Tag Archives: CPT Guidelines

How To Code – Wound Repair or Closure

Wound Repair or closure

Wound Types –

  1. Abrasion – skin scrapped off
  2. Laceration – ragged skin tear , crushed tissue
  3. Amputation – surgical removal of limb
  4. Incision – cut, wound from a sharp object
  5. Puncture – by penetrating or nailing object , by bullets
  6. Avulsion – tearing away of tissues from a body part

3 Factors to be considered while coding wound closure

  1. Length – length of wound (in cm)
  2. Complexity – complexity of repair
  3. Site – site of wound repair

Wound repair classification as per CPT manual

  • Simple Repair (12001 – 12021) –

    • Superficial wound repair or one layer closure.
    • Involves epidermis, dermis and subcutaneous tissue.
    • Require one layer suturing for closure
  • Intermediate Repair (12031- 12057)

    • One or more layers of subcutaneous tissue and superficial (non – muscle) fascia in addition of epidermis and dermis.
    • Simple closure of heavily contaminated wounds which requires extensive cleaning or removal of particulate matter also coded as intermediate closure
  • Complex Repair (13100 – 13160)

    • Involves complicated wound closure including revision, debridement, extensive undermining, stents or retention sutures.

 

Classification Site of Wound Length of Wound CPT Code
       
Simple repairs Scalp, neck, axillae, external genitalia, trunk, extremities including hands and feet 2.5 cm or less 12001
2.6 to 7.5 cm 12002
7.6 to 12.5 cm 12004
12.6 to 20.0 cm 12005
20.1 to 30.0 cm 12006
Over 30.0 cm 12007
Face, ears, eyelids, nose, lips, mucous membranes 2.5 cm or less 12011
2.6 to 5.0 cm 12013
5.1 to 7.5 cm 12014
7.6 to 12.5 cm 12015
12.6 to 20.0 cm 12016
20.1 to 30.0 cm 12017
Over 30.0 cm 12018
       
Intermediate Repair Scalp, axillae, trunk, extremities excluding hands and feet 2.5 cm or less 12031
  2.6 to 7.5 cm 12032
  7.6 to 12.5 cm 12034
  12.6 to 20.0 cm 12035
  20.1 to 30.0 cm 12036
  Over 30.0 cm 12037
Necks, hands, feet, external genitalia 2.5 cm or less 12041
  2.6 to 7.5 cm 12042
  7.6 to 12.5 cm 12044
  12.6 to 20.0 cm 12045
  20.1 to 30.0 cm 12046
  Over 30.0 cm 12047
Face, ears, eyelids, nose, lips and mucous membrane 2.5 cm or less 12051
  2.6 to 5.0 cm 12052
  5.1 to 7.5 cm 12053
  7.6 to 12.5 cm 12054
  12.6 to 20.0 cm 12055
  20.1 to 30.0 cm 12056
  Over 30.0 cm 12057
       
Complex Repair Trunk 1.1 to 2.5 cm 13100
  2.6 to 7.5 cm 13101
  Each additional 5 cm or less +13102
Scalp, arms, legs 1.1 to 2.5 cm 13120
  2.6 to 7.5 cm 13121
  Each additional 5 cm or less +13122
Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, feet 1.1 to 2.5 cm 13131
  2.6 to 7.5 cm 13132
  Each additional 5 cm or less +13133
Eyelids, nose, ears, and lips 1.1 to 2.5 cm 13151
  2.6 to 7.5 cm 13152
  Each additional 5 cm or less +13153
       

 

Coding Rules: For multiple wounds

  • When more than one classification of wound repair are given (more than one repair type), code more complicated as primary and less complicated as secondary with modifier -59 (distinct procedural service).

