Tag Archives: CPT

How to Code – Debridement

Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. The goal of debridement is to cleanse the wound, reduce bacterial contamination, and provide an optimal environment for wound healing or possible surgical intervention. The usual end point of debridement is removal of pathological tissue and/or foreign material until healthy tissue is exposed.

Techniques 

Debridement techniques include, among others, sharp and blunt dissection, curettement, scrubbing, and forceful irrigation. Surgical instruments may include a scrub brush, irrigation device, electrocautery, laser, sharp curette, forceps, scissors, burr, or scalpel Prior to debridement.

Debridement CPT Codes  : 11000 – 11047

  1. 11000 & 11001 – For Eczematous Debridement
  2. 11004 – 11006 – For debridement of Soft tissue infection(i.e. upto skin, subcutaneous tissue and muscle,fascia level)
  3. 11010 – 11012 – Excisional Debridement
  4. 11042 – 11047 – Wound Debridement

Excisional Debridement

defined as the “surgical removal or cutting away of devitalized tissue, necrosis, or slough,” which could be performed in the operating room, emergency room, or at the patient’s bedside.

Some surgical procedure codes include debridement as a part of the service. You may report a debridement as a separate service when the medical record indicates that a greater than usual debridement was provided. For example, if an extensive debridement of an open fracture was performed when usually a simple debridement would be performed, you report the additional service using a debridement code from the 11010-11012 range.

Divided according to location:

11010 – skin and subcutaneous level

11011 – Muscle , Fascia level

11012 – Bone level

Wound Debridement

11042 – 11047 – Wound Debridement

Divided according to – Depth of tissue –

11042 – skin and subcutaneous level

11043 – Muscle , Fascia level

11044 – Bone level

Diveded according to Surface Area –

11042,11043,11044 – upto 20 sq cm

11045, 11046 – More than 20 Sq cm

Coding tips –  When reporting one wound, report the depth of the deepest level of tissue removed. When reporting multiple wounds, sum the surface area of the wound at the same depth. Do not combine sums of different depths.

Other Important Points to Remember while coding for debridement

  1. These debridement codes do not apply to debridement of burned surfaces. For debridement of burned surfaces, CPT codes 16000-16036 are reported.
  2. Do not assign additional codes for debridement when these procedures are an integral part of the total procedure performed. A debridement carried out in conjunction with another procedure is often, but not always, included in the code for the procedure.
  3. Do not use these codes for pressure ulcers, for Pressure ulcers – code 15920-15999

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

How to Code CABG

Coronary artery bypass grafts (CABG) is a surgical procedure performed in order to go around (bypass) blockages in the coronary arteries to improve blood flow.  This post will address why the procedure is performed, how the procedure is performed, and how to code the procedure.Coronary_artery_bypass_grafting

A healthy vessel is taken from elsewhere in the patient’s body.  This is known as harvesting or procurement.  The surgeon may harvest an artery, a vein, or both.  The saphenous vein from the leg is one of the more common vessels harvested for use in bypass grafts.

There are two types of CABGs performed.  One is the traditional open chest bypass surgery and the keyhole procedures (minimally invasive).  Here we are addressing open chest procedure.

CABG coding rules

In order to properly code a CABG procedure, a coder needs the following information:

  • How many grafts were performed?
  • How many were arterial? Which artery(ies)?
  • How many were venous? Which Vein(s)?
  • How were they procured?
  • Did the patient have a previous CABG procedure performed?

Here are the codes:
33510-33516 – Venous only
33533-33536 Arterial with or without veins
+33517-33523 venous add on codes to be used with 33533-33536 for combined A-V grafting.

Here are the Rules:
33510-33536 are used based on type of bypass graft and the number of coronary arteries bypassed.
Types of vessels (harvesting them is usually global to the procedure) used for graft: saphenous vein, left internal mammary (LIMA), upper extremity vein (can bill for that one-35500), or femoropopliteal vein (can bill for that one-35572).
Venous grafts codes 33510-33516 are for venous by pass only. They would never be reported with 33533-33536, that is an arterial by pass code. If arteries and veins used together, then use arterial by pass codes and add on codes +33517 – +33523 for the veins.
Add-on codes A-V codes +33517 – +33523 are never used alone. They represent the venous graft in the combined arterial-venous CABG procedures are can be used with 33533-33536.
To determine the number of bypass grafts in a CABG, count the number of distal anastomoses, where the bypass graft artery or vein is sutured to the coronary artery.
If any of the veins are harvest endoscopy use add on code +33508

+ 33530 – REOPERATION, CABG or valve procedure, more than one month after original operation. 

