1. CHAPTER 9
GENERAL SURGERY I 1

2. Male Genital System Anatomic Subsection
Penis
Testis
Epididymis
Tunica Vaginalis
Scrotum
Vas Deferens
Spermatic Cord
Seminal Vesicles
Prostate
What is the basis for the subheadings for the Male Genital System codes? (Divided into anatomical subheadings)
What is the basis for the division of the category subheadings? (Subheadings are divided by procedure.)
What subheading under the Male Genital System has the greatest number of codes? (The Penis subheading, because a large number of repair codes are included here; the other subheadings are used mainly for incision and excision.)
Figure: 9.1 2

3. Subsection Format Format: Incision
Destruction (method used & if simple or extensive)
Excision
Introduction
Repair
Manipulation
Suture

4. Biopsy Codes Located in subheading to which refer
Example Biopsy codes in subheadings:
Epididymis (Excision)
Testis (Excision)
The codes for biopsy are located under the anatomical subheading to which they refer. 4

5. Penis Incision category differs from Integumentary System codes
Penis Incision codes for deeper structures
Example: erectile tissue
The Incision category under the Penis subheading differs from the codes in the Integumentary System subsection in that the penis incision codes are used for deep incision—not simply for abscess of the skin.
The Incision category codes are 5

6. Destruction (54050-54065) Codes divided on
Extent: Simple or extensive
Method of destruction: e.g., chemical, cryosurgery
Extensive destruction can be by any method
The Destruction subcategory includes codes
Simple destruction is further divided by method of destruction.
The code for extensive lesion destruction can be used regardless of the method employed. 6

7. Excision (54100-54164) Commonly used codes biopsy and circumcision
Appropriate circumcision code is based on method and age of patient
Biopsy, penis
Simple biopsy (separate procedure)
Complex biopsy 54105
The Excision category includes codes for biopsy, excision of plaque (Peyronie disease), removal of foreign bodies, amputations, and circumcision. 7

8. Peyronie Disease Curvature of penis Result of plaque formation
Surgical removal of plaque ( )
Grafting may be necessary to correct defect
Report with 54111, 54112
If harvesting of graft is through a separate incision, see & 20926, as appropriate
There are 2 areas for treatment of Peyronie Disease. In the excision category and introduction category. 8

9. Circumcision Divided based on if device was or was not utilized
Clamp: 54150
No clamp: (neonate), (non-neonate, less than 28 days)
Circumcision descriptors now include a code for circumcision using a clamp or other device performed with a regional dorsal penile or ring block.
The circumcision codes are divided by neonate (28 days or less) and older than 28 days.
The purpose of the clamp that is used for circumcision retrains the foreskin while it is being trimmed.
Excision of the foreskin without clamping is typically sutured after the removal. 9

10. Introduction ( )
Many procedures for corpora cavernosum (spongy body of penis)
Injection procedures for Peyronie disease (toughening of the corpora cavernosum)
Treatments for erectile dysfunction
54240 and have a global, professional (26), and technical component (tc)
Use of the appropriate modifier is important when assigning
If hospital setting, physician uses modifier -26 on procedure code
The Introduction category includes many procedures involving the corpora cavernosum.
Such procedures include injection procedures for Peyronie’s disease and treatments for erectile dysfunction.
Injection of steroids help to decrease the pain, deformity, and fibrous tissue size. 10

11. Repair (54300-54440) Many plastic repairs
Some repairs are staged (more than one stage)—Modifier -58
Stage indicated in code description
Repair of wounds involving skin and subcutaneous tissue of external male genitalia:
See Integumentary Codes
The repair category includes many plastic repairs.
Some repairs involve more than one stage.
Is the stage of repair incorporated into the code description? (Yes) 11

12. Chordee and Hypospadias
Chordee: Ventral curve (downward) of penis
Hypospadias: Congenital abnormality
Urethral meatus (opening) is abnormally placed
Repair codes report repair services for chordee and hypospadias
There are degrees of hypospadias. The degree depends on the location of the opening whether it is anterior, middle, or posterior.
Hypospadias can lead to chordee. 12