 

Hierarchy is

 

  • Same classification –
    1. Wounds from Same group of anatomic sites – Combine the length of all wounds
    2. Wounds from different group of anatomic sites – Don’t combine, coded separately (greater length wound will be coded as primary)
  • For each anatomic site, the lengths of wounds are totaled together by complexity (simple, intermediate, complex ). For Example All the simple wounds of the same site grouping are reported together; all the intermediate wounds of the same site grouping are reported together; and all the complex wounds of the same site grouping are reported together.
  • Three things are considered components (parts) of integumentary wound repair:
    1. Simple ligation (tying) of small vessels is considered part of the wound repair and is not reported separately. Simple ligation of medium or major arteries in a wound is, however, reported separately.
    2. Simple exploration of surrounding tissue, nerves, vessels, and tendons is considered part of the wound repair process and is not listed separately.
    3. Normal debridement (cleaning and removing skin or tissue from the wound until normal, healthy tissue is exposed) is not listed separately.

How to Code – Excision of Lesions

Excision of Lesions

Excision is defined as a full thickness (through the dermis) excision of a lesion.

Treatment types for lesions:

  1. Paring – Peeling or scrapping
  2. Shaving – Slicing
  3. Excision – Cutting and removal
  4. Destruction (Ablation) – Laser, Electrocautery, freezing, burning , chemicals
Check while coding Excision –
  1. Site of lesion
  2. of lesions
  3. Size of excised lesions
  4. Type of lesion – Benign or malignant

Prior to excision, the greatest diameter of the lesion is measured. The measurement includes the margin (extra tissue taken from around the lesion) at its narrowest part.

Closure of lesions –

  1. Simple closure – Non layered closure
  2. Intermediate closure – Layered
  3. Complex closure – greater than layered

Simple closure is always included with excision code and not coded separately while intermediate and complex closure can be reported additionally.

The shaving of lesions requires no closure because no incision has been made.

Pairing or cutting – 11055 – 11057

For benign hyperkeratotic skin lesion such as a callus or corn. It includes removal by peeling and scraping.

Biopsy  –  11100 – 11101

Procedure of removing tissue for histopathology (study of microscopic tissue changes)

2 types – Incisional biopsy – (open, sharp, and partial removal ) – its not excision , CPT lesion biopsy codes, only a portion of the lesion and some of the surrounding tissue is removed.

Excisional biopsy – ( complete removal)  –  its biopsy with excision , code only excision here.

Do not code biopsy and excision separately as biopsy is always included in excision code.

Skin Tags – 11200 – 11201

Skin tags are flaps of skin (benign lesions) that can appear anywhere, but most often appear on the neck or trunk, especially in older people . Skin tags are removed in a variety of ways—scissors, blades, ligatures, electrosurgery, or chemicals.

Shaving  – 11300-11313

Performed by using a scalpel blade or other sharp instrument

EXCISION  :

Categorised on the basis of lesion type – whether benign or malignant. Codes are categorised as – site of excision and size of lesion ( ie excision diameter )

Site of Excision

Benign lesion – 11400-11471

  1. Trunk, arms, legs – 11400-11406
  2. Scalp, neck, hands feet, genitalia – 11420-11426
  3. Face, ears, eyelids, nose, lips, mucous membrane – 11440-11446

Malignant lesion – 11600 – 11646

  1. Trunk, arms, legs – 11600-11606
  2. Scalp, neck, hands, feet, genitalia – 11620-11626
  3. Face, ears, eyelids (skin only), nose, lips – 11640-11646
Size of Lesion ( ie excision diameter )

As per CPT®, “Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision.”

excised diameter equals the length of the lesion at its longest point, plus two times the narrowest margin. For example, if the lesion measures 1 cm at its greatest, and the surgeon removes a margin of 0.5 cm on all sides, the total excised diameter is 2.0 cm (1.0 cm + [2 x 0.5 cm]).

