1. CURRENT PROCEDURAL TERMINOLOGY

2. SURGERY-INTEGUMENTARY SYSTEM
Incision and Drainage :
Incision and drainage and clinical lancing are minor surgical procedures to release pus or pressure built up under the skin, such as from an abscess, boil. It is performed by treating the area with an antiseptic, such as iodine-based solution, and then making a small incision to puncture the skin using a sterile instrument such as a sharp needle, a pointed scalpel or a lancet. This allows the pus fluid to escape by draining out through the incision.

3. 10060 – Incision and drainage of abscess(Eg
10060 – Incision and drainage of abscess(Eg. Carbuncle, suppurative hydradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia) simple or single.

4. 10061 – Complicated or multiple
10061 – Complicated or multiple.(Packing , Tube placed, Vessel loop Placed)
For Eg :

5. 10080 – Incision and drainage of pilonidal cyst ; simple.
10081 – complicated.
26010 – Drainage of finger abscess ; simple.
46040 – Incision and drainage of ischiorectal and /or perirectal abscess.
46050 – Incision and drainage of perianal abscess, superficial.

6. 56420 – Incision and drainage of Bartholin’s gland abscess.
54700 – Incision and drainage of epididymis, testis and/or scrotal space(Eg. Abscess or hematoma)
56405 – Incision and drainage of vulva or perineal abscess
41800 – Drainage of abscess , cyst, hematoma from dentoalveolar structures.

7. Note : I & D at different anatomical sites – Need to use CPT 10061.
10160 – Puncture aspiration of abscess , hematoma, bulla or cyst.
NOTE :
I & D done (pus drained) – Billable.
Bloody pus drained – Billable.
No pus drained or no drainage & blood drained – Non billable

8. Foreign body removed through incision – Billable.
FOREIGN BODY REMOVAL :
10120 – Incision and removal of foreign body, subcutaneous tissues; simple.
28190 – Removal of foreign body, foot ; subcutaneous.
Note- Foreign body removal by using forcep , needle , hemostat – Non billable.
Foreign body removed through incision – Billable.

9. 69200 – Removal foreign body from external auditory canal without general anesthesia ( through any medical equipment Eg ; curette)

10. 69210 – Removal of impacted cerumen requiring instrumentation, 1 or both ears.
Note : If cerumen impaction removed by using irrigation – non billable.
If cerumen impaction removed by using extensive irrigation – Billable.

11. 30300 – Removal foreign body , intranasal ; office type procedure.

12. Removal of foreign body from eye by using curette, forceps, cotton ball , Q Tip, opthalmic burr.
65205 – Removal of foreign body, external eye ; conjunctiva superficial.
65220 – Removal of foreign body from cornea without slit lamp.
65222 – Removal of foreign body from cornea with slit lamp.
Removal of Rust ring

13. Laceration Repair Coding
Repair complexity Location Wound Size
1.Repair Complexity
Simple, or single-layer, repairs ( ) involve “primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures,” according to CPT.

15. Intermediate repairs ( ) involve “one or more of the deeper layers of subcutaneous tissue and superficial (non- muscle) fascia, in addition to the skin (epidermal and dermal) closure,” according to CPT. Intermediate repairs generally will involve layered closure. A single-layer closure may qualify as an intermediate repair, however, if the wound is heavily contaminated and requires extensive cleaning or removal of particulate matter

16. For Eg:

17. Complex repairs ( )involve more than layered closure via scar revision & debridement, such as extensive undermining, stents, or retention sutures. Extensive revision or repair of traumatic lacerations or avulsions, for example, would qualify as complex repairs. In addition, complex repairs may include reconstructive or creation of a defect to be repaired (for instance, scar excision with subsequent closure).

18. 2. Wound Location
Within each level of repair, CPT categorizes wounds by anatomic location. For example, simple repair codes apply to wounds of the neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet).

19. 3. Wound Size
After narrowing your code choice according to repair complexity and anatomic location for each wound, select a final code according to the size of the repaired wound(s).

20. Note : Laceration repair with dermabond , Dermaglue, Surgiceal, Octaseal, staples , mastisol is billable procedures.
Laceration repair with Steristrips , Surgicel, is not billable.
Laceration repair with steristrip and then dermabond also not billable.
For medicare patient if laceration is repaired by using dermabond ,Skin Adhesive – need to use G0168

21. 12020- Closure of wound dehiscence.
Debridement:
11042 – debridement of subcutaneous tissue(includes epidermis and dermis) first 20sq cm or less.
16020 – Dressing or debridement of partial thickness burns initial or subsequent(less than 5% of body surface area).

22. Fractures & dislocations
Definition of Fracture : A break in bone or cartilage. Although usually a result of trauma, a fracture can be the result of an acquired disease of bone, such as osteoporosis, or of abnormal formation of bone in a congenital disease of bone, such as osteogenesis imperfecta ('brittle bone disease'). Definition of Dislocation : there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Dislocations can occur in any joint major (shoulder, knees, etc.) or minor (toes, fingers, etc.). The most common joint dislocation is a shoulder dislocation.

