Coding Chapter 12
Carpal tunnel decompression surgery is classified in what section
nervous
SHOULD YOU REPORT MODIFIER 58 WHEN A TEMP CAST IS APPLIED AND THE PT LATER UNDERGOES A RESOTRATIVE TX
no
Nasal vestibule
nose's entrance
Xenografts
obtained from another species
report a manipulation code _--
once for any region including multiple regions during the same op session
How many codes are reported for exploration of spinal fusion
only one
There are different codes for an arytenoidectomy done _____ vrs _______
open vrs endoscopic
Classifications based on skin condition
open/ compound, closed/simple
Allogenous
originating in another person
Autogenous
originating in the patient's body
Biopsy codes are not reported for multiple ___ or _____ lesions even if taken from different areas
similar or identical
Closed aka
simple
Codes for the nose range from ______ to _________
simple control of nosebleed to complex surgery
Write the Coding Tip on page 576 in your book!
...
abdomen
...
exploration
...
femur (thigh region) and knee joint
...
foot and toes
...
forearm and wrist
...
hands and fingers
...
leg (tibia and fibula) and ankle joint
...
nothing here
...
nothing here either
...
pelvis and hip joints
...
read example on 566
...
shoulder
...
Modifier ___ can be added if turbinate surgery is performed on both sides
-50
What codes are included in fracture management? Do you report separate codes for any of these?
-Pinning -Open/Closed tx -Application and removal of initial cast or splint -Normal, uncomplicated follow up care (Do not report separate codes for these)
What falls under codes 20100-20103 Penetrating Trauma?
-Surgical exploration and enlargement of the wound -Extension of dissection (to determine penetration) -Debridement -Removal of foreign bodies -Ligation of coagulation of minor subcutaneous and or muscular blood vessels of the tissue, muscle, and or fascia not requiring thoracotomy or laparotomy
3 Methods of closed fracture treatment
-With manipulation/reduction which means realignment -Without manipulation/reduction which means the bones are not realigned and a cast is placed to stabilize -With or without skeletal traction
What are bundled in with the diagnostic endoscopy?
-anesthesia -electrocautery -access to cavities -shaving/debridement
Types include
-direct -indirect -use of operating a microscope -use of fiberoptic scope
Report excision codes for ____ and _______ on muscle or bone
-epiphyseal bar procedures and biopsy
Examples of headings in respiratory
-nose -larynx -lungs and pleura -trachea and bronchi -accessory sinus
What id bundled in with surgical sinus endoscopy?
-sinusotomy -diagnostic endoscopy
Accessory Sinuses
...
Application of casts and strapping
...
Arthrodesis
...
Back and Flank
...
Coding Tip: Closed and Open fractures many not receive the same type of tx. For ex: Closed may receive open tx and open may receive closed tx.
...
ENDOSCOPY/ARTHROSCOPY
...
EXCISION
...
Endoscopy
...
Excision
...
Excision (larynx)
...
Fracture and or Dislocation
...
Fracture and/or dislocation
...
Grafts or Implants
...
Head
...
Head Prosthesis
...
Humerus (upper arm) and elbow
...
INCISION
...
Incision
...
Intro
...
Introduction or Removal
...
Just example
...
Just look at examples
...
Larynx
...
Lung Transplant
...
Lungs and Pleura
...
Manipulation
...
Musculoskeletal System Notes
...
NOTHING IMPORTANT HERE
...
Neck and Thorax
...
Nose
...
Nothing important in this section
...
Nothing important in this section except example
...
Osteotomy
...
Other Procedures
...
Other Procedures:
...
Removal
...
Repair
...
Repair Revision, Reconstruction
...
Repair, Revision, and or Reconstruction
...
Replantation
...
Respiratory System
...
Review the coding tip on page 572 about using codes 30130-30140 with a procedure to gain access to the ethmoid bone
...
Spinal instrumentation
...
Spine (Vertebral Column)
...
Surgical Collapse Therapy: Thoracoplasty
...
Trachea and Bronchi
...
Vertebral Body, Embolization or Injection
...
Wound Exploration- Trauma
...