13. Testis Excision (54500-54535) Biopsy: Incisional or percutaneous
Biopsy, excision, orchiectomy
Biopsy: Incisional or percutaneous
Orchiectomy codes reported by:
Simple or radical
Unilateral or bilateral
With or without testicular prosthesis insertion
Approach used
(Cont’d…)
What does orchiectomy mean? (Removal of the testis)
If the procedure is done bilaterally, modifier -50 would be used, unless the code is specified as bilateral. 13

14. Testis Exploration (54550, 54560) Undescended testis (crytorchidism)
(…Cont’d)
Exploration (54550, 54560)
Undescended testis (crytorchidism)
Congenital
Testis or testes did not descend into scrotal sac
Unilateral or bilateral
Often associated with hernia
Repair ( )
Orchiopexy: Moving and fixation of testis to scrotal sac
Abdominal approach: 54650
Laparoscopic: 54692
Code selection based on approach (inguinal, scrotal, or abdominal)
Check CCI edits for bundled procedures
Many times the undescended testis is associated with a hernia.
Use modifier -50 to indicate bilateral procedure. 14

15. Epididymis Narrow, coiled tube Connects efferent ducts to vas deferens
I&D abscess or hematoma: 54700
Excision category ( )
Biopsy
Lesion or spermatocele (cyst)
Repair Category (54900, 54901)
Vasectomy reversal (epididymovasostomy)
Report operating microscope separately (69990)
Only 4 categories are in the Epididymis subheading; Incision, Excision, Exploration, and Repair.
Code is for an abscess or hematoma of the testis, scrotal space or epididymis.
What is a spermatocele? (Cyst that contains sperm) 15

16. Tunica Vaginalis (55000-55060) Serous sheath of testis
Site of hydrocele (fluid collection) (unilateral or bilateral)
Treatment options, such as aspirate, inject, excise, repair
Repair: Bottle type repair (55060)
Drain
Reposition
Catheter left in place
Like Epididymis subheading the tunica vaginalis contains only 3 categories, Incision, Excision, and Repair.
All are for treatments of hydrocele. 16

17. Scrotum (55100-55180) Sac that contains testes
Site of lesion, abscess, hematoma
I&D
Scrotoplasty (oscheoplasty)
Traumatic defect
Congenital abnormality
May require grafting
Simple skin flaps included scrotoplasty
More complex grafts/flaps reported separately
Scrotum is the sac that contains the testes.
If an incision is performed on a lesion of the skin, refer to the Integumentary System.
Skin flaps may need to be used to repair the defect after a scrotoplasty. If a simple skin flap is performed this is included in the procedure. More complex grafts are reported separately. 17

18. Vas Deferens ( )
Tube that conducts sperm from testes to urethra
Incision: Vasotomy to collect sperm sample or identify obstruction
Excision: Vasectomy for sterilization procedure is described as either unilateral or bilateral
Do not use modifier -50
Introduction: Dye for radiographic procedure
Repair: Remove obstruction, anastomose ends, semen sampling included
Operating microscope: 69990
In which category would you find vasectomy codes? (Excision)
A postoperative semen examination is included with code 18

19. Spermatic Cord (55500-55559) Hydrocele: 55500 with -50 bilateral
Variocele: Trapped blood causes vessels to swell, for excision:
Scrotal approach: 55530
Abdominal approach: 55535
Laparoscopy: 55550
Excision of varicocele and hernia repair: 55540
Watch: “separate procedure” designation. These only billed if only service performed or if procedure totally unrelated to another procedure performed during the same session
The spermatic cord is a collection of structures that suspend the testes in the scrotum.
The procedures in this subheading are either performed excisionally or laparoscopically. 19

20. Seminal Vesicles (55600-55680) Pair of bands, posterior to bladder
Provide majority of semen fluid
Incision: Vesiculotomy
Simple 55600, complicated 55605
Excision: Vesiculectomy
For removal of tumor, calculus, or other obstruction
55650, any approach
Add -50 for bilateral
What is a vesiculotomy? (A surgical cutting into the seminal vesicles)
Why is this performed? (To relieve pressure due to inflammation) 20