CPT Assistant:

“When performing a “redo” operation, a repeat sternotomy is performed. This requires removal of previously placed wire sutures, which may have become embedded in the bony portion of the sternum. The anterior cardiac chambers, great vessels and other mediastinal structures may be densely adherent to the posterior table of the sternum, so the sternal incision must be made with extreme care so as to avoid potentially catastrophic hemorrhage. Once the mediastinum has been entered, the scarring and adhesions from prior surgery may obscure the anatomic landmarks and make dissection both difficult and hazardous. Code 33530 is intended to describe this increased technical difficulty associated with the reoperation”

CABG Coding Tips…

  1. Procurement of a venous graft is integral to the performance of a coronary artery bypass using venous bypasses. CPT codes 37700-37735 (ligation of saphenous veins) are not to be separately reported in addition to CPT codes 33510-33523 (coronary artery bypass).  
  1. When a coronary artery bypass is performed, the more comprehensive code describing the procedure performed should be used. When venous grafting only is performed, only one code in the group of the coronary artery bypass CPT codes 33510-33516 (venous graft only) can be reported; no other bypass codes should be reported with these codes.  One code in the group of CPT codes 33517-33523 (combined arterial-venous grafting) and one code in the group of CPT codes 33533-33536 (arterial grafting) can be reported together to accurately describe combined arterial-venous bypass.  When only arterial grafting is performed, only one code in the group of CPT codes 33533-33536 (arterial grafting) is coded.
  1. During venous or combined arterial venous coronary artery bypass grafting procedures (CPT codes 33510-33523), it is occasionally necessary to perform epi-aortic ultrasound. This procedure may be reported with CPT code 76986 (ultrasonic guidance, intraoperative) appending modifier -59CPT code 76986 should not be reported for ultrasound guidance utilized to procure the vascular graft.
  1. 4. When an intervascular shunt procedure is performed as a part of another procedure at the same site requiring vascular revision, a service for a shunt procedure is not separately reported from CPT codes 36800-36861 (intervascular cannulization/shunt). By CPT Manual definition, this series of codes represents “separate procedures” (see separate procedure policy in Chapter I, Section J).
  1. An aneurysm repair may require direct repair with or without graft insertion, thromboendarterectomy and/or bypass. When a thromboendarterectomy is undertaken at the site of the aneurysm and it is necessary for an aneurysm repair or graft insertion, a separate service is not reported for the thromboendarterectomy.  Additionally, if only a bypass is placed, which may require an endarterectomy to place the bypass graft, only the code describing the bypass can be reported.  If both an aneurysm repair (e.g. after rupture) and a bypass are performed at separate non-contiguous sites, the aneurysm repair code and the bypass code should be reported with an anatomic modifier or modifier -59.

If a thromboendarterectomy is medically necessary, due to vascular occlusion on a different vessel at the same session, the appropriate code may be reported, but should include an anatomic modifier or modifier -59, indicating that this represents non-contiguous vessels.  At a given site, only one type of bypass (venous, non-venous) code can be reported. If different vessels are bypassed by different methodology, separate codes may be reported.  If the same vessel has multiple obstructions and requires different types of bypass in different areas, separate codes may be reported; however, it will be necessary to indicate that multiple procedures were performed by using an anatomic modifier or modifier -59.