T1-T2 REPRESENTS ----- INTERSPACESS
1
What is included in the tendon repair codes
1. App. Of immobilization 2. Extension of excision 3. Repair and closure of tendon sheath
2 types of tendons
1. Flexor tendons 2. Extensor tendons
3 bunion procedures
1. Keller procedure 2. Mcbride procedure 3. Mitchell procedure
3 COMPARTMENTS OF A KNEE
1. MEDIAL 2. LATERAL 3. PATELLOFEMORAL
This heading includes codes that are reported when?
1. Replacement procedure performed during or after the period of follow up care 2. Initial service performed without restorative tx or procedure to stabilize or protect a fracture, disocation, etc
Why is precut. Vertebroplasty typically performed?
1. To relieve pain due to vertebral compression fractures 2. To relieve pain due to benign or malignant vertebral lesions
Lung transplants include what components
1. cadaver donor pneumonectomy 2. recipient lung allotransplantation 3. backbench work
C1-C2 AND C2-C3 REPRESENTS --- INTERSPACES
2
T1-T2 REPRESENTS --- SPINAL SEGMENTS
2
There are ___ turbinates on each side of the nasal vestibule
3 (inferior, middle, and superior)
L1-L4 REPRESENTS ---- SPINAL SEGMENTS
4
If a total lung lavage is performed bilaterally what modifier must be added
50
When exploration of spinal fusion is performed in addition to other definitive procedures what modifier must be added to the exploration code
51
When an osteotomy is performed during the same op session as a bone graft report the appropriate code and do not add modifier
51 or 62. Only one surgeon performs the bone grafting
When two surgeons work together to perform an anterior spine osteotomy procedure during the same op session on the same pt and each performs a distinct part of the procedure modifier __ is added to the appropriate procedure codes reported by ea. Surgeon
62
When two surgeons work together to treat distinct parts of open fracture and or dislocation procedures during the same op session and ea. Performs a distinct part of the procedure, mod. --- is added to the procedure codes; however both surgeons must work together a primary surgeons.
62
WHEN 2 SURGEONS COLLABORATE TO PERFORM A SPINAL PROCEDURE DURING THE SAME OP. SESSION ON THE THE SAME PT. AND EACH PERFORMS A DISTINCT PART OF THE PROCEDURE ADD MOD. --- TO THE PROCEDURE CODE REPORTED BY EACH SURGEON.
62 (ALSO ADD TO ADDITIONAL PROCEDURE CODES REPORTED BY EA. SURGEON)
Bone Bank is
allogenous
Severed body part aka
amputation
Percutaneous vertebroplasty involves
A bone cement (hardens in 10 mins) is injected under pressure directly into a fractured vertebra, the cement causes the fragments to congeal and provide stability
What other type of code should be reported with precut. Vertebroplasty
A radiology code for radiological supervision and interpretation
WHEN A PHYSICAN PERFORMS AN INTIAL RESTORATIVE TX AND AN INITIAL CAST IS ALSO APPLIED, THE PHYSICIAN IS RESPONSIBLE FOR PROVIDING
ALL SUBSEQUESNT FRACTURE INJURY CARE,
INSTRUMENTAL CODES ARE REPORTED SEPERATELY IN ADDION TO ---- CODES
ARTHRODESIS
T/F BONE GRAFT CODES ARE REPORTED SEPARETLY IN ADDITION TO ---- CODES
ARTHRODESIS
tibia
largest of the 2 lower leg bones
when arthrodesis is performed with another procedure report ---
an arthrodesis code with mod. 51 and the definitive procedure code
When tx of fractures/dislcoations are performed during a arthrodesis report ___
Appropriate arthrodesis code
When tx of fractures/dislcoations are performed during a bone graft report ___
Appropriate bone graft code (don't add mod. 51 or 62)
Spine procedures are sometimes followed by ___ and may include ___, and ____
Arthrodesis, bone grafts, and instrumentation
Incision contains just one code for ________
Arthrotomy, temporomandibular joint
Arthrodesis aka
Artificial ankylosis
Wagstaff-LeFort fracture
an avulsion of the fibula
Osteogenesis
Bone growth
C
CERVICAL
Spine codes classify procedures performed on the __,___ and ____spine
Cervical, thoracic, and lumbar spine
Mitchell procedure
Complex, double cut osteotomy through the neck of the first metatarsal
ARTHROSCOPY
VISUAL EXAM OF THE INSIDE OF A JOINT
The shoulder heading has codes for procedures on the ---, ---, ---, ----, ---, and ----
Clavicle, scapula, humerus head/neck, sternoclavicular joint, scrominoclavicular joint, and should joint
Osteotomy includes ____, -----, and ----- so separate codes are not needed.