21. Prostate ( )
BPH, Benign Prostatic Hyperplasia
Enlargement of the prostate
Treatment options:
Urethral stent (52282) keeps urethra open at level of prostate
TUMT (53850) microwave heat
TUNA (53852) radiofrequency
Each code description lists approach and bundled procedures, if appropriate
What are some of the symptoms of BPH? (Urinary frequency, urgency, nocturia, decreases in force of urine stream and feeling bladder not fully emptied)
Symptoms of BPH are caused by excess prostate tissue pressing against the urethra and bladder. 21

22. BPH or Neoplasm Surgical Options
TURP (52601, 52630) gold-standard
Through urethra, electrical loop removes obstruction
TUIP (52450)
Incisions relieve pressure, no tissue removed
What does TURP stand for? (Transurethral resection of the prostate)
What does TUIP stand for? (Transurethral incision of the prostate) 22

23. Prostatectomy Two types of codes:
Coagulation (52647)
Vaporization (52648)
Vaporization may be with or without resection
(Cont’d…)
Use of a laser to accomplish the prostatectomy is either considered coagulation or vaporization. 23

24. Prostatectomy Coagulation, laser (52647) Contact or Non-contact
(…Cont’d)
Coagulation, laser (52647)
Contact or Non-contact
Contact: Laser comes in contact with prostate tissue
Non-Contact: Laser does not come in contact with prostate tissue
TULIP (non-contact) no direct view by surgeon
VLAP (non-contact) direct view by surgeon
ILCP (contact) no direct view by surgeon
(Cont’d…)
Coagulation causes the tissue to die and slough off.
During TULIP there is no direct visualization of the prostate and the penetration isn’t as deep as other methods.
VLAP is done under direct visualization of the surgeon. 24

25. Prostatectomy Laser vaporization (52648)
(…Cont’d)
Laser vaporization (52648)
TUVP or TVP (contact) electrical current vaporizes tissue by means of a ball that is rolled over tissue
Laser vaporization with/without resection (52648)
HoLEP or THLR (contact) laser resects tissue with holmium laser fiber
(Cont’d…)
Vaporization is done through electrical currents.
Use of the HoLEP procedure causes less intraoperative bleeding than with a TURP. 25

26. Prostatectomy 55801-55845 open surgical procedures
(…Cont’d)
open surgical procedures
First based on approach
Perineal: Space between rectum and scrotum
Suprapubic: Above the pubic bone
Retropubic: Posterior to the pubic bone
Second based on extent
Subtotal or radical
(Cont’d…)
What does prostatectomy mean? (Removal of the prostate)
Subtotal removal means anything less than total.
Radical removal means total removal of the prostate. 26

27. Prostatectomy LRP (55866) Laparoscopic = minimally invasive
(…Cont’d)
LRP (55866)
Laparoscopic = minimally invasive
RAP (no CPT code)
Use with with -22
A substitute for an open prostatectomy may be a LRP (Laparoscopic Retropubic Prostatectomy)
RAP (Robotic Assisted Prostatectomy) is new and is used at times with LRP. It assists in the performance of some surgical tasks. 27

28. Incision (55700-55725) Prostate Biopsy
Needle or punch, 55700
Needle, transperineal, stereotactic, 55706
Incisional, 55705
When fine needle biopsy/aspiration performed refer to & 10022
Prostatotomy (55720 simple, complicated)
Drain abscess
Either via perineum or through rectum
Complicated = documented complexity, such as excess bleeding
Do not report a needle or punch biopsy with an incisional biopsy during the same operative session.
Do not confuse a biopsy with an FNA (Fine Needle Aspiration). A biopsy is an examination of tissue and an FNA is when fluid is drawn for analysis. 28

29. Brachytherapy for prostate cancer
Methods
High dose, temporary method
Low dose, permanent implants (seeds)
Placement
Transperineal (55875)
Open exposure (55862)
Radioelements reported with _____-77778
Brachytherapy for prostate cancer
This is typically performed in conjunction with a Urologist and a Radiation Oncologist.
What is the difference between the high dose and low dose methods? (High dose is temporary and performed by placement of small catheters into the prostate and radiation treatment is delivered internally. Low dose is when permanent seeds are placed through a needle into the area between the scrotum and anus.)
From Wein AJ, editor: Campbell-Walsh Urology, ed 9, Philadelphia, 2007, Saunders
77776 29