Coding Rules –

  1. First identify a lesion as either benign or malignant, as per pathology results before assigning a code (unless the diagnosis is confirmed in a previous biopsy of the lesion).
  2. When the surgeon removes multiple lesions, treat each as a separate procedure. Append modifier 59 Distinct procedural service to the second and subsequent codes for excisions in the same general location.
  3. If multiple lesions are treated, code the most complex lesion procedure first followed by the others using modifier -51If the code description includes multiple lesions (a stated number of lesions), modifier -51 is not necessary. For example, if the code states “2 to 4 lesions” or “more than 4 lesions,” modifier -51 is not required.
  4. Do not report Local anesthesia and simple closures (12001-12018) in addition to lesion excision.
  5. Intermediate (12031-12057) and complex (13100-13153) repairs and Reconstructive closure (15002-15261, 15570-15770) must be coded additionaly with excision.
  6. Do not report lesion excision in addition to Adjacent tissue transfer (14000-14350).

 

 

How To Code – Incision and Drainage

INCISION – a cut with a sharp surgical instrument.

Acne surgery, abscess, carbuncle, boil, cyst,  hematoma , and wound infection are just some of the conditions for which a physician uses I&D. Check this link to understand what is I & D 

CPT – 10040 – 10180 – Codes are classified according to condition for which I & D is performed.

Method of Drainage – Either Incision or Aspiration (Puncture Aspiration).  It may be left open allowing the continuation of drainage loculations may be broken up using a surgical clamp, and/or the wound may be packed with gauze.

Puncture Aspiration – 10160 – By inserting a needle into a lesion and withdrawing the fluid (aspiration).

Tip: First Verify the body area or location and depth (Superficial or Deep) to check any more specific CPT.

The provider needs to document if the abscess is superficial or deep

For Example – If an I&D is performed deeper than the superficial skin, refer to the codes in the system where the abscess is located. For example, an incision and drainage of a deep abscess on the thigh refer to CPT® code 27301 or incision and drainage of a vulva abscess refer to CPT® code 56405.

These codes are further classified as – Simple/Single (eg. Abscess 10060) OR Complicated/Multiple (eg. Abscess 10061)

complicated I&D would contain:

  • Multiple incisions
  • Drain placements
  • Probing to break up loculations
  • Extensive packing or
  • Subsequent wound closure

CPT – SURGERY GUIDELINES (20000-29999)

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

  • Code 21076-21089 should only be used when the physician actually designs and prepares the prosthesis (i.e., not prepared by an outside laboratory)
  • To report bone graft performed after arthrodesis, see 20930-20938. Do not append modifier 62 to bone graft codes 20900-20938
  • Within the spine section, instrumentation is reported separately and in addition to arthrodesis. To report instrumentation procedures performed with definitive vertebral procedures, see 22840-22855.
  • Modifier 62 may not be applied to the definitive or add on spinal instrumentation procedure codes like 22840-22848 and 22850-22852
  • When arthrodesis is performed in addition to another procedure, the arthrodesis should be reported in addition to the original procedure with modifier 51.
  • Spinal osteotomy procedures are reported when a portion of the vertebral segments is cut and removal in preparation for realigning the spine as part of spinal deformity correction.
  • For excision of an intrinsic lesion of vertebra without deformity correction, see 22100-22116. For decompression of the spinal cord and/or nerve roots, see 63001-63308
  • The three columns are defined as anterior ( anterior two-thirds of the vertebral body), middle (posterior third of the vertebral body and the pedicle), and posterior (articular facets, lamina and spinous process)
  • Procedure codes 22554-22558 are for Single interspace.
  • For additional interspaces use 22585. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies, which contain the intervertebral discs and includes the nucleus pulposus, annulus fibrosus and two cartilaginous endplates.
  • When instrumentation reinsertion or removal is reported in conjunction with other definitive procedures including arthrodesis, decompression and exploration of fusion, append modifier 51 to 22849, 22850, 22852 and 22855.
  • Code 22849 should not be reported with 22850, 22852 and 22855 at the same spinal levels.
  • To report exploration of fusion, see 22830. When exploration is reported in conjunction with other definitive procedures, including arthrodesis and decompression, append 51 modifier to 22830.
  • Application of casts and strapping procedure are coded when the cast application or strapping is a replacement procedure used during or after the period of follow-up care, or when the cast application or strapping is an initial service performed without a restorative treatment or procedure to stabilize or protect a fracture, injury or dislocation and/or to afford comfort to a patient.
  • Restorative treatment or procedure rendered by another physician following the application of the initial cast/splint/strap may be reported with a treatment of fracture and/or dislocation code.
  • Initial cast/strap/splint procedure is always included in the treatment of fracture/dislocation codes.
  • Temporary cast/strap/splint is not considered to be part of the preoperative care and the use of the modifier 56 is not applicable.
  • Supply code for cast/strap/splint is 99070; it can be used in addition to evaluation and management code as appropriate.