Corpectomy, discectomy, and laminectomy
ENDOSCOPIC AND ARTHROSCOPIC PROCEDURES ARE --- OR ---
DIAGNOSTIC OR SURGICAL
------ IS PROBABLY THE MOST COMMON TYPE OF PROCEDURE PERFORMED
DX KNEE ARTHROSCOPY
ENDOSCOPY
VISUAL EXAM OF THE INTERIOR OF A BODY CAVITY OR ORGAN
McBride procedure
Distal soft tissue release that corrects soft tissue deformity at the mtp joint
What happens when major blood vessels need repaired via thoractomy or laparotomy?
Do not report the -otomy code. Report the repair code
Codes for injections are based on ________
anatomic site
T or F Regardless of tumor size, you use the same code.
False! This use to be true. Our book is wrong though.
________ management codes are found throughout the musculoskeletal system subsection.
Fracture
Open Fracture Treatment
Fracture site is surgically opened
How is the Musculoskeletal System subsection arranged?
From head to toe according to body area
Patients who are candidates for precut. Vertebroplasty?
Functional disability and severe pain in which pain meds and support braces don't resolve
arthrodesis performed for reasons other than to correct spinal deformity is classified according to ---
anatomical approach
The codes for procedures in the humerus heading is performed on the
Humerus, elbow, and head/neck of the radius and olecranon process
WHEN AN ARTHRODESIS IS PERFORMED IN ADDITION TO ANOTHER PROCEDURE REPORT THE ARTHRODESIS CODE _______ AND USE MODIFIER ---
IN ADDITION TO THE OTHER PROCEDURE, AND USE MOD. 51 ON THE ARTHRODESIS CODE
Graft aka
Implant
An osteotomy is an
Incision into the bone
Osteotomy codes differentiate btw --- and --- approaches
anterior and posterior
When a simple, intermediate, or complex repair of wound is performed without enlargement of wound area, extension of dissection to determine penetration, debridement, removal, or foreign body then what do you report?
Just the repair code from the integumentary system
L
LUMBAR
Colpoclesis aka
LeFort procedure which involves the surgical repair of a uterine prolapse or a vaginal vault prolapse
PROCEDURES S ON THE BONES, MUSCLES, AND TISSUE OF THE SPINAL COLUMN IS CLASSIFIED IN THE --- SECTION
MUSCULOSKELETAL
Spinal osteotomy involves
Making incisions in vertebral bone to remove pieces or wedges of bone to correct a deformity
mtp joint
Metatarsophalangeal joint
PROCEDURES PERFORMED ON THE NERVES AND SPINAL CORD IS CLASSIFIED IN THE --- SECTION
NERVOUS
SHOULD YOU REPORT A CODE FOR THE APPLICATION OF A CAST, SPLINT, OR STAPPING DEVICE WITH THE INITIAL RESTORATIVE TX
NO , THE FIRST ONE IS INCLUDED IN THE TX OF FRACTURE/DISLOCATION CODE
SHOULD YOU REPORT AN E&m CODE AT THE TIME OF CASTING
NO, UNLESS SIGNIFICANT IDENTIFIABLE FURTHER SERVICES WERE PROVIDED AT THE TIME OF THE CASTING
a wedge resection may be performed on what part of the lung?
any part of a diseased lung
When osteotomy is performed during same op session as a spinal instrumentation report the --- code but do not add modifier ----.
appropriate, 51
if 2 surgeons perform a procedure that also includes spinal instrumentation can both surgeons report it?
No only one surgeon performs a spinal instrumentation so do not add a modifier 62 as well
Do you add a modifier 50 to a total laryngectomy with bilateral neck dissection?
No. The larynx is a single organ. You need to code a total laryngectomy with dissection and then an extra radical neck dissection code. Ex: 31365 and 38720-59
When should you add modifier 51 to the spinal instrumentation code?
Only when its performed during same op session as other definitive procedures
Internal Fixation often called
Open reduction with internal fixation or ORIF
Clinically requires an injury with sufficient force to penetrate skin, subcutaneous tissue, muscle , and or bone
Open/Compound
Internal Fixation Device
Pins, screws, and or plates are inserted through or within the fracture area to stabilize and immobilize the injury
What does the nose heading include?
Procedures performed on the nose, nasal septum, intra nasal tissue, etc
The manipulation setting contains codes for reporting _____ manipulation which requires anesthesia
TMJ
WHEN ONE PHYSICIAN APPLIES A CAST SPLINT, OR STRAPPING DEVICE AS INITIAL TX OF A FRACTURE OR DISLOCATION AND A DIFFERENT PHYSICIAN LATER PERFORMS RESTORATIVE TX REPORT
TX OF FRACTURE FROM THE MUSCULOSKELETAL SYSTEM
What do you do if an incision of soft tissue abscess is performed and it is located in deeper tissues than those associated with the integumentary system?
Report 20005 for the incision and drainage of a soft tissue abscess, sub fascia, which involves the soft tissue below the deep fascia (the physician thoroughly debrides and irrigates the affected area, examines underlying tissue and bone for signs of infection, removes dead bone or tissue, and closes the site)
Deep abscesses aka
SUBFASCIAL
It is important to differentiate btw ____ and ____
Segments and interspaces
Keller procedure
Simple resection of the base of the proximal phalanx with removal of the medial eminence
Closed Fracture Treatment
Site is not opened or exposed
Extensor tendons
Straightn the fingers
Do not code separately sutures stables or steri strips in the back and flank section
T
T
THORACIC
If osteotomy is performed during same op session as an arthrodesis simply report --- and --
The appropriate code and the 51 modifier attached
When tx of fractures/dislocations are performed during a spinal implementation report
The appropriate code but don't add mod. 62
When spinal instrumentation is performed during the same op session as the exploration of spinal fusion what must you report?
The appropriate instrumentation code
What subheadings are included under Lung and Pleura?
The regular headings on pg 570 like incision, excision, etc plus two extra headings. (Lung transplant and Surgical collapse therapy)
T or F The accessory sinuses heading contains unique coding guidelines for endoscopy procedures.
True
T or F When the control of nosebleed is performed during a procedure, it is considered integral and is not reported separate.
True
There are separate codes for harvested grafts. T/F
True
WHEN IS AN ENDO/ARTHROSCHOPY CONSIDERED DIAGNOSTIC
WHEN IT IS PERFORMED TO VISUALIZE AN ABNORM. OR DETERMINE EXTENT OF DISEASE
When a procedure for inferior turbinate surgery, nasal endoscopy, and septoplasty occur then code
a code for each because they are all separate (with appropriate modifier)
Lung transplants include the 3 components how is a code assigned to these?
a code is assigned to each by the physician who performed the component
Arthrocentesis
a procedure done to puncture the joint for fluid removal or medication injection
Interdental wiring
a stabilization procedure that involves the insertion of wires between teeth
femur
long bone of the thigh
Where are CPT guidelines related to the the subsections located?
at the beginning of the section
Prosthesis
created for rehab patients who have facial, oral, or other anatomic deficiencies that require an artificial ear, eye, or nose or an intraoral obturator
How is the Respiratory system arranged?
according to body area from nose to lungs
percutaneous needle biopsy
long needle inserted through the skin and into other tissue to obtain tissue for diagnostic evaluation
Classification based on position of fracture line
longitudinal, transverse, oblique, spiral. and stellate
tibial plateau
lower portion of femur that articulates with the tibia
What modifiers do you add to endoscopy codes?