30. Reproductive System Procedure (55920)
Reports placement of catheters/needles into pelvic organs/genitalia for subsequent interstitial radioelement application
What is the time required to complete intersex surgery? (Extended period of time) 30

31. Intersex Surgery (55970, 55980) There only 2 codes within subsection
Male to female
Female to male
Complicated procedures completed over extended period of time
Performed by multiple physicians with extensive specialized training
How many codes are contained in the Intersex Surgery subsection? (Two codes) 31

32. Urinary System Anatomic divisions
Kidney
Ureter
Bladder
Urethra
Procedures on prostate in either Urinary or Male Genital System
(Cont’d…)
Procedures involving the urinary system are reported using codes
What are the four subheadings for the urinary system codes? (The codes are arranged anatomically by four subheadings: kidney, ureter, bladder, and urethra.) 32

33. Urinary System Further divided by procedure Incision Excision
(…Cont’d)
Further divided by procedure
Incision
Excision
On what basis are the category codes organized? (Arranged by procedure—incision, excision, introduction, and repair.) 33

34. Kidney (50010-50592) Endoscopy codes for procedures done through
Previously established stoma
Incision
Most cystoscopy procedures have zero global days
A cystoscopy is a visual examination of urinary bladder by means of cystoscope
The Kidney subheading includes codes
Endoscopy codes are assigned according to approach—either a previously established stoma is used as an entry point (which is created by placing a catheter through the skin and into the kidney), or an incision is used.
When coding endoscopy procedures, the coder must identify the entry method in order to assign the right code. 34

35. Incision (50010-50135) Caution: Renal exploration Renal abscess
Kidney located in retroperitoneal area
Each has codes for procedures
Renal exploration
Kidney diagnostic procedure (50010), no further procedures performed
Retroperitoneal area diagnostic procedure (49010)
Renal abscess
Kidney abscess (50020)
If radiological supervision & interpretation were performed see 75989
Retroperitoneal abscess (49060)
What is the reason for renal exploration? (When the cause of the patient’s condition is unknown)
If something is found on the exploratory procedure and a corrective procedure ensues, do not bill for the exploratory procedure.
Exploratory = Diagnostic. 35

36. Procedures
Nephrostomy (50040): Insertion of catheter into kidney with one end in kidney and one end outside body
Nephrotomy (50045): Exploration of inside of kidney
No definitive procedure
Verify all CCI code edits to prevent unbundling
Nephrolithotomy ( ): Removal of calculus
(Cont’d…)
It is important to know the difference in these terms and understand that the surgeon may start out performing a nephrotomy to explore the kidney and find a reason for the patient’s urinary obstruction and the procedure than becomes a nephrolithotomy when a calculus is found. 36

37. Procedures ESWL: Use of shock waves to fragment calculus
(…Cont’d)
ESWL: Use of shock waves to fragment calculus
Percutaneous lithotripsy: Insertion of probe to pulverize calculus
Basket attached to probe and pulverized calculus removed
Percutaneous nephrostolithotomy (PCNL) or pyelostolithomy
Removal of kidney calculus
How is ESWL performed? (The patient is placed on a water-filled cushion on his or her back and while the patient is under general anesthesia shock waves are targeted to the stones, which are pulverized with repeated shocks.
What is the benefit of this? (It breaks up large stones and makes them easier to pass.) 37

38. Excision ( )
Nephrectomy: Partial or total (radical) excision of kidney ( )
Radical: Removal of fascia, fatty tissue, regional lymph node, adrenal gland
Nephrectomy medical record documentation should indicate if procedure was partial or total, laparoscopic, or open, and if any structures were removed
Code describes a complicated nephrectomy because of previous surgery on same kidney
Ablation
Cryosurgery, 50250
Laparoscope, 50542
Percutaneous, 50593
What is a nephrectomy? (Removal of a kidney)
Nephrectomy codes are based on the complexity and extent of the procedure.
What does ablation mean? (The cutting away or erosion of tissue) 38

