The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 7 Surgery Coding: Part 1 Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

Learning Outcomes Interpret the guidelines for coding surgical procedures. Determine which services are included in the global surgical package. Identify unusual services and treatments and report them accurately. 7-2

Learning Outcomes Distinguish between biopsies, excisions, and wound repair. Apply the guidelines to determine the best, most appropriate code. Decide how and when to use modifiers. 7-3

Introduction As a coding specialist, you will have a different responsibility when it comes to coding surgical procedures, depending upon where you work. 7-4

The Surgical Package All codes in the Surgery section of CPT already include: E/M encounter after the decision to have surgery and before the procedure, most often the day before or the same day as the procedure 7-5

The Surgery Package All codes in the Surgery section of CPT already include: Topical, local, and some types of regional anesthesia only when administered by the surgeon The operation or procedure itself Immediate post-operative care 7-6

The Surgery Package All codes in the Surgery section of CPT already include: Follow-up care during the global period The length of the global period will vary depending upon the standard of care for that specific procedure. Supplies 7-7

Services NOT Included Diagnostic tests and procedures Post-operative therapies A more comprehensive version of the original procedure Staged or multi-part procedures Care for post-operative complications 7-8

Surgery Modifiers 58 Staged or related procedures during the post-operative period 76 Repeat procedure - same physician 78 Related procedure during post- operative period 77 Repeat procedure - another physician 79 Unrelated procedure during post- operative period 7-9

More Than One Physician 54 Surgical care only 55 Post-operative management only 56 Pre-operative management only 7-10

Unusual Circumstances Modifier 22 Unusual Procedure Service When using this modifier, be certain to attach a supplemental report to the claim to explain the details. 7-11

Surgery Guidelines A 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. 7-12

Integumentary System Biopsies Only use a separate code for a biopsy when the procedure is provided separately from any other procedure or service. 7-13

Integumentary System Excisions When a lesion is removed, code each lesion separately. Code includes local anesthetic Code includes simple closure 7-14

Integumentary System Excisions Code determined by Size of lesion + Size of margins x 2 = Coded size of lesion 7-15

Integumentary System Excisions If the closure of the excision site requires more than a simple closure, code the closure separately. Intermediate closure (repair) Complex closure (repair) 7-16

Integumentary System Re-Excisions When performed at the same surgical session, simply adjust the size of the lesion for coding. When performed at a later date, use modifier

Integumentary System Wound Repair 1.Same complexity on same anatomical site: Add all lengths together to use one code for total repair. 7-18

Integumentary System Wound Repair 2. Codes for multiple wounds are listed in order from most complex to the simplest. All additional repairs, after the first, use modifier 51 to each. 7-19

Integumentary System Wound Repair 3. Debridement or decontamination of a wound is included in the code for the repair. When this is extensive and requires extra work, code separately. 7-20

Integumentary System Skin Replacement Surgery You will need to know: 1. The size of the recipient area, the anatomical site of the recipient area, and the type of graft. Preparation of recipient site, such as simple debridement or avulsion, is included in this code and not to be reported separately. 7-21

Integumentary System Skin Replacement Surgery 2. The site from which the graft was harvested. –Patient’s own body –Live donor (another body) –Cadaver (a deceased person) –Skin substitute –Another species 7-22

Integumentary System Skin Replacement Surgery 3. When planned in stages, use modifier 58 with the second, and subsequent, procedures. 4. Donor site repair is coded separately. 7-23

Integumentary System Skin Replacement Surgery 5. Size of recipient site is measured In 100 sq cm increments for patients age 10 and older Body area percentage: 1% increments for infants and children 7-24

Integumentary System Skin Replacement Surgery When extensive immobilization is performed, such as large plaster casts or traction, code this separately. 7-25

Integumentary System Destruction Removal of diseased or unwanted tissue using… –Surgery –Curettement –Laser treatment –Electrosurgery –Chemical treatment –Cryosurgery 7-26

Mohs Surgery Mohs Micrographic Surgery Specially trained physician acting as both surgeon and pathologist Repairs are not included and should be coded separately. 7-27

Chapter Summary Coding surgical procedures will require determining those services included and those that must be coded separately. 7-28