lt and rt or -50
Closed reduction of a fracture is the same as
manipulation
Codes for tx of fractures and joint injuries are classified according to type of _________ and ________
manipulation and stabilization
according to cpt a therapeutic wedge resection requires attention to ____ and ______
margins and complete resection of the diseased lung (even when a more extensive resection is performed during a later operative episode)
Femoral Neck
based on location
Flexor tendors
bend fingers
Report excision codes for surgery performed on ___ and ___ of the face or scalp
bone and soft tissue
the knee is comprised of
bones, cartilage, ligaments, and tendons
Conchae defined
bony plates covered by spongy mucosa with curved margins
LeFort III
brings the entire midface forward, from the upper teeth to just above the cheekbones
LeFort I
brings the lower midface forward (from the level of the upper teeth) to just above the nostrils
Closed fracture
broken bones do not protrude and there are no open wounds Ex: burns, deep abrasions, involvement of subcutaneous requiring debridement and skin contusions
Open fracture
broken bones that can be seen through an open wound or protruding through the skin
hallus valgus repair codes are reported to correct
buniuons
if you report manipulation of the spine without anesthesia report a code from the ___ section
medicine
define pleura
membrane that envelops the lungs and lines the walls of the pleural cavity
LeFort I, II, and III are _____ bilateral fractures of facial bones that contain large, unstable fragments
complex
Open aka
compound
Turbinates are aka
conchae
ligaments
connective tissue that connects bone to bone and control stability of the knee
What type of sedation is a pt usually under when precut. Vertebroplasty is being performed
conscious sedation
Extensive shaving and debridement should be reported ______
separate with a -51
bunions
caused by bone inflammation and swelling and result in medical deviation and axial rotation of the first mtp joint
Pathological
caused by weakness from disease
Musculoskeletal System
classifies procedures performed on bones, cartilage, joints, ligaments, muscles, and tendons (including casting and strapping)
Respiratory System
classifies procedures performed on the nose , accessory organs, sinuses, larynx, trachea, bronchi, lungs, and pleura
Types of injury codes include
closed and open fractures and joint injuries
Examples of types of fractures
closed, open, percutaneous
What do the neck and thorax headings include?
codes for procedures performed on soft tissues of the neck and thorax
What does the larynx heading contain?
codes for procedures performed on the epiglottis and larynx and inside the trachea
What does the accessory sinus heading contain?
codes for procedures performed on the maxillary, frontal, ethmoid, and spheroid sinuses
define brushing
combing the mucous lining of the traches or bronchus with a bronchial brush to collect cells
Subglottic stenosis
narrowing of the airway below the vocal cords, adjacent to the cricoid cartilage
When a surgical endoscopy of accessory sinuses is performed, and evaluation of ________ is also performed as part of the procedure
nasal access regions (diagnostic endoscopy)
what does the routine fiberoptic bronchoscopy usually inspect other than the bronchus
nasal cavity, pharynx, and larynx
What do musculoskeletel system notes include ?
definitions of fractures and clarify that the type of fracture does not necessarily correspond to the type of TX provided
Head prosthesis codes
describe professional services that involve designing and preparing a prosthesis for a patient
pneumonolysis
division of tissues that attach the lung to the wall of the chest cavity
what tool is used to perform an endoscopy of the trachea or bronchus
either a flexible fiberoptic scope or a rigid scope with or without cell washings or brushing
Do not code a laryngoscopy separately when it is performed as part of an emergency or nonemergency _______
endotracheal tube
The middle turbinate is part of the _________
ethmoid bone (so if the middle turbinate is removed during ethmoidectomy, a code for the removal is integral)
Back and Flank only contains ______
excision
Do not report a biopsy code in addition to an _______
excision , destruction, or other type of removal during the same op session
Skeletal traction
exerts a pulling force on the affected limb to realign bone or joint
Stellate usually found in
fingers and toes
Stabilization
fixation or immobilization
pleural effusion
fluid in the pleural cavity prevents the lung from fully expanding which makes it difficult to breathe
define cell washing
flushing fluid into an area and removing the fluid using aspiration technique to collect cells
Gastrocnemious
from the calf
Tensor fascia lata
from the thigh
Fascia lata tissue is harvested from _________ or _____
gastrocnemius fascia or tensor fascia lata
Classification based on bone condition
green stick, comminuted, Compression, impacted
External fixation device
hardware is inserted through bone and skin and held rigid with cross braces outside of the body
the femur articulates with the
hip bone, tibia, and patella
Why are artenoidopexy and arytenoidectomy performed?
improve breathing
bone graft procedure are reported ___ to the arthrodesis codes
in addition
Where are unique coding instructions for Musculoskletal and Respiratory Systems located?
in the notes below headings or codes
define recipient lung allotransplantation
include transplantation of a single or double lung allograft and care of the recipient
Turbinate excision and submucous resection codes are typically reported for ________ turbinate surgery.
inferior
therapeutic pneumothorax
injection of air into the pleural space
Introduction and removal codes are reported for what?
injection procedures, removal of foreign bodies, insert and application of surgical hardware, arthrocentesis, and aspirations
percutaneous pleural biopsy involves
inserting a long needle through skin into the chest wall to obtain pleural tissue w/out direct visualization of the pleura
What do diagnostic endoscopy codes include?
inspection of the interior of the nasal cavity and its meatus,turbinates, and sphenoethmoid recess
define cadaver donor pneumonectomy
involved harvesting the allograft and preserving the allograft with cold preservation solution and cold maintenance
define backbench work
involves preparing the cadaver donor lung allograft prior to lung transplantation and dissecting allograft from surrounding soft tissues to prepare the pulmonary venous/atrial cuff, pulmonary artery, and bronchus
Dislocation
joint injury
What is coded if a sinusotomy is performed in conjunction with a sinus endoscopy
just one code to include both
If a physician is performing a surgical endoscopy; however, it fails and the physician must switch to an open procedure what should you code?
just the open procedure
if a diagnostic endoscopy of the trachea and bronchi is performed at the same time a surgical endoscopy is being performed what do you report as your code?
just the surgical endoscopy
what is an example of a hinge joint
knee
Closed and open fractures may receive __________ tx
per cutaneous skeletal fixation
Surgical Injections
performed by inserting a needle directly into a joint or tendon sheath, trigger point, or ganglion cyst to aspirate fluid or inject medications
Open nasal surgical approach
performed by making an incision into skin or tissues inside the nasal cavity
Surgical sinus endoscopy
performed through the nose, using a fiber-optic endoscopy
Internal fixation device is less ____ than wiring
permanent
What do CPT codes located in the Head category include?
procedures performed on the skull, facial bones, and temporomandibular joint (TMI)
What do respiratory guidelines do?
provide instructions for the selection of appropriate codes Example: approach
pneumoncentesis?
puncture of pleural space with a transthoracic needed to drain fluid or to obtain material for dx study
LeFort II aka
pyramidal fracture
Excision includes
radical resection of tumor, partial and total excision of ribs, costotransversectomy, osteotomy of sternum, sternal debridement, and radical resection of sternum
LeFort I, II, or III procedures
reconstruction of the face
Harvested cartilage tissue is often used for _________
reconstruction purposes
Manipulation aka
reduction
wedge resection
removal of a portion of lung that is less than a segment
lobectomy
removal of a single lobe
segmentectomy
removal of one segment of a lobe
total pneumonectomy
removal of the entire lung
extrapleural resection of ribs is the
removal of the ribs
External device is always _______
removed (after fracture is healed)
Harvesting
removing tissue for transplantation
Tendon tissue is harvested for the purpose of _____
repairing another tendon
What do you do when a physician performs sinus endoscopy with partial ethmoidectomy and septoplasty?
report a code for each procedure because 2 distinct procedures are being performed (30520-50 and 31254-50-51)
If an open procedure, thoracotomy, or another open chest procedure immediately follows a diagnostic thorascopy what codes need to be reported
report both procedures and sequence the open procedure first
When a surgical thoracoscopy is converted to an open procedure what code must you report?
report the code for the open procedure only
Back and Flank codes are
reported for biopsy, tumor excision, and radical resection of tumor procedures performed on the back and flank
thoraplasty
resection of ribs to allow the chest wall to retract, reducing the size of the pleural space
How are turbinates removed?
resection or excision with or without endoscopy, cauterization, debridement, laser, cryotherapy, radiofrequency, or ablation
If an endoscopy is performed to evaluate the sinus cavity prior to sinusotomy, report just _______________
sinusotomy code
2 types of splints
sterotactic and dynamic (not in book)
T/F WHEN ANYTHING IN ADDITIN TO VISUALIZATION IS PERFORMED THE ENDO/ARTHROSCOPY CODES ARE CONSIDERED
surgical
What is arthrodesis
surgical fixation of a joint
Pyramidal Fracture
surgical fracture of the midfacial skeleton at an apex near the superior aspect of the nasal bones
Thoracoplasty
surgical lung collapse therapy
thoracentesis
surgical puncture of the chest wall with a needle to obtain fluid from the pleural cavity
T or F Removal procedure is included in the global service and is not coded separately
t
T or F Do not report a code for diagnostic endoscopy in addition to a surgical endoscopic procedure..
t meaning do not code both a diagnostic and surgical procedure code if performed in one operation
codes for harvesting and inserting tendon grafts from another site, repairing nerves, and treating fracture are reported in addition to ____
tendon repair
When a traumatic injury with an open wound requires surgical debridement but the type of fracture requires manipulation and casting instead of a fixation device, code
the closed fracture treatment in addition to the debridement code
Arytenoidectomy
the excision of arytenoid cartilage, which is located bilateral vocal fold
Direct laryngoscopy
the insertion of a flexible or rigid fiberoptic scope or a rigid laryngoscope to visualize back of the throat while the physician wears headgear that contains a mirror and light source; the mirror reflects light into the patient's mouth, allowing the physician to visualize the throat
Subluxation
the partial displacement of a bone from it joint
what do the surgical collapse therapy and thoracoplasty codes classify
the procedure to therapeutically collapse a pt's lung
Augmentation
the process of enlarging or increasing
Arytenoidopexy
the surgical fixation of arytenoid al cartilage and/or surrounding muscle
Replantation defined
the surgical reattachment of a finger, hand, toe, foot, leg, or an arm that has been completely severed from a body
When surgery is performed on the turbinates, what is important to identify?
the type of turbinate procedure and the technique used
Laryngoscopy
the visualization of the back of the throat, including the larynx and vocal cords
In the event a wedge resection is being performed but a intraoperative pathology consultation determines that a more extensive resection is necessary in the same anatomic location what is coded?
the wedge resection is coded as a diagnostic wedge resection and then code the more extensive resection as well
In the event a wedge resection is being performed and the intraoperative pathology consult determines that a more extensive resection is NOT necessary what do you code?
the wedge resection is coded as a therapeutic wedge resection
why is a thoracentesis performed
to make a diagnostic evaluation or to drain excess fluid from a pt with severe pleural effusion
Dislocation or luxation is a ________
total displacement of bone from its joint
When a laryngoscopy is part of a tracheostomy, only code the ________
tracheostomy
What does a fiberoptic scope do?
transmits light
Harvested bone tissue
transplanted to another site to promote osteogenesis or to provide structural stability
t/f a diagnostic endoscopy is often performed during an open surgical procedure to evaluate the surgical field
true
t/f arthrodesis may be performed independently from other procedures
true
t/f bunion deformities develop differently and repair requires different levels of complexity and different techniqures
true
t/f each lung has multiple segments
true
t/f if a nasal endoscopy , laryngoscopy is performed in addition to a bronchoscopy, you must only report the bronchoscopy
true
t/f some arthrodesis codes are exempt from modifier 51
true
t/f if pt undergoes precut. Vertebroplastry on L1 and L2 you must report 2 radiology codes for each segment
true (3M will give you two codes the book is wrong)
t/f spinal instrumentation procedures are reported in addition to the arthrodesis codes
true (the book wants you to add mod. 51 to the spinal instrumentation code, but this is wrong)
t/f manipulation of spine under anesthesia is performed to treat back pain and other disorders
true, the idea is that the pt is more relaxed under anesthia and better manipulation results
arthroscopic knee surgery is commonly performed and codes are located
under endoscopy/arthroscopy heading of musculoskeletal system
What do endoscopy codes classify?
unilateral procedures
Obturator
used to close a gap
Endoscopic nasal surgical approach
utilizes a fiberoptic endoscope instrument , which is inserted through the nostrils
tracheobronchoscopy
visual exam of interior of trachea and bronchus
define bronchoscopy
visual exam of the interior of the bronchus
thorascopy
visual exam of the pleural cavity and it provides an alternative to open lung or thoracotomy procedures to hrpleural disorders surgically
define tracheoscopy
visual exam of the trachea
Larynx
voice box
When do you report other procedure codes?
when procedures are performed that are not reportable with codes from the grafts or implants codes
trachea aka
windpipe
DOES THE SURGICAL ENDOSCOPY/ARTHROSCOPY ALWAYS INCLUDE DIAGNOSTIC ENDOSCOPY/ARHTROSCOPY
yes