39. Renal Transplant (50300-50880) Backbench work Retrieval of organ
Deceased (50300)
Living (50320, open; 50547, laparoscopy)
Preparation of organ
Deceased (50323)
Living (50325)
Transplantation
Without nephrectomy, 50360
With nephrectomy, 50365
Add -50 for bilateral procedure
Allotransplantation is a transplant between two people who are not related.
Autotransplantation is a transfer of tissue from one part of a person’s body to another part of their body. 39

40. Introduction (50382-50398) Aspirations
Catheters and injections for radiography
Insertion of guide wires
Tube changes
Usually reported with radiology component
What additional component is usually reported with procedures in the Introduction category? (These are usually reported with a Radiology component.)
These category codes include extensive notes, which should be read by coders before they code in this area. 40

41. Repair (50400-50540) Pyeloplasty Closure of fistula (abnormal opening)
Repair of ureteropelvic junction (UPJ)
Simple 50400
Complicated 50405
Closure of fistula (abnormal opening)
What does the UPJ connect? (It connects the renal pelvis to the ureter.)
Usually congenital defect but it can be acquired.
Closure of a fistula depends on the approach. It will either be abdominal or thoracic. 41

42. Laparoscopy (50541-50549) Ablation of renal Cyst (50541)
Lesion (50542)
Cryoablation (50250)
Percutaneous (0135T)
What are the codes in this category based on? (The extent of the procedure) 42

43. Endoscopy (50551-50580) Renal endoscopy codes divided by
Established connection between kidney and body exterior ( )
Nephrotomy or pyelotomy ( )
Further divided based on purpose
Biopsy
Removal of foreign body/calculus
Renal Endoscopic procedures are less invasive than open procedures and often can be performed on an outpatient basis. 43

44. Ureter Divided based on type of procedure
Incision
Excision
Laparoscopy codes describe surgical procedures
Codes may be bilateral or unilateral
The Ureter subheading includes codes
On what basis are the Ureter subheading codes divided? (Codes are divided according to type of procedure—incision, excision, introduction, repair, laparoscopy, or endoscopy.)
The endoscopy codes in this subheading ( ) are used to report procedures that involve an established stoma. 44

45. Incision (50600-50630) Report open procedures Explore or drain (50600)
Insert indwelling stent (50605)
Remove calculus ( )
Based on location of upper third, middle third, or lower third
What is the medical term for the removal of a calculus from the ureter? (Ureterolithotomy)
Laparoscopic approach billed with
Open approach billed with 45

46. Excision and Introduction (50650-50690)
Ureterectomy (50650, 50660)
Bladder cuff excision or total excision
Introduction
Reports injections, manometric (measures pressure) studies, change of stents/tubes
Bladder cuff is the tissue that connects the ureter to the bladder.
Excision of the bladder cuff is only coded if it is the only procedure performed. If it is performed in conjunction with another procedure it is bundled in and not separately reportable.
Manometric studies are tests to measure kidney and ureter flow and pressure. 46

47. Laparoscopy and Endoscopy (50945-50980)
Laparoscopic placement of urethral stent (50947, 50948)
Endoscopy codes ( ) for procedure through established stoma
Why is a urethral stent placed? (Because of a UVJ obstruction)
The Endoscopy Category can be intimidating due to the medical terminology used in this category.
Great knowledge of medical terminology will increase your coding accuracy. 47

48. Bladder Many bundled codes
Example: Urethral dilation is included with insertion of cystoscope
Read all descriptions carefully for site, technique and reason for procedure
The Bladder subheading ( ) includes many usual services, for example, incision and excision, but it also contains urodynamic category.
When coding from this subheading, it will help to know the anatomy of the bladder. 48

49. Incision and Excision Incision (51020-51080) Excision (51500-51597)
Suprapubic catheter placement, 51102
Cystotomy ( ) for lesion destruction, insertion of radioactive material, fulguration (use of electrical current)
Excision ( )
Cystotomies & cystectomies ( )
Codes divided based on extent of procedure
Aspirations are done to remove urine from the bladder.
If imaging guidance is used, this is separately reportable.
A urachal cyst is found between the umbilicus and bladder dome, and is often found in young children when the cyst becomes infected. 49