CPT – SURGERY GUIDELINES (CARDIOVASCULAR SYSTEM) – PART 2

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Cardiovascular system:

  • Procurement of the saphenous vein graft is included in the description of the work for 33510-33516 and should not be reported as a separate service or co-surgery.
  • To report harvesting of an upper extremity vein, use 35500 in addition to the bypass procedure.
  • To report harvesting of a femoropopliteal vein segment, report 35572 in addition to the bypass procedure.
  • Same guideline applies to combined arterial-venous grafting and arterial grafting.
  • Codes 33880-33891 represent a family of procedures to report placement of an endovascular graft for repair of the descending thoracic aorta. These codes include all device introduction, manipulation, positioning and deployment.
  • All balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, either before or after endograft deployment are not separately reportable.
  • Open arterial exposure and associated closure of the arteriotomy sites (eg, 34812, 34820, 34833, 34834), introduction of guidewires and catheters (eg, 36140, 36200-36218), and extensive repair or replacement of an artery (eg, 35226, 35286) should be additionally reported.
  • Transposition of subclavian artery to carotid and carotid-carotid bypass performed in conjunction with endovascular repair of the descending thoracic aorta (eg, 33889, 33891) should be separately reported.
  • The primary codes, 33880 and 33881 include placement of all distal extensions. If required proximal extension can be reported separately.
  • For fluoroscopic guidance in conjunction with endovascular repair of the thoracic aorta, use code 75956-75959 as appropriate.
  • Codes 75956 and 75957 include all angiography of the thoracic aorta and its branches for diagnostic imaging prior to deployment of the primary endovascular devices, fluoroscopic guidance in the delivery of the endovascular components and intra-procedural arterial angiography (eg, confirm position, detect endoleak, and evaluate runoff).
  • Code 75958 includes the analogous services for placement of each proximal thoracic endovascular extension.
  • Code 75959 includes the analogous services for placement of a distal thoracic endovascular extensions paced during a procedure after the primary repair.
  • Other interventional procedures performed at the time of endovascular repair of the descending thoracic aorta should be additionally reported (eg, innominate, carotid, subclavian, visceral, or iliac artery transluminal angioplasty or stenting, arterial embolization, intravascular ultrasound, when performed before or after deployment of the aortic prostheses.
  • Same guideline applied to Endovascular repair of abdominal aortic aneurysm and iliac aneurysm.
  • Use 0048T to report the insertion of a ventricular assist device (VAD) performed via percutaneous.
  • Use 33975, 33976, 33979 to report the insertion of VAD performed via transthoracic approach.
  • Use 33977, 33978, 33980, 0050T to report the removal of VAD which also includes removal of the entire device, including the cannulas.
  • Use 33981-33983 to report the replacement of ventricular assist device pump which includes the removal of the pump and insertion of new pump, connection, de-airing and initiation of the new pump.
  • Use insertion code 33975, 33976, 33979 to report replacement of the entire VAD system. Removal of previous placed VAD is not separately reported.
  • Adjuvant technique maybe required at the time a bypass graft is created to improve patency of the lower extremity autogenous or synthetic bypass graft (eg, femoral-popliteal, femoral-tibial, or popliteal-tibial arteries.
  • Code 35685 should be reported in addition to the primary synthetic bypass graft procedure, when an interposition of venous tissue id placed at the anastomosis between the synthetic bypass conduit and the involved artery. This procedure includes harvesting.
  • Code 35686 should be reported in addition to the primary bypass graft procedure, when autogenous vein is used to create a fistula between the tibial or peroneal artery and vein at or beyond the distal bypass anastomosis site of the involved artery.
  • Code 35879 and 35881 describe open revision of graft threatening stenosis of lower extremity arterial bypass graft using vein patch angioplasty or segmental vein interposition techniques.
  • For thrombectomy with open revision of graft other than hemodialysis graft or fistula, use 35876
  • For direct repair of a lower extremity blood vessel (with or without patch angioplasty), use 35226.
  • For repair of lower extremity blood vessels using a vein graft use 35256.
  • Venipuncture collection of a specimen from an established catheter use 36592
  • Venipuncture collection of a specimen form capillary blood, use 36416
  • Venipunture collection of a specimen from a completely implantable venous access device use 36591
  • Venipuncture collection of a specimen form venous blood, use 36415

