1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 7-1 Chapter 7 Surgery Coding, Part 1

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives 7.1 Distinguish among the types of surgical procedures. 7.2 Determine which services are included in the global surgical package. 7.3 Interpret the impact on coding of the global time frames. 7-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives (cont.) 7.4 Identify unusual services and treatments and report them accurately. 7.5 Apply the guidelines to determine the meaning of a separate procedure. 7.6 Abstract physician documentation of procedures on the integumentary system. 7-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Complex closure Donor area (site) Excision Full-thickness Global period Harvesting 7-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Intermediate closure Recipient area Simple closure Standard of care Surgical approach 7-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgery A surgical procedure can take place in various locations depending on procedure –Ambulatory surgical center (same day surgery) –Physician’s office –Hospital –Clinic 7-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Types of Surgical Procedures Prophylactic –Performed to prevent a condition from developing. Diagnostic –Performed so that the physician can gather more details about the condition or concern at issue. Therapeutic –Performed to correct or fix a problem. 7-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgical Approaches Noninvasive, or external –Procedure does not enter the patient’s body. Minimally invasive –Procedure uses the smallest openings to enter the body to accomplish the procedure. 7-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgical Approaches (cont.) Percutaneous approach –Instruments are inserted into the body by a puncture or small incision to access the intended anatomical site. –Example: Needle biopsy 7-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgical Approaches (cont.) Percutaneous endoscopic approach –Uses instruments inserted into the body by a puncture or small incision to access and visualize the intended anatomical site. –Example: Laparoscopy 7-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgical Approaches (cont.) Via natural or artificial opening approach –Instrumentations enter the body through a natural opening, or an artificial opening, to visualize the intended anatomical site. –Example: Flexible esophagoscopy 7-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgical Approaches (cont.) Via natural or artificial opening endoscopic approach –Involves insertion of a scope through a natural opening, or an artificial opening, to visualize and aid in the performance of a procedure on the intended anatomical site. –Example: Colonoscopy with polyp removal 7-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Surgical Package E/M services after the decision to have surgery and before the procedure. Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia provided by surgeon. The operation or procedure itself. Immediate postoperative care. Follow-up care during the global period. Supplies 7-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Services Not Included Diagnostic tests and procedures. Postoperative therapies. A more comprehensive version of the original procedure. Staged or multi-part procedures. Care for postoperative complications. Unrelated surgical procedure during the postoperative period. 7-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgery Modifiers –58 Staged or related procedures during the postoperative period. –76 Repeat procedure—same physician. –77 Repeat procedure—another physician. –78 Related procedure during postoperative period. –79 Unrelated procedure during postoperative period. 7-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Global Periods All procedures have global period time frames assigned. Can range from 0–90 days based on the standard of care for a treatment or service. 7-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Services Provided by More Than One Physician Expected that the same physician will provide all of the surgical package’s elements. When more than one physician is involved, modifiers explain who did what and when: –54 Surgical care only –55 Postoperative management only –56 Preoperative management only 7-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Unusual Services and Treatments Modifier 22 Unusual Procedure Service When using this modifier, be certain to attach a supplemental report to the claim to explain the reason why this procedure was more complicated than usual. 7-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Surgery Guidelines Separate Procedure –Separate procedure can be performed alone or along with others. –When performed along with others, use modifier 59 Distinct procedural service to confirm that reporting both is not an error. 7-19

20. © 2016 McGraw-Hill Education. All rights reserved. INTEGUMENTARY SYSTEM Surgical Procedures on Specific Body Systems 1-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System Incision and drainage (I&D) –Physician performs an incision (cuts into the tissue) and drainage to extract infected material. Debridement –Carefully cleaning out a wound. 7-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Biopsies –Not part of the Surgical Package. –Reported Separately. –Only use a separate code for a biopsy when the biopsy is provided on a different date of service. 7-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Excisions –Code the excision of each lesion separately. –Determined by anatomical site and size of lesion removed (including margins). –Code includes local anesthetic. –Code includes simple closure. –If the closure of the excision site requires more than a simple closure, code the closure separately. 7-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Re-excision –When performed at the same surgical session, adjust the size of the lesion for coding. –When performed at a later date, append modifier 58. 7-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Wound Repair –Same complexity on same anatomical site: add all lengths together and use one code for total repair. –Each additional repair code should be appended with modifier 59 Distinct Procedural Service. –Extensive debridement of the wound should be coded separately. 7-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Adjacent Tissue Transfer and/or Rearrangement –Z-plasty is a double transposition flap. –W-plasty uses several small, triangular- shaped flaps, alternating inversion. –V-Y plasty uses a V-shaped flap that is next to the defect with surrounding skin raised up and brought into the wound. 7-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Adjacent Tissue Transfer and/or Rearrangement (cont.) - Rotation flap is a raised subdermal plane, semicircular in shape, pivoted around into the defect. –Random island flap is a section of skin moved into the defect with its blood supply. –Advancement flap involves a subdermal place of skin, longitudinally moved to the defect. Required elements from physician’s notes –Anatomical site –Size of defect 7-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Skin Replacement Surgery and Flaps –The size of the recipient area. –The location of the recipient area. –The type of graft. When planned in stages, use modifier 58 with the second, and subsequent, procedures. Donor site repair is coded separately. 7-28

29. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Destruction –Removal of diseased or unwanted tissue Cauterization Cryosurgical Curettage Electrosurgical methods Laser surgery 7-29

30. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Integumentary System (cont.) Mohs Micrographic Surgery –Codes 17311–17315. –Specially trained physician acts as both surgeon and pathologist. –Repairs are not included and should be coded separately. 7-30

31. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary Coding surgical procedures requires determining those services included and those that must be coded separately. The Surgery section of CPT not only includes codes for reporting services provided in an operating room under general anesthesia but also includes codes for reporting simple and small procedures such as removing a splinter. 7-31