50. Introduction ( )
Injection procedures ( ) for urethrocystography
Radiographic S&I reported separately
Instillation of anticarcinogenic agent via a catheter for bladder cancer
Retention time included
The catheterization can be simple (Foley) or complicated (Anatomical anomaly or catheter fracture)
The carcinogenic agent that is instilled in the bladder is retained for a period of time with the patient lying down. The agent is then drained and the treatment is concluded. 50

51. Urodynamics ( )
Procedures relate to motion and flow of urine (motor & sensory function)
Used to diagnose urine flow obstructions
Bundled: All usual, necessary instruments, equipment, supplies, and technical assistance
Always code urodynamic code in addition to all other cysto codes if both are performed
Modifier -51 is reported for multiple procedures
What is urodynamics? (Motion and flow of urine)
What are some possible causes of urine flow obstruction? (Renal calculus, narrowing of the ureter, cysts, etc.)
If the physician performs only the professional component of the service (e.g., interpretation), then the modifier -26 is added to the code. 51

52. Repair and Laparoscopy
Cystoplasty
Cystourethroplasty
Vesicourethropexy/uretropexy (urinary incontinence)
Laparoscopy ( )
Stress incontinence procedures
Define: Cystoplasty—Repair of the bladder.
Cystourethroplasty—Repair of the bladder and the urethra.
Urethropexy—Repair for urinary incontinence. 52

53. Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy
Many combination codes
Notes before indicate that included are:
Meatotomy
Urethral calibration
Urethral dilation
Urethroscopy
Cystoscopy
Ureteral catheterization, etc.
Take special care in this category to read codes carefully. All of the procedures included are found in the description.
Many third-party payers have a list of edits on codes that cannot be reported with other codes. 53

54. Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy
52000 is assigned for IVP, if appropriate
52005 is assigned for retrograde pyelogram
When coding cystourethroscopies with dilation ask following questions:
Is patient male or female?
Is this an initial or subsequent procedure?
Was general or spinal anesthesia used?

55. Transurethral Surgery (52204-52355)
Urethra/bladder,
TURBT ( )
Excision or fulguration of bladder tumor
Ureter/pelvis,
Includes insertion and removal of temporary stents
Divided by codes for urethra/bladder and ureter/pelvis.
As in other areas if a procedure starts as a diagnostic procedure and turns into a surgical procedure the diagnostic procedure is not billed. 55

56. Vesical Neck and Prostate (52400-52700)
Contains codes for transurethral resection of the prostate (TURP)
Example: complete transurethral electrosurgical resection of the prostate
Other approaches are reported with
Example: reports a removal of the prostate gland (prostatectomy) through an incision in the perineum
Codes in this category are based on approach.
Watch the wording, whether it is a resection or an incision. 56

57. Urethra Excision (53200-53275) Repair (53400-53520)
53210 female
53215 male
Repair ( )
Urethroplasty may be one or two stage
Some codes divided based on male/female
Manipulation ( )
Stretches of narrowed passage
Many codes are divided based on whether the patient is male or female.
The dilation codes under the Manipulation category are based on whether it’s initial or subsequent and if the patient is male or female. 57

58. Digestive System
Divided by anatomic site from mouth to abdomen, peritoneum, and omentum + organs that aid digestive process
Many bundled procedures
Surgical procedures for open & endoscopic approaches:
Mouth & related structures
Pharynx
Adenoids
Tonsils
Esophagus
Stomach
Intestines
Appendix
Rectum and anus
Liver
Biliary tract
Pancreas
The Digestive System subsection includes codes
On what basis are the digestive system codes divided? (According to anatomical site beginning with the lips and ending with the abdomen, peritoneum, and omentum)
What are some of the organs that aid the digestive process and are included in this subsection? (Organs such as the pancreas, liver, and gallbladder)
What else is included in this subsection? (Abdomen, peritoneum, omentum, and hernias) 58

59. Lips (40490-40799) Vermilionectomy (40500) is shaving of lip
Vermilion border: Area between lip and mucosal surface of mouth
Large defects ( )
Repaired with procedures such as transverse wedge excision (40510)
Chelioplasty is lip repair
Full thickness repair ( )
Cleft lip repair ( )
This is the first subheading of the Digestive Subsection.
Name a reason why a vermilionectomy with repair would need to be performed. (A patient with cancer of the lip)
What is a cleft lip? (A congenital defect when the muscle and tissue of the lip didn’t close properly) 59

60. Tongue and Floor of Mouth (41000-41599)
Incision and drainage codes based on:
Sublingual (under tongue)
Submandibular (under mandible)
Masticator space (floor of mouth to hyoid bone)
Extraoral (outside mouth) I&D of abscess, cyst, hematoma on floor of mouth
Incision and drainages are based on the location of the abscess, cyst or hematoma.
What other categories fall under the Tongue and Floor of Mouth Subheading? (Excision, repair, and other procedures) 60

61. Dentoalveolar Structures and Palate/Uvula
Bone (osseous) and soft structures of mouth
Anchors teeth
Palate/Uvula ( )
Palate (roof of mouth)
Uvula (pendulous structure at back of throat)
Dentoalveolar procedures consist of drainage of abscesses or cysts and excisions of lesions.
Palate/Uvula Subheading contains codes for incisions, excisions, and repairs.
Grafts are reported separately. 61

62. Salivary Gland and Ducts (42300-42699)
Three salivary glands
Parotid
Submandibular
Sublingual
Codes divided initially by gland
Codes are divided based on the gland the procedure is performed on or the number of glands involved.
Imaging guidance is reported separately. 62

63. Pharynx, Adenoids, and Tonsils (42700-42999)
Incision codes initially divided on approach
Intraoral
External
Tonsillectomy and adenoidectomy
Based on gland removed and age of patient
Which category are the biopsies found in? (Excision, Destruction)
Incision category is for peritonsillar abscesses. 63

64. Esophagus (43020-43499) Approaches—Incision, Excision
Cervical
Thoracic
Abdominal
Endoscopy
Code esophageal dilation
Know the device or method used
How each device works
Whether dilation was endoscopic or non-endoscopic
Diagnostic endoscopy always included in surgical endoscopy
The key for billing removal of foreign bodies of the esophagus is the approach.
What approach does code use? (Cervical) 64

65. Esophagoscopy (43200-43228) Limited to esophagus only
Scope may be advanced into stomach but is short of pylorus
If scope transverses pyloric channel, becomes an EGD ( )
If scope passes beyond second portion of duodenum, becomes an ERCP procedure ( )

66. Stomach (43500-43999) Gastric bypass performed for morbid obesity
Many different types, such as RNY
May be performed via a laparoscope
Bariatric surgery ( )
Gastric restrictive device (such as band)
Some procedures are performed open, when the stomach is in full view to the physician, and others are done laparoscopically. Be certain to identify the approach used.
The gastric banding is adjustable because the band is a hollow tube that can be inflated and deflated with the administration of fluid. 66

67. Intestines (Except Rectum) (44005-44799)
Separate procedures common
Colostomies always bundled with major procedure
Unless code states otherwise
Small intestine extends for 20 feet from pyloric sphincter to first part of large intestine
Large intestine extends from end of ilium to anus, 4 parts (cecum, colon, sigmoid colon, and rectum)
Be sure to watch for the codes listed as separate procedures 67

68. Endoscopy, Small Intestine and Stomal (44360-44397)
Diagnostic bundled into surgical endoscopic
Code to furthest extent of procedure
Endoscopic codes can be found throughout the Digestive System subsection by anatomical site.
Is diagnostic endoscopy coded separately when surgical endoscopy is performed? (No, surgical endoscopy always includes diagnostic endoscopy.)
Once anatomic site has been determined, what other factor guides code selection? (The surgical procedure) 68

69. Endoscopy Terminology
Notes define specific terminology
Code descriptions are specific regarding:
Technique and depth of scope
Esophagoscopy: Esophagus only
Esophagogastroscopy: Esophagus to past diaphragm
Esophagogastroduodenoscopy: Esophagus to beyond pyloric channel
Read notes preceding
(Cont’d…)
The notes define the specific terminology that should be used.
In particular, read the notes preceding codes 69

70. Endoscopy Terminology
(…Cont’d)
Sigmoidoscopy: Entire rectum, sigmoid colon, and may include part of the descending colon
Proctosigmoidoscopy: Rectum and sigmoid colon
Colonoscopy: Entire colon, rectum to cecum, and may include terminal ileum
Understanding the terminology is crucial to coding the procedure appropriately.
What is the route through which the endoscope is inserted during a sigmoidoscopy? (The endoscope is passed through the entire rectum, sigmoid colon, and possibly part of the descending colon.)
Which parts of the anatomy are involved in a colonoscopy? (The entire colon, rectum to cecum, with possible inclusion of the terminal ileum) 70

71. Colon Procedures & Screening
For colonoscopy procedures determine how it was performed:
Through a colostomy
Through a colotomy
Through the rectum
For Colorectal Cancer Screening see HCPCS Level II codes:
G0107
G0104
G0105
G0106
G0120
G0122

72. Laparoscopy and Endoscopy
Some subheadings have both laparoscopy (from outside) and endoscopy (from inside) procedures
Example: Subheading Esophagus
Endoscopy views inside
Laparoscopy inserted through umbilicus, views from outside
Laparoscopic bariatric surgery codes ( )
Use of gastric band and/or subcutaneous port components
Some headings include both laparoscopy (outside) and endoscopy (inside) procedures. 72

73. Abdomen, Peritoneum, and Omentum Subheading (49000-49999)
Laparoscopy
Diagnostic (49320)
Surgical ( )
Repair category contains hernia repair codes
The Abdomen, Peritoneum, and Omentum subheading includes a repair category that contains hernia repair codes. 73

74. Hemorrhoidectomy and Fistulectomy Codes (46221-46320)
Divided by
Complexity
Simple: no plastic procedure involved
Complex: includes plastic procedure and fissurectomy
Anatomy
Subcutaneous: no muscle involvement
Submuscular: splinter muscle
Complex fistulectomy involves excision/incision of multiple fistulas
What is a hemorrhoid? (It is inflammation of the area around the anus)
Hemorrhoids may occur inside or outside of the body.
There are different degrees of severity.
Who should determine the degree of severity? (Physician) 74

75. Hernia Codes Divided on
Type
Example: inguinal, femoral
Initial or subsequent repair
Age of patient
Clinical presentation:
Strangulated: Blood supply cut off
Incarcerated: Cannot be returned to cavity (not reducible)
Implantation of mesh or prosthesis is reported separately
Hernia repairs using an abdominal approach are reported with the use of codes
Hernia repairs performed through laparoscopy are reported by means of codes
Name some areas that hernias may occur. (inguinal, umbilical, incisional, epigastric, lumbar) 75

76. Mediastinum Area between lungs Figure: 9.23
What is the mediastinum? (The area between the lungs)
Where does the Mediastinum and Diaphragm subsection fall in the CPT book? (Directly after the cardiology subsection)
Figure: 9.23 76

77. Mediastinum (39000-39499) Assigned by approach
Incision codes for foreign body removal or biopsy
Excision codes for removal of cyst or tumor
Endoscopy with or without biopsy (39400)
The Mediastinum subheading is divided by procedures and includes incision, excision, and endoscopy categories.
Procedures are reported with use of the codes
Codes are based on the surgical approach taken to perform the mediastinotomy—either cervical (neck area) or across the thoracic area or sternum.
What primary distinction is made in the excision codes that are listed under the Mediastinum subheading? (The excision codes vary according to whether a tumor or a cyst was excised.) 77

78. Diaphragm (39501-39561) Only category: Repair
Most codes for hernia or laceration repairs
Where is the diaphragm located? (The diaphragm is the wall of muscle that separates the thoracic and abdominal cavities.)
Only 1 category under Diaphragm subheading, repair.
Repairs consist of Lacerations and hernias.
How are the hernias of the diaphragm divided out? (Type of hernia, age of patient (neonate or other than neonate), and approach (transthoracic, or combined thoracoabdominal)) 78

79. Conclusion CHAPTER 9
GENERAL SURGERY I 79