  1. When an open vascular procedure (e.g. thromboendarterectomy) is performed, the closure and repair are included in the description of the vascular procedure. Accordingly, the CPT codes 35201-35286 (repair of blood vessel) are not to be reported in addition to the primary vascular procedure.
  1. When an unsuccessful percutaneous vascular procedure is followed by an open procedure at the same session/same physician (e.g. percutaneous transluminal angioplasty, thrombectomy, embolectomy, etc. followed by a similar open procedure such as thromboendarterectomy), only the service for the successful procedure, which is usually the more extensive, open procedure is reported (see sequential procedure policy, Chapter I, Section M). In the case where a percutaneous procedure is performed at the site of one lesion, and an open procedure is performed at a separate lesion, the services for the percutaneous procedure should be reported with modifier -59 only if the lesions are in distinct anatomical vessels.
  1. The HCPCS/CPT codes 36000, 36406, 36410, etc. represent very common procedures performed to gain venous access for phlebotomy, prophylactic intravenous access, infusion therapy, chemotherapy, hydration, transfusion, drug administration, etc. When intravenous access is routinely obtained in the course of performing other medical/diagnostic/surgical procedures, or is necessary to accomplish the procedure (e.g. infusion therapy, chemotherapy), it is inappropriate to bill separately for the venous access services.  The work of gaining routine vascular access is integral to and therefore included in the work value of the procedure.  HCPCS/CPT codes G0345, G0346 (90760-90761 in 2006) should not be reported for infusions to maintain patency of a vascular access site.
  1. When a (non-coronary) percutaneous intravascular interventional procedure is performed at the same session/site as diagnostic angiography (arteriogram/venogram), only one selective catheter placement code for the involved site should be reported. If the angiogram and the percutaneous intravascular interventional procedure are not performed in immediate sequence and the catheters are left in place during the interim, a second selective catheter placement or access code should not be reported. Additionally, dye injections to position the catheter should not be reported as a second angiography procedure.
  1. Diagnostic angiograms performed on the same date of service as a percutaneous intravascular interventional procedure should be reported with modifier -59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology.  Report the repeat angiogram with modifier -59.  If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier -52 to the angiogram CPT code.  If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure.
  1. When a median sternotomy is performed to accomplish cardiothoracic procedures, the repair of the sternal incision is part of the primary procedure. The CPT codes 21820-21825 (treatment of sternum fracture) are not separately reported nor should the removal of embedded wires be reported if a repeat procedure or return to the operating room (e.g. postoperative hemorrhage on the day of surgery) is necessary.
  1. When existing vascular access lines or selectively placed catheters are used to procure arterial or venous samples, billing for the sample collection separately is inappropriate.
  1. Peripheral vascular bypass CPT codes describe bypass procedures using venous grafts (CPT codes 35501-35587) and using other types of bypass procedures (arterial reconstruction, composite). Because, at a given site of obstruction, only one type of bypass is performed, these groups of codes are mutually exclusive.  When different sites are treated with different bypass procedures in the same operative session, the different bypass procedures may be separately reported, using an anatomic modifier or modifier -59.
  1. Vascular obstruction may be caused by thrombosis, embolism and/or atherosclerosis as well as other conditions. Treatment may, therefore, include thrombectomy, embolectomy and/or endarterectomy; these procedures may be performed alone or in combination.  CPT codes are available describing the separate services (CPT codes 34001 – 34203) and describing these services with thromboendarterectomy (CPT codes 35301 – 35381).  Only the more comprehensive code describing the services performed for a given site can be reported; therefore, for a given site, a code from both of the above groups cannot be reported together.  Additionally, in accordance with the sequential procedure policy, if a balloon thrombectomy fails, and requires a performance of an open thromboendarterectomy, only the more comprehensive service that was performed (generally the open procedure) is reported.
  1. When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the column one atherectomy procedure that was performed (generally the open procedure) is reported (see sequential procedure policy, Chapter I, Section M).
  1. CPT codes 35800-35860 are to be used when a return to the operating room is necessary for exploration for postoperative hemorrhage; accordingly, these codes are not to be coded for bleeding that occurs during the initial operative session. Generally, when these codes are used, they are to be reported with modifier -78 indicating that the service represents a return to the operating room for a related procedure during the postoperative period.

Donloadable CPC Practice Exam Donloadable CPC Practice Exam

Operative Note Practice Scenario – 10

An esophagogastroduodenoscopy was performed with balloon dilation to open an esophageal stricture. After three attempts, the balloon dilation was unsuccessful. Jumbo biopsy forceps were then used to remove a section of the scarred stricture to create a wedge and prevent the stricture from constricting the esophageal lumen.

Codes:

Operative Note Practice Scenario – 8

The patient was brought in for surgical intervention of a mature, symptomatic cataract in the left eye and high intraocular pressures despite medical therapy. Procedures performed were an external trabeculectomy and phacoemulsification with posterior chamber intraocular lens placement.

Discharge diagnoses: (1) Advanced primary open-angle glaucoma, severe stage, (2) cataract, left eye.

Codes:

Operative Note Practice Scenario – 7

Preoperative diagnoses: Rhegm atogenous retinal detachment and nuclear sclerotic cataract, both to the right eye.

Name of Procedures: A 25-gauge pars plana vitrectomy, retinal detachment repair, air fluid exchange, air gas exchange with SF6 24%, indirect ophthalmoscope-delivered laser, all to the right eye.

Description of Procedure: The patient was seen in the pre-operative holding area and all questions about the procedure answered. Right eye was identified as the correct operative site and informed consent was confirmed. The patient was rolled in the supine position to the operative suite where appropriate cardiac and pulmonary monitoring devices were applied per anesthesia. The patient was placed under general anesthesia without complication. Right eye was prepped and draped in normal sterile fashion. Sterile lid speculum was placed. A standard 3-port 25-guage vitrectomy unit was used after placing the infusion cannula 4 mm posterior to the infratemporal limbus. Correct position was visualized before turning it on. Additional 2 ports were placed without complication. Initial vitrectomy was performed and carried out into the periphery with the aid of scleral depression. A posterior vitreous detachment was already present. The retinal detachment extended from 12 o’clock temporally down to 6:30 o’clock. Directly temporally there was an old demarcation line with a small horseshoe retinal tear in the middle near the aura. This was trimmed free from vitreous. A drainage retinotomy was then created along the superior temporal arcade with electric diathermy. Air fluid exchange was then performed with drainage of subretinal fluid using a 25-guage backflush cannula. The retina was seen to lay flat. Plugs were placed and indirect ophthalmoscope was used to place laser retinopexy around the retinotomy site, the previously marked retinal hole and in a 360 degree retinopexy fashion. Drainage was performed one more time before placing SF6 24% into the posterior segment. Sclerotomy ports were removed in sequential fashion. All wounds were found to be airtight. The patient was given subconjunctival injections of Ancef and Decadron. A sterile led speculum was removed. A light pressure patch was placed. The patient was taken to recovery room in stable condition after being awakened form general anesthesia in stable condition. He was to remain face down overnight and follow up tomorrow for post-operative exam and instructions.

Codes:

Operative Note Practice Scenario – 6

Pre-operative diagnosis: Right knee medial meniscus tear

Post-operative diagnosis:

  1. Right knee medial meniscus tear
  2. Right knee lateral meniscus tear
  3. Tricompartmental arthritis of the knee

Name of Procedure: Video arthroscopy of right knee with arthroscopic partial medial and lateral meniscectomies and chondroplasty.

Description of Procedure: Once consent was obtained, the patient was brought to the operating theater and placed on the operating room table in the supine position. Following smooth induction of general anesthesia, a tourniquet was placed around the patient’s right thigh. The right lower extremity was then prepped and draped in the usual sterile orthopedic fashion. The extremity was elevated and exsanguinated and tourniquet was inflated. A superomedial portal was made as an outflow portal and a cannula was introduced in the knee. An anterolateral portal was made and the camera was placed in the knee. Upon inspecting the knee the patient was noted to have a large amount of synovitis throughout the knee. The patellofemoral joint was first visualized. The patient had outerbridge grade 3, fraying of the patella and 2 of the trochlea. There was some fraying of the cartilage there. The camera was then passed around the medial femoral condyle to the medial compartment of the knee. The patient had a grade 3 wear involving the entire medial femoral condyle and some of the tibial condyle as well. However, he did have a large complex fragmented tear of the posterior horn of the medial meniscus. The arthroscopic portal was made after localizing it with a spinal needle. Using a combination of biters, the shaver and the ArthroCare wand, the posterior horn of the medial meniscus was debrided to a stable base. The medial meniscus was sealed with ArthroCare wand to prevent further fraying. Next, the notch was visualized and the ACL was inspected. The ACL was intact. The knee was placed into a figure 4 position and the lateral compartment was visualized. The lateral femoral condyle was intact. However, there was some grade 2 wear of the lateral tibial plateau. The patient did have a tear of the lateral meniscus as well. This was debrided with the biter and the shaver. The knee was then extended and a chondroplasty of the patellofemoral joint was performed using the shaver. The free edge of the fibrillations was debrided to prevent any further fraying or breakdown of the articular cartilage. The instruments were then removed. The wound was infiltrated with Marcaine for postoperative analgesia and the arthroscopic portals were closed primarily with 4-0 Monocryl. Anesthesia was then reversed and the patient was awakened and taken to recovery room in stable condition

Codes:

Operative Note Practice Scenario – 5

Pre-operative diagnosis: Lipoma of right upper arm

Post-operative diagnosis: Lipoma of right upper arm

Name of procedure: Excision of lipoma from right upper arm with layered closure of 6 cm incision.

Indications: The patient is a 70 year-old female who has a mass on the upper right arm which has been present for several years and has slowly increased in size. She now comes in for elective resection.

Description of Procedure: The patient was taken to the operating room and placed in the supine position on the operating room table. The right arm was supported on a pillow and secured to the bed. The skin overlying the mass of the upper arm was prepped with Betadine and then draped in sterile fashion. The skin overlying the mass was then anesthetized with 1% lidocaine with epinephrine. A transverse 6 cm incision was made. Subcutaneous tissue was divided with electocautery down through subcutaneous fat until the capsule of the lipoma could be identified. The lipoma was then easily dissected free from all surrounding tissue. There was a feeder vessel exiting the deltoid muscle beneath it. This was treated with electrocautery. The mass was removed intact without problems and appeared to be a typical lipoma. The wound was inspected for hemostasis and with this assured, the subdermal tissues were closed with interrupted 3-0 Vicryl and the skin was closed with a running subcuticular stitch of 5-0 Monocryl. Steri-Strips, Telfa and Tegadem dressings were applied. The patient tolerated the procedure very well and was able to ambulate from the minor surgery room without difficulty.

Codes:

Operative Note Practice Scenario – 4

Pre-operative Diagnosis: Breast Cancer, Need for Chemotherapy

Post-operative Diagnosis: Same

Procedure Performed: Insertion of Infusaport

This 65-year-old patient was taken to the operation room and placed supine on the OR table. After adequate sedation, the area of the anterior chest and neck were prepped and draped in sterile fashion. Access to the right subclavian vein was done in posterior fashion, and the wire was visualized under fluoroscopy to be in the right atrium. A pocket was made on the lateral aspect of the right clavicle, and the pocket was developed. The catheter was guided from the site of the pocket to the exit site of the wire. The dilator and sheath were placed over the wire and the dilator and wire were both removed. The catheter was immediately inserted into the sheath. The sheath was separated and removed. The tip was pulled back to the superior vena cava/right atrial junction. The catheter was cut to length at the pocket site and attached to the Infusaport with the connector in a steadfast fashion. The port was placed in the pocket and anchored to the chest wall with 3-0 nylon sutures that were placed to immobilize ad anchor the port. Then antibiotic irrigation was done. The port was tested, and it flushed back blood and flushed heparinized saline without occurrence. The subcutaneous tissue and subcuticular tissue were reapproximated with 4-0 Vicryl suture in a running fashion. Steri-Strips and a sterile dressing were applied. The patient tolerated the procedure well.

The patient was sent for a post-operative chest x-ray.

Chest x-ray single view findings: Single view was taken of the chest in frontal position. This demonstrates proper placement of the catheter tip in the right atrium. No other findings.

Codes:

Operative Note Practice Scenario – 3

Preoperative Diagnosis: Hematuria

Postoperative Diagnosis: Right Ureter Stone

Procedure Performed: Cystoscopy with Bilateral RPG, Right Ureteroscopy, and Stent placement. The patient was taken to the cystoscopy room, placed in the dorsolithotomy position, surgical site prepped and draped in the usual fashion. Following general anesthesia, rigid cystoscopy was performed with video guidance. Bladder was viewed in all quadrants without findings of foreign body, tumor or stone, normal ureteral orifice, bladder neck, and urethra. Right RPG was performed with open-ended catheter and a defect was seen in the mid ureter. There was no filing defect or obstruction seen in the remainder of the ureter. The left-sided RPG was performed, and no significant obstruction or filling defect was noted. Guidewire was passed in the right renal pelvis, adjacent to this, rigid ureteroscope was passed and the stone was encountered. The stone was removed with the basket forceps. The ureteroscope was then passed to the level of the iliacs without further stones being encountered. The ureteroscope was removed. 7 French x 26 centimeter double J stent was then placed, position was confirmed with fluoroscopy and procedure was terminated.

Codes: