BILLING GUIDES Correct Coding Policies: Musculoskeletal System (CPT Codes 20000 29999)
CONFIDENTIAL
The general guidelines regarding correct coding apply to CPT codes in the range of 20000 29999. Specific issues unique to this section of CPT are clarified in the following guidelines. Biopsy. In accordance with the sequential procedure policy, when a biopsy is performed in conjunction with any excision, destruction, removal, repair or internal fixation procedure, the biopsy procedure is not to be separately coded, assuming a diagnosis has already been established that makes the excision, destruction, removal, repair of fixation procedure medically necessary. If the biopsy is performed at a different site and represents a significant, separately identifiable service, a biopsy service can be reported. For example, if a patient presents with an upper extremity fracture and, during an internal fixation procedure, it is determined to be medically reasonable to perform a bone biopsy of the iliac crest while under the same anaesthetic, a separate service for a bone biopsy, with modifier 59, could be reported. If, however, through the same incision, a biopsy of the humerus was obtained, this service is not to be separately reported. When the decision to perform the more comprehensive procedure (excision, destruction, removal, repair, or fixation procedure) depends on the results of the biopsy procedure, the biopsy procedure may be separately reported. Additionally, in accordance with the sequential procedure policy, when an arthroscopic procedure is followed by an open procedure at the same session, only the open procedure is reported. If an arthroscopic service is performed at on site and an open procedure is performed at another, the arthroscopic service is reported with a modifier indicating that these services were performed at different anatomic site (e.g. modifier RT or LT, or modifier 59, etc.) Spinal Surgery Second surgeon for exposure. When 2 surgeons work together as primary surgeons, append modifier -62 and bill at 62.5% of the procedure code to report distinctive operative work [refer codes 22548, 22554 (neck), 22556 (thorax) 22558 (lumbar), 22585 (additional level)]. General Policy Statements 1. When a tissue transfer procedure (e.g. graft) is described in the principal procedure code, a separate service is not reported for performing the tissue transfer service necessary to complete the procedure. 2. In situations where monitoring of interstitial fluid pressure is routinely performed as part of the postoperative care (e.g. distal lower extremity procedures with risk of anterior compartment compression), a separate code for monitoring of interstitial fluid pressure (e.g. CPT code 20950) should not be reported. 3. Routinely, exploration of the surgical field is performed during a surgical session; codes describing independent exploratory service are not to be reported when a more comprehensive procedure is being performed in the same area. 4. Debridements (CPT codes 11040 11042, and 11720 11721) are included in the surgical procedures conducted on the musculoskeletal system when debridement of tissue is in the immediate surgical field of other than fractures and dislocations. If, however, tissue debridement is necessary for a more extensive area (e.g. concurrent soft tissue damage due to trauma), the debridement codes can be reported. In open fractures and/or dislocations, debridement of tissue due to fracture should be separately reported using CPT codes 11010 11012. 5. Grafts, such as CPT codes 20900 20924, are to be separately reported only if the major procedure code description does not include graft in its definition. 6. The CPT code 20926 is a general code for tissue grafting (e.g. para-tendon, fat, dermis) to be used when the primary procedure does not include grafting and when another graft code does not more accurately describe the nature of the grafting procedure being performed. Accordingly, it should not be used with codes in which the graft is already listed as a part of the procedure or with other grafting codes.
Surgicom Coding
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SURGICOM-MEDIHELP BILLING GUIDES CONFIDENTIAL Correct Coding Policies: Respiratory, Cardiovascular, Blood & Lymphatic Systems (CPT Codes 30000 39999)
A. Introduction The general guidelines regarding correct coding apply to the CPT codes in the range of 30000 39999. Specific issues unique to this section are clarified in the following guidelines. B. Respiratory System 1. Because the upper airway is bordered by a mucocutaneous margin, several CPT codes may define services involving biopsy, destruction, excision, removal, revision, etc., of lesions of this margin, specifically the nasal and oral surfaces. When billing a CPT code for these services, only one CPT code that most accurately describes the service performed should be coded, generally either from the CPT section describing integumentary service (CPT codes 10040 19499) or respiratory service (CPT codes 30000 32999). In keeping with the general guidelines previously promulgated, when a biopsy of an established lesion of the respiratory system is obtained as part of an excision, destruction, or other type of removal, either endoscopically or surgically, at the same session, a biopsy code is not to be reported by the surgeon in addition to the removal code. In the case of multiple similar or identical lesions, the biopsy code is not separately reported even if the biopsy was performed in a different area. When the decision to perform the more comprehensive procedure (excision, destruction, or other type of removal) is dependent on the results of the biopsy, the procedure may be separately reported. If, at the same session, a biopsy is necessary to establish the need for surgery, modifier 58 would be used to indicate this. 2. When laryngoscopy is required for placement of an endotracheal tube (e.g. CPT code 31500), a laryngoscopy code is not to be separately coded. In addition, when a laryngoscopy is used to place an endotracheal tube for non-emergent reason (e.g. general anaesthesia, bronchoscopy, etc.) a separate service is not to be reported for the laryngoscopy. The CPT code 31500 refers only to endotracheal intubation as an emergency procedure and is not reported when an elective intubation is performed. When intubation is performed in the setting of a rapidly deteriorating patient who will require mechanical ventilation, a separate service may be reported with adequate documentation of the reasons for intubation. 3. When tracheotomy is performed as an essential part of laryngeal surgery, in accordance with the separate produce policy, the CPT code 31600 is not separately reported. This would include laryngotomy, laryngectomy, and laryngoplasty code or other codes that routinely require of a tracheostomy. 4. If a laryngoscopy is required for the placement of a tracheostomy, the tracheostomy (CPT code 31603 31614) is reported and not the laryngoscopy. 5. A surgical thoracoscopy is included in and not to be separately reported from an open thoracotomy when performed at the same session; the thoracotomy would represent the most extensive procedure successfully accomplished, If, however, the thoracoscopy was performed for purpose of an initial diagnosis and the decision to performed surgery is based in the results of the thoracoscopy, then it is separately reported. Modifier 58 may be used to indicate that the diagnostic thoracoscopy are staged or planned procedures. C. Cardiovascular System 1. When an intervascular shunt procedure is performed as part of another procedure at the same site requiring vascular revision, a service for a shunt procedure is not separately reported from CPT codes 36800 36861 (Intervascular cannulisation/shunt). By CPT definition, this series of codes represents separate procedures. 2. An aneurysm repair may require direct repair with or without graft insertion, thromboendarterectomy, and/or bypass. When a thromboendarterectomy is undertaken at the site of the aneurysm and it is necessary for an aneurysm repair or graft insertion, a separate service is not reported for the thromboendarterectomy. Additionally, if only a bypass is placed, which may require an endarterectomy to place the bypass graft, only the code describing the bypass can be reported. If both an aneurysm repair (e.g. after rupture) and a bypass are performed at separate non-contiguous sites, the aneurysm repair code and the bypass code should be reported with an anatomic modifier or modifier 59. If a thromboendarterectomy is medically necessary, due to vascular occlusion on a different vessel at the same session, the appropriate code may be reported but should include an anatomic modifier or modifier 59, indicating that this represents non-contiguous vessels. At a given site, only one type of bypass (venous, non-venous) code can be reported. If different vessels are bypassed by different methodology, separate codes may be reported. If the same vessels has multiple obstructions and requires different types of bypass in different areas, separate codes may be reported; however, it will be necessary to indicate that multiple procedures were performed by using an anatomic modifier or modifier 59. 3. When an open vascular procedure (e.g. thromboendarterectomy) is performed, the closure and repair are included in the description of the vascular procedure. Accordingly, the CPT codes 35201 35286 (Repair of blood vessel) are not to be reported in addition to the primary vascular procedure. 4. When an unsuccessful percutaneous vascular procedure is followed by an open procedure at the same session/same physician (e.g. percutaneous transluminal angioplasty, thrombectomy, embolectomy, etc., followed by a similar open procedure such as thromboendarterectomy), only the service for the successful procedure- which is usually the most extensive, open procedure-is reported (sequential procedure policy). When a percutaneous procedure is performed at the site of one lesion and an open procedure is performed at a separate lesion, the services for the percutaneous procedure should be reported with modifier 59 only if the lesions are in distinct anatomical vessels. Surgicom Coding
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SURGICOM-MEDIHELP BILLING GUIDES CONFIDENTIAL Correct Coding Policies: Respiratory, Cardiovascular, Blood & Lymphatic Systems (CPT Codes 30000 39999)
The CPT codes 36000, 36406, 36410, 90784, etc., represent very common procedure performed to gain venous access for phlebotomy, prophylactic intravenous access, infusion therapy, chemotherapy, and drug administration, among others. When intravenous access is routinely obtained in the course of performing other medical/diagnostic/surgical procedures, or is necessary to accomplish the procedure (e.g. infusion therapy, chemotherapy), it is inappropriate to bill separately for the venous access service. The work of gaining routine vascular access is integral to and therefore included in the work value of the procedure. When the service is performed alone to a service does not routinely require vascular access, these codes may be separately reported. 6. When (non-coronary) percutaneous intravascular interventional procedure is performed at the same session/site as a diagnostic angiography (arteriogram/venogram), only one selective catheter placement code for the involved site should be reported. If the angiogram and the percutaneous intravascular interventional procedure are not performed in immediate sequence and the catheters are left in place during the interim, a second selective catheter placement or access code should not be reported. Additionally, dye injections to position the catheter should not be reported as a second angiography procedure. 7. Diagnostic angiograms performed on the same date of service as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 52 and 59. If the previous diagnostic angiogram was complete, the provider should not report a second angiogram for the d ye injections necessary to perform the percutaneous intravascular interventional procedure. 8. When existing vascular access lines or selectively placed catheters are used to procure arterial or venous samples, billing for the sample collection separately is inappropriate. 9. Peripheral vascular bypass CPT codes describe bypass procedures using venous grafts (CPT codes 35501 35587) and using other types of bypass procedures (arterial reconstruction, composite). Because, at a given site of obstruction, only one type of bypass is performed, these groups of codes are mutually exclusive. When different sites are treated with different bypass procedures in the same operative session, the different bypass procedures may be separately reported, using an anatomic modifier or modifier 59. 10. Vascular obstruction may be caused by thrombosis, embolism, and/or atherosclerosis as well as other conditions. Treatment may, therefore, include thrombectomy, embolectomy and/or endarterectomy; these procedures may be performed alone or in combination. CPT codes are available describing the separate service services (CPT codes 34001 34203) and describing these service with thromboendarterectomy (CPT code 35301 35381). Only the most comprehensive code describing the services performed for a given site can be reported; therefore, for a given site, a code from both of the above groups cannot be reported together. Additionally, in accordance with the sequential procedure policy, if a balloon thrombectomy fails, making an open thromboendarterectomy necessary, only the more comprehensive service that was performed (generally the open procedure) is reported. 11. When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the atherectomy procedure is reported. 12. CPT codes 35800 35860 are to be used when a return to the operating room is necessary for exploration for postoperative haemorrhage; accordingly, these codes are not to be coded for bleeding that occurs during the initial operative session. Generally, when these codes are used, they are to be reported with modifier 78, indicating that the service represents a return to the operating room for a related procedure during the postoperative period. D. Haemic and Lymphatic Systems When bone marrow aspiration is performed alone, the appropriate code to report is CPT code 38220. When a bone marrow biopsy is performed, the appropriate code is CPT code 38221 (Bone marrow biopsy); this code cannot be reported with CPT code 20220 (Bone biopsy). CPT codes 38220 and 38221 may be reported only if the two procedures are performed at separate sites or at separate patient encounters. Separate site include bone marrow aspiration and biopsy in different bones or two separate skin incisions over the same bone. When both a bone marrow biopsy (CPT code 38221) and bone marrow aspiration (CPT code 38220) are performed at the same site through the same skin incision, only the bone marrow biopsy (CPT 38221) should be reported. E. General Policy Statements Global surgery rules prevent separate payment for postoperative pain management when provided by the physician performing an operative procedure. CPT code 36000, 36410, 37202, 62318 - 62319, 64415 64417, 64450, 64470, 64475, and 90780 describe service that may be used to manage postoperative pain. The service describe by these codes may be reported only if performed for purposes unrelated to the postoperative pain management.
5.
Surgicom Coding
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SURGICOM-MEDIHELP BILLING GUIDES Correct Coding Policies Surgery: Digestive System (CPT Codes 40000 49999)
CONFIDENTIAL
A. Introduction. The general policy statements defined previously also apply to procedures described by the CPT range of codes 40490-49999, which deal with the digestive system. The nature of services identified in this section requires specific clarification in relationship to these general policy statements. B. Abdominal Procedures 1. When any open abdominal procedure is performed, an exploration of the surgical field is routinely performed to identify anatomic structures or any anomalies that may be present. Accordingly, an exploratory laparotomy (CPT code 49000) is not separately reported with any open abdominal procedure. If routine exploration of the abdomen during an open abdominal procedure identifies abnormalities requiring a more extensive surgical field that makes the procedure unusual, modifier 22 may be reported with supporting documentation in the medical record, indicating that an unusual procedural service was performed. 2. When, in the course of a hepatectomy, a cholecystectomy is necessary in order to successfully perform the hepatectomy, a separate procedure code is not coded for the cholecystectomy; component procedures necessary to perform a more comprehensive procedure are included in the code describing the more comprehensive service. 3. Appendectomies are commonly performed incidentally during many abdominal procedures. The appendectomy is to be reported separately only if it is medically necessary. If done incidental to another procedure, the appendectomy would be included in the major procedure performed. 4. When, in the course of an open abdominal procedure, a hernia repair is performed, a service is reported only if the hernia repair is medically necessary at a different incisional site. Incidental hernia repair in the course of an abdominal procedure that is not medically necessary should not be reported. The medical record should document the medical necessity of the service. 5. When a recurrent hernia requires repair, the appropriate recurrent hernia repair code is reported. A code for incisional hernia repair is not to be reported in addition to the recurrent hernia repair unless a medically necessary incisional hernia repair is performed at a different site. In this case, modifier 59 should be attached to the incisional hernia repair code. 6. When a vagotomy is performed in conjunction with oesophageal or gastric surgery, the appropriate CPT code describing the comprehensive service is reported. The range of CPT codes 64752 64760 includes services described by the vagotomy codes performed as separate procedure and are not reported in addition to oesophageal or gastric surgical CPT codes (e.g. 43635 43641), which include vagotomy as part of the service. 7. When a closure of an enterostomy or enterovesical fistula requires the resection and anastomosis of a segment of bowel, the CPT codes 44626 and 44661 include the anastomosis or the enteric resection. Accordingly, additional enteric resection codes are not to be reported. 8. In accordance with the sequential procedure policy, only one code for haemorrhoidectomy is reported; the most extensive procedure necessary to successfully accomplish the haemorrhoidectomy would be appropriate. Additionally, if, in the course of a haemorrhoidectomy, an abscess is identified and drained, a separate procedure code is not reported for the incision and drainage, as this was performed in the course of haemorrhoidectomy. If the incision and drainage of the abscess occurred at a different site than the haemorrhoidectomy, then this procedure could appropriately be reported with modifier 59. 9. A number of groups of codes describe surgical procedures of a progressively more comprehensive nature or with different approaches to accomplish similar services. In general, these groups of codes are not to be reported together (see mutually exclusive policy). While a number of these groups of codes exist in CPT, several specific examples include CPT codes 45110 45123 for proctectomies, CPT codes 44140 44160 for colectomies, CPT codes 43620 43639 for gastrectomies, and CPT codes 48140 48180 for pancreatectomies. 10. When it is necessary to create or revise an enterostomy, or remove or excise a section of bowel due to fistula formation, a separate enterostomy closure code or fistula closure code is not reported. In the case of creating or revising an enterostomy, the closure is mutually exclusive and in the case of fistula excision, the closure is included in the excision procedure. 11. Because the digestive tract is bordered by a mucocutaneous margin, several CPT codes may define services involving biopsy, destruction, excision, removal, etc. of lesions of the margin. When a lesion involving this margin is identified and it is medically necessary to remove it, only one code that most accurately describes the service performed should be submitted, generally either from the CPT section describing integumentary services (10040 19499) or that describing digestive services (40490 49999). For example, if a patient presents with a benign lip lesion, and it is removed with a wedge excision, it would be acceptable to bill the CPT code 40510 (Excision of lip) or the appropriate code from CPT codes 11440 11446 (excision of lesions); billing a code from both sections would be inappropriate. 12. Laparoscopic procedures performed in place of an open procedure are subject to the standard surgical practice guidelines. 13. Global surgery rules prevent separate payment for postoperative pain management when provided by the surgeon performing an operative procedure. CPT codes 36000, 36410, 37202, 62318 62319, 64415 64417, 64450, 64470, 64475, and 90780 describe services that may be utilized for postoperative pain management. The services described by these codes may be reported only if performed for purposes unrelated to the postoperative pain management.
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Surgicom Coding
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SURGICOM-MEDIHELP BILLING GUIDES Correct Coding Policies Surgery: Digestive System: endoscopy (CPT Codes 40000 49999)
CONFIDENTIAL
1. 2. 3.
4.
5. 6.
8.
9. 10. 11. 12.
13. 14.
CCSA 2010
Surgicom Coding
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7.
Endoscopic Services are performed in many settings office, outpatient or hospital. Procedures that are performed as an integral part of an endoscopic procedure are considered part of the endoscopic procedure. Services such as venous access (e.g. CPT code 36000) &/or injection (e.g. CPT codes 90780 90784), oximetry (e.g. CPT codes 94670 and 94761) are included in the endoscopic procedure code. These codes are not to be reported separately. When a diagnostic endoscopy is performed in conjunction with endoscopic therapeutic services, the appropriate CPT code to use is the most comprehensive endoscopy code describing the service performed. If the same therapeutic endoscopy service is performed repeatedly (e.g. polyp removal) in the same area, only one CPT code is reported with one unit of service. If different therapeutic services are performed and are not adequately described by a more comprehensive CPT code, use the multiple GI endoscopy rules (see below). Multiple GI endoscopy rule: if a colonoscopic snare polypectomy (45385) is performed in the caecum, as well as a hot biopsy polypectomy in the left colon (45384) as well as rectal biopsy (45380) is performed, the billing strategy is for the separate procedures in the same family is as follows: a. colonoscopic snare polypectomy (45385) 100% charge full & ICD code C18.0; b. colonoscopy with hot biopsy polypectomy in the left colon (45384) minus (45378 base procedure of the family), reduced to 50% and denoted by modifier 59 as well as separate unique ICD code e.g. C18.6; c. colonoscopy and rectal biopsy (45380) minus (45378) reduced to 50% and denoted by modifier 59as well as separate unique ICD code e.g. A09. When a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported. Gastroenterologic tests included in CPT codes 91000 91299 are frequently complementary to endoscopic procedures. Oesophageal and gastric washings for cytology are described as part of an upper endoscopy (CPT code 43235) and, therefore, CPT codes 91000 (oesophageal intubation) and 91055 (gastric intubation) should not be separately reported when performed as part of an upper endoscopic procedure. Provocative testing (CPT code 91052) can be expedited during gastrointestinal endoscopy (procurement of gastric specimens): when performed at the same time as GI endoscopy, CPT code 91052 should be coded with modifier 52, indicating that a reduced level of service was performed. When a small intestinal endoscopy or enteroscopy is performed as a necessary part of a procedure, only the most comprehensive code describing the service performed is to be reported. When services described by the range of CPT codes 44360 44386 (small intestinal endoscopies) are performed as part of another service (e.g. surgical repair or creation of enterostomy, etc.) these codes are not separately reported. When an endoscopic procedure is confirmatory or is performed to establish anatomical landmarks (scout endoscopy), the endoscopic procedure is not separately reported. When the endoscopic procedure is performed as diagnostic procedure upon which the decision to perform a more extensive (open) procedure is made, the endoscopic procedure may be separately reported. Modifier 58 may be used to indicate that the diagnostic endoscopy and the more extensive, open procedure are staged or planned services. When endoscopic oesophageal dilation is performed, the appropriate endoscopic oesophageal dilation code is to be reported. The CPT codes 43450 43458 (dilation of oesophagus) are not used in addition (even if attempted unsuccessfully prior to endoscopic dilation); in such a case, modifier 22 could be used to indicate an unusual endoscopic dilation procedure. When it is necessary to perform diagnostic endoscopy of the hepatic/biliary/pancreatic system using separate approaches (e.g. biliary T-tube endoscopy with ERCP, etc.) the appropriate CPT codes for both may be reported. However, the code should include modifier 51, indicating multiple procedures were performed at the same session. When intubation of the GI tract is performed (e.g. percutaneous G-tube placement, etc.), it is not appropriate to bill a separate code for tube removal. Specifically, the CPT code 43247 (endoscopic removal of foreign body) is not to be reported for routine removal of therapeutic devices previously placed. When an endoscopic or open procedure is performed and a biopsy is also performed, followed by excision, destruction, or removal of the biopsied lesion, the biopsy is not separately reported. Additionally, when bleeding results from an endoscopic or surgical service, the control of bleeding at the time of the service is included in the endoscopic procedure. Separate procedure codes for control of bleeding are not to be coded. In the case of endoscopy, if it is necessary to repeat the endoscopy at a later time during the same day to control bleeding, a procedure code for endoscopic control of bleeding may be reported with modifier 78, indicating that this service represents a return to the endoscopy suite or operating room for a related procedure during the postoperative period. In the case of open surgical services, the appropriate complication codes may be reported if a return to the operating room is necessary, but the complication code should not be reported if the complication described by the CPT code occurred during the same operative session. Only the most extensive endoscopic procedure is reported for a session (e.g. if a sigmoidoscopy is completed and the physician performs a colonoscopy during the same session, only the colonoscopy is coded). It is, however, acceptable to bill for multiple services provided during an endoscopic procedure (with the exception of treating bleeding induced by the procedure). When a transabdominal colonoscopy (via colostomy) (CPT code 45355) and/or standard sigmoidoscopy or colonoscopy is performed as a necessary part of an open procedure (e.g. colectomy), the endoscopic procedure or procedures are not separately reported. On the other hand, if either endoscopic procedure is performed as a diagnostic procedure upon which the decision to perform the open procedure is made, the procedure(s) may be reported separately. Modifier 58 may be used to indicate that the diagnostic endoscopy and the open procedure are staged or planned services. CPT Guide: Digestive System Introduction Ver. 01/20108
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2010surgicom MedihelpCPTBILLINGGUIDES

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CCSA 2010

SURGICOM-MEDIHELP BILLING GUIDES

CTP based on CCSA 2010 Prepared for exclusive use by Surgicom

Surgicom Billing Tables Medihelp 2010

SURGICOM-MEDIHELP BILLING GUIDES

Surgicom Correct Coding Help Desk Medihelp CPT contract

Stephen Grobler 051-4442878 / 051-4442889 / fax 051-4440267 or 0866-412178 / sgrobler@global.co.za

CCSA2010 COPYRIGHT NOTICE

SURGICOM-MEDIHELP BILLING GUIDES

Introduction to CPT Coding

CPT Guide: Introduction Ver. 01/2010

SURGICOM-MEDIHELP BILLING GUIDES

CPT General Modifiers

SURGICOM-MEDIHELP BILLING GUIDES

CPT General Modifiers

Decision for Surgery Staged or Related Procedure or Service by Same Surgeon

Distinct Procedural Service.

Procedures Performed on Infants less than 4 kg

SURGICOM-MEDIHELP BILLING GUIDES

CPT General Modifiers

SURGICOM-MEDIHELP BILLING GUIDES

Billing Component Modifiers

Technical component (TC)

Technical component: equipment, facility and staff costs

Assistant Modifiers (See categories of assistants assigned to individual procedures)

2 non-specialist assistants OR 1 specialist assistant

1 non-specialist assistant AND 1 specialist assistant

See categories of assistants assigned to individual procedures

Assistant code A allows reimbursement of 1 non-specialist assistant at operation

Assistant code C allows reimbursement of 1 non-specialist assistant AND 1 specialist assistant

Assistant code D allows reimbursement of 2 specialist assistants

EVALUATION & MANAGEMENT (E/M) 2010 MEDIHELP

SURGICOM-MEDIHELP BILLING GUIDES

Consultation "Second opinion"

99201 99202 99203 99204 99205

HOSPITAL INPATIENT SERVICES (POS 21)

Hospital discharge day management

1.03 1.85 2.65

R 129.71 R 232.97 R 333.71

99218 99219 99220

1.74 2.88 4.04

R 219.12 Low severity R 362.68 Moderate severity R 508.75 High severity

Hospital Observation Services Discharge day

Admission and discharge on same day

99235 99235 99236

Emergency Department Services

Critical Care Services

Comprehensive examination, high complexity

Consultation in hospital Second opinion

After hours Services

99251 99252 99253 99254 99255

1.35 2.10 3.18 4.59 5.6

Refer to detailed tabulation and notes for accurate billing

SURGICOM-MEDIHELP BILLING GUIDES Evaluation and Management (E/M) Services Guidelines

SURGICOM-MEDIHELP BILLING GUIDES Evaluation and Management (E/M) Services Guidelines

E/M Prolonged Services with Direct (Face-to-Face) Patient Contact (99354-99359).

Surgicom Coding CPT Guide:

E & M Services Ver. 01/2010

SURGICOM-MEDIHELP BILLING GUIDES Evaluation and Management (E/M) Services Guidelines

99291 X 1 AND 99292 X 4

99291 and 99292 as appropriate

Surgicom Coding CPT Guide: