Chapter 13 Surgery guidelines and General Surgery

Introduction to the Surgery Section

The Surgery section of the CPT manual is the largest section, covering codes from 10004 to 69990. This section is organized into multiple subsections, most of which are categorized based on medical specialties or body systems (e.g., Integumentary, Musculoskeletal, Respiratory, Cardiovascular, Digestive, and Female Genital systems).

Understanding the content of the Surgery section is vital, as it covers a wide array of surgical procedures. Let's delve into the key elements of this section, focusing on the general information, guidelines, and unlisted procedures.

Surgery Section Guidelines

Each subsection in the Surgery section begins with guidelines that define key concepts and help with accurate coding. The guidelines are crucial for understanding the correct way to interpret the surgical codes and procedures. Here's a look at some important topics covered in the guidelines:

Services: Explains how to use Evaluation and Management (E/M) codes in conjunction with surgical services.
CPT Surgical Package Definition: Defines what is included in the surgical package (e.g., preoperative and postoperative care).
Follow-up Care for Diagnostic and Therapeutic Procedures: Differentiates follow-up care for diagnostic and therapeutic surgeries.
Supplied Materials: Provides guidance on reporting materials and supplies used in surgery.
Reporting More Than One Procedure/Service: Discusses when to use modifiers for multiple procedures performed in a single session.
Separate Procedure: Explains how to assign codes for procedures labeled as "separate procedures."
Unlisted Service or Procedure: Defines when to report unlisted services or procedures.
Special Report: Guidelines for including and submitting special reports with unlisted or complex procedures.
Surgical Destruction: Clarifies methods of destruction and when they should be coded separately.

Importance of Notes in the Surgery Section

Notes play a critical role in the Surgery section, offering special instructions or additional context for specific codes or groups of codes. These notes are usually not repeated in the section guidelines and should be read carefully to ensure correct coding. There are different types of notes, including:

Subsection Notes: These provide important instructions for the entire subsection.
Subheading Notes: Offer more specific guidance for a narrower category within the subsection.
Category Notes: Offer clarification on specific categories of codes.
Subcategory Notes: Provide additional context for particular subcategories of codes.

Unlisted Procedure Codes

An unlisted procedure code is used when a procedure does not have a specific CPT code. These codes are located in the Surgery Guidelines and are presented by anatomic site. For example, 25999 is the unlisted procedure code for the forearm or wrist.

Guidelines for Reporting Unlisted Procedures

Unlisted codes are used when no standard CPT code is available for the procedure performed.
If a Category III code is available for the procedure, that code should be used instead of an unlisted Category I code.
Category III codes are temporary codes for emerging technologies, services, and procedures. Reimbursement for Category III codes may vary depending on the payer.
When reporting an unlisted code, it is important to provide a special report with a detailed description of the procedure, why it was necessary, and any supporting documentation.

General Recommendations

Always Review Guidelines: Always review the guidelines and notes provided in the Surgery section before proceeding with coding. This will help ensure that the correct procedures and codes are selected.
Documentation: Proper documentation is essential, especially when reporting unlisted or Category III codes. Ensure that all necessary details are included to support the necessity of the procedure.
Understand Modifiers: Certain modifiers may be required when multiple procedures are performed, or when specific conditions apply, such as when the procedure is a separate service.

Quick Check 13-1 (Answer: False)

This question asks whether a listing of subsections with instructional notes is included in the Surgery section guidelines. The correct answer is False, because the guidelines explain how to apply the codes but do not list all subsections with instructional notes.

Summary

The Surgery section of the CPT manual is extensive and covers a wide range of procedures. Familiarity with the guidelines, special notes, and unlisted procedure codes is essential for accurate coding. Always consult the relevant guidelines and notes for each subsection, as this will ensure that you report the correct codes for the procedures performed and avoid errors in reimbursement.

Special Reports

When using an unlisted procedure code to report a surgical service, it's crucial to submit a special report alongside the claim. This report is designed to provide an in-depth explanation of the procedure performed, particularly when no specific CPT code is available. According to the CPT manual, the special report should include:

Definition and description: Clear explanation of the nature, extent, and necessity of the procedure.
Time and effort: Information on the duration of the procedure and the effort required.
Equipment used: Details on the equipment and materials involved in the procedure.

Caution About Unlisted Codes

Unlisted codes should only be used after thorough research confirms that no more specific CPT code exists. For instance, when the first total disc arthroplasty (artificial disc) procedure was performed, there was no specific code, so a special report was necessary to describe the procedure. Eventually, a Category III code (0090T) was introduced, and later a Category I code replaced it.

Medical supplier representatives can be helpful in gathering the necessary details to support a new technique used during the procedure.

Separate Procedure

Some CPT codes have the phrase "separate procedure" after the description. This indicates that the procedure is a minor procedure and can only be reported under certain circumstances:

If the procedure is performed alone, it should be reported using the code.
If the procedure is performed with a major procedure on the same body area, it is considered incidental and bundled with the major procedure (no separate code).

However, in some cases, the minor procedure may not be bundled and would be reported separately if:

The minor procedure is performed at a different site or on a different body area.
The minor procedure is performed as a staged procedure or sequential procedure, in which case a modifier (e.g., modifier -58) may be used.

Examples of Separate Procedures:

Bundled into major procedure: If a breast biopsy (CPT 19100, separate procedure) is done during a modified radical mastectomy (CPT 19307), only the mastectomy would be reported since the biopsy is considered incidental.
Separate procedures: If a breast biopsy (CPT 19100, separate procedure) and esophagoscopy (CPT 43200) are performed, both should be reported since they are done on different body areas.
Bundled into major procedure: If a salpingo-oophorectomy (CPT 58720, separate procedure) is done alongside an abdominal hysterectomy (CPT 58150), only the hysterectomy would be reported, as the salpingo-oophorectomy is considered incidental.

Quick Check 13-3 (Answer: False)

This question asks whether both minor and major procedures should be reported when performed on the same body area. The correct answer is False, as the minor procedure is generally considered bundled into the major procedure if they are performed on the same site.

Surgical Package

The surgical package encompasses all the services related to the surgery and is paid for as a bundled payment. The components of the surgical package typically include:

Preoperative visits: Initial assessments before the surgery.
Intraoperative services: Services performed during the procedure itself.
Postoperative visits: Routine follow-up care.
Supplies: Necessary materials used during the surgery.
Miscellaneous services: Tasks like dressing changes or catheter removal.

However, certain services are not included in the surgical package, such as:

Follow-up care for complications or exacerbations (worsening conditions) that require additional services.
General anesthesia services, which are reported separately by the anesthesiologist.

The definition of what is included in the surgical package varies among third-party payers. For example:

Medicare often includes costs for complications and follow-up care in the global surgical payment.
Commercial payers may allow additional charges for complications.

The global period refers to the timeframe in which postoperative care is included in the surgical package, usually 90 days for major surgeries and 10 days for minor ones.

Example: Surgical Package and Global Days

In CPT codes 10080 and 10081 for incision and drainage of a pilonidal cyst, the global days may differ:

Code 10080 may have zero global days, meaning additional services can be charged separately.
Code 10081 may have a 10-day global period, meaning services like suture removal or routine follow-up care are included in the reimbursement.

It's essential to know the global days for each procedure to ensure proper billing and avoid errors.

Materials and Supply Codes

When additional materials or supplies are used beyond the typical items in an office visit, these may be coded separately. For example:

A surgical tray used during a wound repair might be identified using CPT code 99070, which can be reported in addition to the office visit or procedure.

Summary

Accurate coding in surgery involves understanding when to report unlisted procedures with a special report, recognizing the implications of "separate procedure" codes, and knowing the components of a surgical package. Additionally, recognizing when to report materials or supplies separately ensures all aspects of the procedure are properly reimbursed. Always stay updated on third-party payer policies to ensure compliance and proper reimbursement.

Exercise 13-3: General Subsection

1. The physician palpates a cyst on the right breast and performs a fine needle aspiration biopsy in the office.
Code: 10021

2. A patient presents to the outpatient surgical center at the clinic for a fine needle aspiration biopsy of the thyroid. Ultrasound guidance is utilized during the aspiration.
Code: 10005

Chapter Review: Theory

What is the largest section of the six CPT manual sections?
Answer: Surgery section.
Does Medicare reimburse for every surgical tray?
Answer: No.
The subsections in the Surgery section are usually divided according to specialty, body system, or site.
These are found at the beginning of each section and contain information specific to the section:
Answer: Guidelines.
This symbol indicates new or revised text within the current edition of the CPT manual:
Answer: b ▸◂.
Information within parentheses is referred to as:
Answer: Parenthetical expression or phrase.
Before assigning this type of code, you must be certain that a more specific Category I or a Category III code is not available:
Answer: Unlisted procedure code.
This report contains the nature, extent, need, time, effort, and (at times) the equipment necessary to provide a service:
Answer: Special report.
This designation within the CPT manual indicates a procedure that is only reported when it is performed as the only procedure or when another procedure performed at the same time is unrelated to this procedure. This is a:
Answer: Separate procedure.
When time, effort, and services are bundled together, they form a(n):
Answer: Surgical package.
Local anesthesia is defined as local infiltration, metacarpal/digital block, or topical anesthesia.
According to Medicare guidelines, complications of a surgical procedure are usually included in the reimbursement for a major surgical procedure.
Code 99070 is a CPT code that can be assigned to report a surgical tray.
Code A4550 is a HCPCS code that can be assigned to report a surgical tray.
This code reports a postoperative follow-up visit that is included in the global service:
Answer: 99024.

Chapter Review: Practical

Destruction is a part of a surgical procedure, and different methods of destruction are not ordinarily listed separately.
Care of the condition for which a diagnostic procedure was performed or of other preexisting conditions is not included and may be listed separately.
There are “Notes” in the Burns, Debridement Treatment category.
The only code in the Operating Microscope subsection is 69990.
Follow-up care for therapeutic surgical procedures includes only that care which is usually part of the surgical package (two words).
For cytopathology evaluation of fine needle aspirate, see 88172, 88173, 88177.

Chapter Review: Learning Objectives

Most surgery subsections are defined according to body system or medical specialty.
Notes in the CPT manual may appear before subsections, subheadings, categories, and subcategories.
Unlisted codes identify procedures or services throughout the Surgery section that indicate there is no specific CPT code available.
Pertinent information in a special report should include an adequate definition or description of the nature, extent, and need for the procedure.
The term “separate procedure” is an indication of how, or if, the code should be reported separately.
General anesthesia services are reported separately by the anesthesiologist.
Surgery: “General subsection” codes are divided based on whether imaging guidance was used during the aspiration and if so, the type of guidance performed.

Chapter Review: Glossary

Includes nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service.
Answer: Special report.
Procedures that, when performed at the same time as a major procedure, are considered incidental and not reported separately.
Answer: Separate procedure.
Considered unusual, experimental, or new and do not have a specific CPT code assigned.
Answer: Unlisted procedure.
Through the skin.
Answer: Percutaneous.
Use of a needle and syringe to withdraw fluid.
Answer: Aspiration.