CPT – SURGERY GUIDELINES (Cardiovascular System) – Part 1

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Cardiovascular system:

  • Selective vascular catheterizations should be coded to include introduction and all lesser order selective catheterizations used in the approach (eg, the description for a selective right middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries)
  • Additional second and/or third order arterial catheterizations within the same family of arteries supplied by a single first order should be expressed by 36218 or 36248.
  • Additional first order or higher order vessel different from a previously selected and coded family should be separately coded.
  • A pacemaker or pacing cardioverter defibrillator includes a pulse generator containing electronics, a battery and one or more electrodes (leads).
  • A dual chamber pacemaker system includes a pulse generator and one electrode inserted in the right atrium and one electrode inserted in the right ventricle. In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular pacing), in this event, transvenous placement of the electrode should be separately reported using code 33224 or 33225. Epicardial placement of the electrode should be separately reported using 33202-33203.
  • Electrode positioning on the epicardial surface of the heart requires a thoractomy, or thoracosopic placement of the leads.
  • Removal of electrodes may first be attempted by transvenous extraction (33234. 33235 or 33244). However, if transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes (33238 or 33243).
  • Use 33212, 33213, 33221. 33230, 33231, 33240 as appropriate in addition to the thoracotomy or endoscopic epicardial lead placement codes (33202 or 33203) to report the insertion of the generator if done by the same physician during the same session.
  • Use 33213 to report insert transvenous single lead only without pulse generator.
  • Use 33217 to report insert transvenous dual lead only without pulse generator.
  • Use 33217 and 33224 to report insert transvenous multiple lead only without pulse generator.
  • Use 33212 or 33240 to report initial pulse generator insertion only with existing single lead.
  • Use 33213 or 33230 to report initial pulse generator insertion only with existing dual lead.
  • Use 33221 or 33231 to report initial pulse generator insertion only with existing multiple lead.
  • Use 33206 (atrial) or 33207 (ventricular) or 33249 to report initial pulse generator insertion or replacement plus insertion of transvenous single lead.
  • Use 33208 or 33249 to report initial pulse generator insertion or replacement plus insertion of transvenous dual lead.
  • Use 33208 and 33225 or 33249 and 33225 to report initial pulse generator insertion or replacement plus insertion of transvenous multiple lead.
  • Use 33214 or 33241 and 33249 to report Upgrade single chamber system to dual chamber system which includes removal of existing pulse generator.
  • Use 33233 or 33241 to report removal pulse generator only without replacement.
  • Use 33227 or 33262 to report removal pulse generator with replacement pulse generator only single lead (transvenous)
  • Use 33228 or 33263 to report removal pulse generator with replacement pulse generator only dual lead (transvenous)
  • Use 33229 or 33264 to report removal pulse generator with replacement pulse generator only multiple lead (transvenous)
  • Use 33234 or 33244 to report removal transvenous electrode only single lead system.
  • Use 33235 or 33244 to report removal transvenous electrode only dual lead system.
  • Use 33233 + (33234 or 33235) + (33206 or 33207 or 33208) and 33225, when appropriate to report removal and replacement of pulse generator and transvenous electrodes for pacemaker.
  • Use 33241 + 33244 + 33249 and 33225, when appropriate to report removal and replacement of pulse generator and transvenous electrodes for Implantable cardioverter defibrillator.
  • Codes 33254-33256 are only to be reported when there is no concurrently performed procedure that requires median sternotomy or cardiopulmonary bypass.
  • The appropriate atrial tissue ablation add-on code, 33257, 33258 and 33259 should be reported in addition to an open cardiac procedure requiring sternotomy or cardiopulmonary bypass if performed concurrently.
  • Limited electrophysiological operative ablation and reconstruction includes:
    • Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium.
  • Extensive electrophysiological operative ablation and reconstruction includes:
    • Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium.
    • Additional ablation of atrial tissue to eliminate sustained supraventricular dysrhythmias. This must include operative ablation that involves either the right atrium, the atrial septum, or left atrium in continuity with the atrioventricular annulus.
  • Surgical vascular endoscopy always includes diagnostic endoscopy.

