CPT - Surgery
Arthroscopy of the right wrist with complete synovectomy
29845-RT arthroscopy, surgical, wrist
The surgeon performed an anterior-to posterior (total) intranasal endoscopic ethmoctomy with sphenoidotomy
31257 Endoscopy, nose, surgical
Patient has a large obstructing mass of the left glottis and subglottis. A direct laryngoscopy with biopsy was performed to reveal squamous cell carcinoma
31535 laryngoscoy, direct, biopsy
D&C performed for a patient with dysfunctional bleeding
58120 dilation and curettage, corpus uteri
Abdominal hysterectomy with salpingo-oophorectomy (uterus weight 270g)
58150 hysterectomy, abdominal, total
Endometrial cryoablation with ultrasonic guidance
58356 ablation, endometrial, with ultrasound guidance
Excision of rectal tumor transanal endoscopic approach
0184T Rcetum, tumor, excision, transanal endoscopic
Fine needle aspiration biopsy of mass in check, under fluoroscopic guidance
10007 biopsy, skin lesion, fine needle
Patient has a Grade III ulcer of the left heel. The physician debrided the 4 cm x 2 cm x 0.5 cm ulcer to the subcutaneous tissue. The #15 blade removed the fibrinous tissue
11005 debridement, skin, infected 11008 removal, mesh abdominal wall
The surgeon performs debridement down to and including the fascia of the abdominal wall due to necrotizing facilitis
11005 debridement, skin, skin, subcutaneous tissue, infected (The index entry for necrotized leads to an incorrect code)
Debridement of below-knee amputation stump. The necrotic wounds were sharply excised down to and including the fascia with a 10-blade scalpel (15 sq cm)
11043 debridement, muscle
Paring of 3 hyperkeratotic lesions from the patient's foot
11056 lesion, skin, paring
In the physician's office, the patient had a punch biopsy of a 1.0 cm skin lesion of the neck
11104 biopsy, skin lesion, punch
A wedge of tissue was biopsied from a mass on the patient's back. The sample was sent to pathology
11106 biopsy, skin lesion, incisional 11103 biopsy, skin lesion, tangential
Full-thickness wedge skin biopsies of suspicious tissue of the arm and hand
11106 biopsy, skin, incisional 11107 add-on code
Diagnosis: mass of chest area. The surgeon made an elliptical incision encompassing the whole mass (6.5 cm x 3 cm x 1.5 cm) dissecting laterally deep to the subcutaneous tissue. Pathology report reveals inflamed epidermal cyst.
11406 Lesion, skin, excision, benign
Pphysician excised a 1.0 cm squamous cell carcinoma from the forehead. The excision required margins of 1.0 cm around the lesion
11642 lesion, skin, excision, malignant
Layered (intermediate) wound repair of a 3-cm laceration of the hand and an intermediate repair of 5.0 cm of arm
12042 repair, wound, intermediate 12032-59 repair, wound, intermediate
Wide excision of a malignant lesion of back (5.0 cm x 3.0 cm) with adjacent skin graft
14001 skin graft and flap, tissue transfer
Physician performs a wide resection of a 3.0 cm malignant skin lesion of the left leg. The defect required an adjacent tissue transfer measuring 15 q cm
14021 skin graft and flap, tissue transfer
The surgeon performed a tubed pedicle flap from the forehead to cover the defect on the nose
15576 pedicle flap, formation
Laser removal of 16 lesions from the back
17111 lesion, skin, destruction, benign
With the use of ultrasound guidance, the surgeon placed a metallic clip to identify the suspicious tissue in the left breast. A percutaneous core needle biopsy was performed
19083-T breast, biopsy, with localization device placement, ultrasound guidance
bilateral total mastectomy with reconstruction using double-pedicle TRAM
19303-50 mastectomy, simple, complete 19369-50 reconstruction, breast, transverse rectus abdominis myocutaneous
Surgical exploration of stab wound of chest with included coagulation of blood vessels and enlargement of the wound
20101 wound, exploration, penetrating, chest
Open treatment with internal fixation of 3 rib fractures
21811 fracture, rib, open
Repair of medial collateral ligament of right elbow using local tissue
24345-RT ligament, elbow, collateral ligament, repair
Open reduction with internal fixation (screws), for a fracture of the left humeral shaft
24515-LT fracture, humerus, shaft, open treatment
The surgeon performed open reduction with internal fixation of medial condylar fracture of the humerus
24579 fracture, humerus, condyle, open treatment
Open reduction with internal fixation OORIF) of intertochanteric fractured femur using Gamma nail
27245 fracture, femur, intertrochanteric intramedullary implant
Removal of splinter embedded deep in the left skin
27372-LT removal, foreign body, knee joint
The orthopedic surgeon reduces a fracture of the left proximal fibula. After closed treatment and skeletal traction, the physician applies a short leg cast
27781-LT fracture, fibula, closed treatment (initial cast application included with treatment code)
Closed treatment of distal fibular fracture without manipulation; the patient was int he postoperative period for an arthroscopy of the shoulder performed 2 wks ago; the same physician performed both surgeries
27786-79 Fracture, fibula, closed treatment
Repair of hammertoe, second digit of right foot
28285-T6 hammertoe repair, correction
Arthroscopy of the left elbow with removal of loose body
29834-LT arthroscopy, surgical, elbow
Patient treated in the emergency department for severe epistasis (first visit for this condition); physician performs posterior packing, bilateral
30905 Epistaxis (see hemorrhage, nasal) Hemorrhage, control, nasal, initial (note: although this is a bilateral procedure, the NCCI edits did not prompt for -50)
Direct larngoscopy with injection of botulinum toxin for treatment of laryngeal dystoria
31570 Larynx, endoscopy, direct
The patient has a history of persistent hoarseness. The surgeon perfomrs a flexible laryngoscopy to evaluate the larynx
31575 laryngoscopy, flexibe, diagnostic
Flexible bronchoscopy with bronchial brushings and cell washings
31623 bronchoscopy, brushings (code for cell washings (31622) is a separate procedure)
bronchoscopy with transbronchial biopsy of lung
31628 bronchoscopy biopsy
Bronchoscopy for removal of tumor using argon plasma coagulation
31641 bronchoscopy, removal, tumor
Bronchoscopy with EBUS-guided transbronchia sampling of 2 mediastinal lymph nodes
31652 bronchoscopy, with endobronchia ustrasound (EBUS)
Percutaneous drainage of pleural cavity via indwelling catheter, with imaging
32557 puncture, pleural cavity, drainage
Insertion of permanent cardiac pacemaker with right atrial and ventricular transvenous electrodes; at a university hospital. The surgeon performed procedure but not the peroperative or postoperative care
33208-54 Pacemaker, heart, insertion (modifier for surgical care only)
The patient has been diagnosed with severe aortic stenosis. Through a percutaneous incision in the leg (transfemoral), the surgeon performs a transcatheter aortic valve replacement (TAVR)
33361 transcatheter aortic valve replacement, femoral artery approach
A coronary artery bypass graft (CABG) procedure was performed. The surgeon bypassed 3 coronary artery sites by grafting the left internal mammary artery (LIMA) and one site was treated by grafting the greater saphenous venous graft to the obtuse marginal from the aorta
33517 Coronary Artery Bypass Graft (CABG), arterial-venous bypass 33535 coronary artery bypass graft (CABG), arterial bypass
Open revision of AV fistula with thrombectomy, patient receiving hemodialysis
36833 arteriovenous fistula, revision, with thrombectomy
Ppercutaneous thrombectomy of forearm AV graft that was inserted for dialysis treatment
36904 thrombectomy, percutaneous, dialysis circuit
A patient is seen for surgical treatment of an occlusion of the femoral artery, left. Percutaneously, under guidance, the surgeon inserts a catheter to perform an atherectomy (lower extremity revascularization)
37225-LT revascularization, artery, femoral/popliteal
Procedure: Excision of pseudoaneurysm of temporal artery. Operative note states that the artery was divided and aneurysm removed. Artery was ligated with fine Vicryl suture
37609 artery, temporal, ligation
Mediastinoscopy with biopsy of mediastinal adenoma
39401 Mediastinoscopy, biopsy, mediastinal mass
Laparoscopic repair of recurrent incisional hernia
49656 hernia, repair, incisional, laparoscopic
Palatoplasty for cleft palate, soft
42200 palatoplasty
ERCP with removal of biliary stent
43275 bile duct, endoscopy, removal, foreign body
Laparoscopic gastric bypass and Roux-en-Y gastroenterostomy performed for obesity
43644 Laparoscopy, gastric restrictive procedures
Laparoscopy pyloroplasty
43659 unlisted laparoscopy procedure, stomach. There is not entry for laparoscopic pyeloplasty. The open procedure is 43800
percutaneous replacement of gastrostomy tube requiring debridement of granulation tissue in order to insert the new tube
43763 gastrostomy tube, replacement, percutaneous, requireing revision of gastrostomy tract
Laparoscopic rectopexy for patient with prolapse
4500 Proctopexy, laparoscopic
Proctosigmoidoscopy with remova of 2 polyps with the use of hot biopsy forceps
45315 proctosigmoidoscopy, removal of polyp
The surgeon performs a colonoscopy that extends to the first portion of the ascending colon before being stopped due to equipment failure
45378-53 Colonoscopy, flexible diagnostic
Under fluoroscopy, the physician percutaneously places an eternal biliary catheter into the bile duct for drainage
47533 bile duct, drainage, catheter, placement
Laparoscopic resection of cystic duct
47579 Unlisted laparoscopy procedure, biliary tract
Laparoscopic aspiration of ovarian cyst
49322 laparoscopy, aspiration
Laparoscopy with aspiration of ovarian cyst
49322 laparoscopy, aspiration, cyst
Recurrent incarcerated inguinal hernia repair with implantation of mesh (56-year-old patient)
49521 hernia, repair, inguinal, incarcerated
Inital repair of strangulated ventral hernia requiring mesh (49-year-old patient)
49568 implantation, mesh
Cystourethroscopy with fulguration of bladder tumor (3.0 cm)
52235 cystourethroscopy, with fulguration, tumor
Cystourethroscopy with ureteroscopy with lithotripsy and insertion of double J ureteral stent
52356 cystourethroscopy, with ureteroscopy
Biopsy of 2 lesions, 1 from labia minora and another from the vaginal oriffice, which requires suture closure
56605 biopsy, vulva (external genitailia) 57105 biopsy, vagina
Vulvectomy, partial removal of skin and superficial subcutaneous tissues
56620 vulvectomy, simple, partial (use definitions at beginning of section)
Hysteroscopy with polypectomy and D&C
58558 hysteroscopy, surgical with biopsy
Diagnosis: Chronic menometrorrhagia, uterine leiomyomata, and left Bartholin's gland cyst Procedure: Operative hysteroscopy with resection of submuccous myomas and left Bartholin's gland cystectomy
58561 hysteroscopy, removal, leiomyomata 56740 Bartholin's Gland, excision
laparoscopy with removal of tubes and ovaries; the operative report indicates that the procedure was extremely difficult to perform and took 2 hrs longer to complete than usual
58661-22 Laparoscopy, removal, fallopian tube
Patient desires elective sterilization. Surgeon performs laparoscopic coagulation of the fallopian tubes
58670 fallopian tube destruction, endoscopic
Total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, dissection of pelvic lymph nodes with removal of a portion of the para-aortic lymph nodes, and dubulking of ovarian tumors
58954 Salpingo-oophorectomy, resection ovarian malignancy
Patient with severe back pain requires a single interlaminar epidural steroid injection, L5-S1 interspace with imaging
62323 epidural, injection
parathyroidectomy
60500 parathyroid gland, excision
Laparoscopic hemithyroidectomy
60650 laparoscopy, adrenal gland, excision. Note: there is misleading index entry for this example. Adrenalectomy, aparoscopic, leads to 50545, which is incorrect
Laparoscopic hemithyroidectomy
60659 unlisted laparoscopy procedure, endocrine system (Laparoscopic procedures, on the endocrine glands are limited. This is a good example for students to leaving the index and explore the codes in the chapter)
Craniotomy for evacuation of supratentorial subdural hematoma
6132 craniotomy, surgery or hematoma, brain, evacuation via crainotomy
Open lumbar laminectomy for decompression of the spinal cord, L3-L4
63005 laminectomy, for decompression, lumbar
Glycerol rhizotomy of trigeminal nerve
64600 trigeminal nerve, destruction
Sciatic neuropasty, leg
64712 neoplasty, pherpheral nerve, sciatic
Suture repair of posterior tibial nerve
64840 suture, nerve
Bilateral tympanostomy with insertion of ventilating tube, performed under general anesthesia
69436-50 tympanostomy, general anesthesia