23. FRACTURE CARE CPT Non Manipulative Manipulative
Manual Reduction(Traction,position)

24. Coding guidelines for fracture care CPT(Non Manipulative)
Follow up days
TYPE of fracture
Disposition
Definitive care

25. Type of Fracture:
Closed type – A closed fracture is a broken bone that does not penetrate the skin
can bill Fracture care CPT

26. Open Fracture :An open fracture can be defined as a broken bone that is in communication through the skin with the environment. The amount of communication can vary from a small puncture wound in the skin to a large avulsion of soft tissue that leaves the bone exposed
Open type - Can’t bill Frcature care CPT except fingers & toes(need to use closed type CPT)

27. Disposition Status :
Discharge – can bill Fracture care CPT.
Admit or Transfer – Can’t bill fracture care

28. Follow up Days:
Can bill CPT:
More than 3 days follow up.
Unknown follow up days.
Call for an appointment .
Follow up days within 4 – 5 days

29. Can’t bill CPT :
Within 3 days follow up days
Note : Follow up mentioned with day – need to calculate properly.
Within Week

30. Definitive Care:
Fracture segment should be immobilized by using Splint, Sling, Immobilizers, ortho shoe, buddy tape, strapping(based on anatomical site)
Note : Fracture Nose – Need X ray and any pain meds(Includes OTC) or Ice application.

31. Fracture Rib : Need X ray and pain med (Includes OTC) or sling, Breathing Exercise, Spirometer.
Modifier : 90 days global period – use 57 & 54 modifier
10 days global period – Use 25 modifier( Nasal Fracture & Nursemaid Elbow)

32. Definition of Dislocation :
There is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Dislocations can occur in any joint major (shoulder, knees, etc.) or minor (toes, fingers, etc.). The most common joint dislocation is a shoulder dislocation.

33. Dislocation Need any manipulative technique to bill CPT
Modifier :
90 days global period – use 57 & 54 modifier
10 days global period – Use 25 modifier(Hip Dislocation And Great toe dislocation 28660, nursemaid elbow )

34. SPLINT
Definition of Splint : A splint is a device used for support or immobilization of a limb or the spine.
Types of Splint :
Static
Dynamic

35. SPLINT
Federal
Commercial

36. Federal Payor :
MD should be applied splint.
Commercial Payor :
Anyone can apply splint but we need NV Check otherwise need to doc. Diff for NV check.
Anatomical modifier : Need to give anatomical modifier except 3 series insurance

37. Billable : Splints(Short & long arm splint, Long & short leg splint, finger splints(Eg. Aluminium foam splint),Volar splint, posterior splint, Thumb spica splint.
Non Billable : Air Splint
Foam Splint
Gel Splint
Cock up Splint
Strapping
Immobilizers
Slings
Buddy tapes
Velcro splint
Ace Wrap

38. Endotracheal Intubation:
CPT – Intubation, endotracheal
Intubation,endotracheal,emergency procedure

39. Central Line Placement:

40. CPT For central line placement :
36555 – Insertion of non tunneled centrally inserted central venous catheter; younger than 5 years of age.
Insertion of non tunneled centrally inserted central venous catheter; more than 5 years of age.

41. PERIPHERAL LINE PLACEMENT(PICC)

42. CPT For peripheral line placement :
36568 – Insertion of peripherally inserted central venous catheter(PICC), without subcutaneous port or pump ; younger than 5 years of age.
Insertion of peripherally inserted central venous catheter(PICC), without subcutaneous port or pump ; more than 5 years of age.

43. Venipuncture :

44. ARTERIAL PUNCTURE

45. CPT :
36410 – venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional , for diagnostic or therapeutic purpose.
36600 – Arterial puncture , withdrawal of blood for diagnosis.

46. CARDIOVERSION

47. Cardioversion
Chemical (Non- Billable)
Electrical (Billable)
92960 – Cardioversion, elective, electrical conversion of arrhythmia ; external.

48. CPT- 92950 – Cardiopulmonary resuscitation ( Eg. In cardiac arrest

49. Arthrocentesis , Aspiration , or injection of major joint or bursa :

50. CPT for Arthrocentesis:
20600 – Arthrocentesis, Aspiration and or injection ; small joint(fingers ,toes)
20605 – Intermediate Joint or Bursa (Eg. Temporomandibular , Acromioclavicular , wrist , Elbow, or ankle, olecronon bursa)
20610 – Major joint or bursa( Eg. Shoulder, hip, Knee joint, Subacromial bursa)

51. CHEST TUBE PLACEMENT
A chest tube is flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air(Pneumothorax) or fluid (Pleural effusion,Blood) or pus(Empyema) from the intrathoracic space.

52. CPT for chest tube Placement :
32551 – Tube thoracostomy , includes connection to drainage system( Eg. Water seal) when performed , open procedure.

53. Thoracentesis
Thoracentesis or pleural tap is an invasive procedure to remove fluid or air from the Pleural cavity for diagnostic or therapeutic purpose.
A Cannula or hollow needle carefully introduced in to the thorax after administration of local anesthesia.

55. CPT for Thoracentesis:
32554 – Thoracentesis , needle or catheter, aspiration of the pleural space without imaging guideline
With imaging guideline

56. Lumbar Puncture
Lumbar puncture is diagnostic and therapeutic procedure is used to remove small amount of CSF fluid from the spinal canal.
Insertion of hollow needle beneath the arachnoid membrane of the spinal cord in the lumbar region to withdraw CSF.

57. CPT for Lumbar Puncture :
62270 – Spinal puncture , lumbar , diagnostic.

58. CPT for nail injuries Nail Avulsion :
Avulsion is an injury , nail forcibly detatched from its anatomical position.
11730 – Avulsion of nail plate, Partial or complete, simple; single.
Minor surgical procedure that involves the removal of small strip of the side of the nail.

59. Subungual Hematoma :
11740 – Evacuation of subungual hematoma.
Nail Trephination was performed by using 18 gauge needle that penetrated the nail plate without breaching the nail bed.
11760 – Repair of nail bed.

60. Trigger point injection
Trigger point is also known as trigger sites are described as hyperirritable spots in skeletal muscle that are associated with palpable nodules in muscle fibre.
Trigger point injection is a technique used in the treatment of painful areas of muscle that contain trigger points.

61. 20552 – Injection ; single or multiple trigger point 1 or 2 muscles.
20553 – Single or multiple trigger points, 3 or more muscles.

62. CPT for Epistaxis Epistaxis : Bleed from the nostril, nasal cavity.
Anterior
Posterior
When blood flows out from the front of nose with the patient in sitting position.
Bleed from the nasolacrimal duct,Mainly the blood flows back into the throat. Patient may swallow it and later have a “coffee-coloured” vomitus. This may erroneously be diagnosed as haematemesis.

63. Note : Cauterization & Afrin spray
Anterior Epistaxis
30901 – Control of nasal hemorrhage , anterior, simple(Limited cautery and/or packing) any method.
Note : Cauterization & Afrin spray
Anterior Epistaxis
Chemical
Electrical

64. 30903 – Control of nasal hemorrhage , anterior, complex(Extensive cautery and/or packing) any method.
Note : Rhino Rocket(Sponge like material or gel gauze wrapped ballon)
Cotton ball dipped with chemical & inserted to the nose(30903)

65. 30905 – Control of nasal hemorrhage, posterior, with posterior nasal packs and or cautery, any method initial

66. CPT for hemorrhoid- external
Hemorrhoids
Internal
External
Incision
Excision

67. 46083 – Incision of Thrombosed hemorrhoid, External
Excision of Thrombosed hemorrhoid, External
The excision of a thrombosed hemorrhoid involves the removal of the skin over the blood clot as well as removal of the blood clot itself.

68. CPT for Nerve block Nerve Block :
Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block (sometimes referred to as simply "nerve block") is a short- term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid and other agents onto or near a nerve

69. 64450 – Injection anesthetic agent other peripheral nerve or branch.
Injection anesthetic agent Trigeminal nerve, any division or branch.

70. Catheter Placement Urinary Catheter :
A urinary catheter is a tube placed in the body to drain and collect urine from the bladder.
Types of catheter:
Foley –(Two way , 3 way)
Straight
Coude tip
Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12 (small) FR to 48 (large) FR (3-16mm) in size.

71. 51701 - Insertion of non-indwelling bladder catheter [e. g
Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) Insertion of a temporary indwelling bladder catheter; simple (Foley)

72. Diagnostic studies Echocardiogram
An echocardiogram (also called an echo) is a type of ultrasound test that uses high-pitched sound waves that are sent through a device called a transducer. The device picks up echoes of the sound waves as they bounce off the different parts of your heart.

73. FAST EXAM : Focused Assessment with Sonography in Trauma (FAST)
93308 – Echocardiography, transthoracic real time with image documentation(2D0) with or without M- code recording , follow up or limited study.
76705 – Ultrasound abdominal ,real time with image documentation ; limited(Eg. Single organ ,quadrant , follow up)

74. Ultrasound
Ultrasound is an oscillating sound pressure wave with a frequency greater than the upper limit of the human hearing range.

75. ELECTROCARDIOGARM :
Electrocardiography (ECG or EKG)is the recording of the electrical activity of the heart. Traditionally this is in the form of a transthoracic (across the thorax or chest) interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the surface of the skin and recorded or displayed by a device external to the body.[3] The recording produced by this noninvasive procedure is termed an electrocardiogram (also ECG or EKG). It is possible to record ECGs invasively using an implantable loop recorder.

76. 93010- Electrocardiogram, Routine ECG with atleast 12 lead ; interpretation and report only.
93042 – Rhythm ECG,1-3 leads; interpretation and report only.

77. Radiology :
The branch of medicine that uses ionizing and nonionizing radiation for the diagnosis and treatment of disease
Check points :
Anatomical location
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