CPT – Surgery Guidelines (30000-39999)

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

  • A surgical sinus endoscopy includes a sinusotomy and diagnostic endoscopy.
  • Codes 31295-31297 describe dilation of sinus ostia by displacement of tissue, any method, and include fluoroscopy if performed.
  • Codes 31233-31297 are used to report unilateral procedures unless otherwise specified.
  • Codes 31231-31235 for diagnostic evaluation refer to employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the spheno-ethmoid recess. Anytime a diagnostic evaluation is performed all these areas would be inspected and a separate code is not reported for each area.
  • Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same physician.
  • Codes 31622-31646 include fluoroscopic guidance, when performed.
  • Pleural cavity and lung biopsy procedures may be accomplished using a percutaneous, Video Assisted Thoracoscopic Surgery (VATS), or thoracotomy approach. They involve the removal of differing amounts of tissue for diagnosis.
  • Lung resection procedures include diagnosis and therapeutic procedures, including the removal of blebs, bullae, cysts and benign or malignant tumors or lesions. These procedures may involve the removal of small portions of the lung or even an entire lung. Additionally lung resection procedure may require the removal of the adjacent structures.
  • A diagnostic wedge resection technique requires only that tissue sample be obtained without particular attention to resection margins.
  • Therapeutic wedge resections require attention to margins and complete resection even when the wedge resection is ultimately followed by a more extensive resection.
  • In the case of a wedge resection where intra-operative pathology consultation determines that a more extensive resection is required in the same anatomic location, it becomes classified as a diagnostic wedge resection. (32507, 32668). When no more extensive resection is required, the same procedure is a therapeutic wedge resection (32505, 32666).
  • More extensive anatomic lung resection procedures, which can be performed with either thoracotomy or Thoracoscopic approaches includes segmentectomy, lobectomy, bilobectomy and pneumonectomy.
  • Diagnostic biopsy of lung is included in surgical resection procedure.
  • The therapeutic wedge resection codes should not be reported in addition to the more extensive lung procedure unless the therapeutic wedge is performed on the different lobe or on the contra lateral lung.
  • When a diagnostic wedge resection is followed by a more extensive procedure on the same anatomical location, report add-on codes 32507 or 32668 with the more extensive procedure.
  • When a therapeutic wedge resection (32505, 32506, 32666 or 32667) is performed in a different lobe than the more extensive lung, report the therapeutic wedge resection with modifier 59.
  • The instillation of a fibrinolytic agent may be performed multiple times per day over the course of several days. Code 32561 should be reported only once on the initial day treatment. Code 32562 should be reported only once on each subsequent day of treatments
  • Cadaver donor pneumonectomy, includes harvesting the allograft and cold preservation of the allograft (perfusing with cold preservation solution and cold maintenance) (use 32850)
  • Recipient lung allotransplantation includes transplantation of a single or double lung allograft and care of the recipient (See 32851-32854).