Medical Assistant Course 04/Medical Coding for the Career Professional

L04-205 Biopsy

"Biopsy" is a term applied to the procedure of removing tissue for histopathology (study of microscopic tissue changes). Removing a tissue sample of a lesion may be by needle aspiration (needle inserted for sampling of cells), incisional biopsy (open, sharp, and partial removal), or by excisional biopsy (complete removal). You would not report both a biopsy and an excision performed at the same time as the biopsy is bundled into the excision service.

L04-104 Medical decision making complexity levels (2)

2. Low-complexity decision making: Limited number of diagnoses and management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated.

L04-046 ICD-10-PCS Coding (3)

These are similar to what you had noticed in your ICD-10-CM. Definitions for each of these can be found on the page directly after the Table of Contents titled: SYMBOLS AND CONVENTIONS.

L04-032 Multiple coding for a single condition (2)

"Code first" notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a "code first" note and an underlying condition is present, the underlying condition should be sequenced first, if known. "Code, if applicable, any causal condition first," notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis.

L04-031 Multiple coding for a single condition (1)

"Use additional code" notes are found in the Tabular List at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition. "use additional code" indicates that a secondary code should be added, if known.

L04-200 Excision—debridement

(11000-11047) describe services of debridement based on depth, body surface, condition, and for 11004-11006 by location. The first debridement codes (11000 and 11001) are reported for eczematous debridement. Eczema is a skin condition that blisters and weeps

L04-2-4 Paring or cutting

(11055-11057) report the services when a physician removes a benign hyperkeratotic skin lesion such as a callus or corn. Paring codes include removal by peeling or scraping.

L04-215 Tissue-expander

(11960-11971) are also located in the Introduction category and report tissue expanders. A tissue expander is an elastic material formed into a sac that is then filled with fluid or air so it expands like a balloon. The expander is placed under the skin and is filled, stretching the skin.

L04-231 Blepharoplasty

(15820-15823), also performed predominantly for cosmetic purposes, is the removal of excess skin and to support the muscles of the upper eyelid. Rhytidectomy is the removal of wrinkles by pulling the skin tight and removing the excess.

L04-232 Rhytidectomy

(15824-15829) report these cosmetic services. Excision of excess skin and subcutaneous tissue of other parts of the body (e.g., abdomen, thigh, buttock, and arm) most commonly due to bariatric surgery is reported with codes in the 15830-15839 range. To report abdominoplasty with panniculectomy (excision of the hanging tissue in the abdominal region, report 15830 with add-on code 15847.

L04-233 Lipectomy (liposuction)

(15876-15879) are divided according to the body area being treated—head, trunk, upper extremities, and lower extremity. If the procedure is performed bilaterally, add modifier -50 to the procedure code.

L04-271 Grafts (or implants): Bone marrow aspiration for bone grafting

(20939) is most commonly used for lumbar spinal fusion. Only report code 20939 in addition to the primary procedure and when performed with spinal surgery. For bone marrow aspiration not performed with spinal surgery, reference code 20999.

L04-403 Hemic and lymphatic systems

(38100-38999) divided into subheadings: Spleen, General, and Lymph Nodes and Lymphatic Channel. Further division is based on type of procedure (i.e., excision, incision, repair). The codes for spleen and lymph nodes are located in the CPT manual index under main terms such as "Spleen," "Lymph Nodes," or "Bone Marrow."

L04-497 Evocative/suppression testing

(80400-80439) testing is performed to measure the effect of evocative or suppressive agents on chemical constituents. Remember that the codes from the Pathology and Laboratory section are only for the tests performed and do not reflect the complete service provided to the patient.

L04-508 Anatomic pathology

(88000-88099) report examination of body fluids or tissues in postmortem (after death) examination. Postmortem examination involves the completion of gross, microscopic, and limited autopsies.

L04-510 Surgical pathology

(88300-88399) describe the evaluation of specimens to determine the pathology of disease processes. When choosing the correct code for pathology, identify the source of the specimen and the reason for the surgical procedure.

L04-519 Immune Globulins

(90281-90399) are passive immunization agents obtained from pooled human plasma that is immune to a particular disease. The codes in this subsection identify only the immune globulin product and must be reported with the appropriate administration code (96365-96368, 96372, 96374, or 96375 as appropriate).

L04-526 Vaccines, toxoids

(90476-90749, 91300-91304) report vaccine products for immunizations. CMS RULES When reporting an adult dose of a pneumococcal vaccine (90732) to Medicare, the pneumococcal administration code is G0009 with a diagnosis code of Z23 (prophylactic vaccination, Streptococcus pneumoniae).

L04-533 Gastroenterology

(91010-91299) contains many types of tests and treatments that are performed on the esophagus, stomach, and intestine.

L04-534 Ophthalmology

(92002-92499) Ophthalmology is a very specialized field and ophthalmologists treat patients for a variety of diseases and injuries. The subheading Special Ophthalmological Services contains bilateral codes.

L04-539 Special otorhinolaryngologic services

(92502-92700) special tests or studies of the ears, nose, and larynx. Audiology (hearing) testing is also located in the Special Otorhinolaryngologic Services subsection. An audiology test may be performed by a physician or an audiologist trained in this area. Otorhinolaryngologic diagnostic and treatment services are usually reported using codes from the Surgery section.

L04-377 Signal-averaged electrocardiography (SAECG)

(93278) SAECG is a type of electrocardiography that can help physicians predict certain tendencies to abnormalities such as ventricular tachycardia. The signal is recorded during nine periods, each lasting 10 to 20 minutes, and the computer manipulates the data produced and predicts certain tendencies. The SAECG is a more sophisticated ECG than the standard ECG and is used when a standard ECG is unable to demonstrate the suspected conductive abnormalities.

L04-384 Intracardiac electrophysiologic procedures/studies

(93600-93662) contains codes that describe services that diagnose and treat the electrical system of the heart using less invasive procedures.

L04-544 Neurology and neuromuscular procedures

(95700-96020) subsection for sleep testing, muscle testing (electromyography), range of motion measurements, cerebral seizure monitoring, and a variety of neurologic function tests.

L04-555 Osteopathic manipulative treatment (OMT)

(98925-98929) is a form of manual treatment applied by a physician to eliminate or alleviate somatic (body) dysfunction and related disorders. The codes are listed according to body regions. These body regions are the head; cervical, thoracic, lumbar, sacral, and pelvic regions; lower extremities; upper extremities; rib cage; abdomen and viscera region.

L04-556 Chiropractic manipulative treatment (CMT)

(98940-98943) the spine is divided into five regions (cervical, thoracic, lumbar, sacral, and pelvic), and the extraspinal regions are divided into five regions (head, lower extremities, upper extremities, rib cage, and abdomen). Chiropractic manipulation is the manipulation of the spinal column and other structures. Each of the codes in the Chiropractic Manipulative Treatment subsection has a professional assessment bundled into the code.

Observation care discharge services

(99217) includes the final examination of the patient upon discharge from observation status. The code is used only with patients who are discharged on a day that follows the first day of observation.

L04-124 The subsection of Hospital Inpatient Services: Subsequent Hospital Care

(99231-99233) is the second subheading of codes in the Hospital Inpatient Services subsection. The Subsequent Hospital Care codes are used by physicians to report daily hospital visits while the patient is hospitalized. Subsequent codes in the subsection indicate (in the "Usually, the patient..." area) the status of the patient, such as stable/unstable or recovering/unresponding.

L04-131 Hospital discharge services

(99238, 99239) are reported on the final day of services for a multiple-day stay in a hospital setting. The codes are based on the time spent by the physician in handling the final discharge of the patient, and the time spent must be documented in the medical record. The Hospital Discharge Services codes are not assigned if the physician is a consultant, unless the primary physician transfers complete care to the consultant.

L04-134 Office or other outpatient consultations

(99241-99245) report consultative services provided to a patient in an office setting. Outpatient consultations include consultations provided in the emergency department because the patient is considered an outpatient in the emergency department setting. The codes are for both new and established patients. The codes in this subsection are of increasing complexity, based on the three key components and any contributory factors.

L04-135 Inpatient consultations

(99251-99255). This subheading is used for both new and established patients and can be reported only one time per patient admission, per consulting physician, per specialty.

L04-136 Critical care service

(99291, 99292) identify services that are provided during medical emergencies to patients over 71 months of age who are either critically ill or injured. Critical care is often, but not required to be, provided in an acute care setting of a hospital. Acute care settings are intensive care units, coronary care units, emergency departments, and similar critical care units of a hospital.

L04-141 Four subheadings of nursing facility services are available: Initial nursing facility care

(99304-99306) do not distinguish between new and established patients. These codes report services provided by the physician at the time of admission or re-admission. Assessments by physicians play a central role in the development of the resident's individualized care plan. The care plan is developed by an interdisciplinary care team using the Resident Assessment Instrument (RAI) and the Minimum Data Set (MDS).

L04-142 Subsequent nursing facility care

(99307-99310) do not distinguish between a new and an established patient. These codes reflect services provided by a physician on a periodic basis when a resident does not need a comprehensive assessment. The higher level codes are assigned to patients with new problems or significant changes in existing problems.

L04-143 Nursing facility discharge services

(99315, 99316) report the services the physician renders to the patient on the day of discharge. The codes are assigned based on the amount of time documented for discharge management. Code 99315 is assigned if 30 minutes or less or when no time is documented. Code 99316 is reported for documented time of greater than 30 minutes. The time spent need not be continuous or spent entirely with the patient but must be documented.

L04-145 Domiciliary, rest home (e.g., boarding home), or custodial care services

(99324-99337) are divided into subheadings based on the patients' status as new or established service provided. The codes are arranged in levels based on the documentation in the patient's medical record. Generally, health services are not available on site, nor are any medical services included in the codes.

L04-635 Anteroposterior (AP)

(front to back) position, in which the patient has his or her front (anterior) closest to the x-ray machine, and the x-ray travels through the patient from the front to the back.

L04-638 Dorsal

(more commonly refers to the "back" but may be stated to mean "supine") means lying on the back; ventral (more commonly refers to the "anterior" but may be stated as "prone") means lying on the stomach; and lateral means lying on the side.

L04-168 Anesthesia Coding: CPT Manual (00100-01999)

* Induced temporary administration of gases or injections of drugs that provides pain relief to the body or a body part. * Anesthesia: General, Regional, and includes administration of fluids, blood, and vital sign monitoring. * ADMINISTERED BY: anesthesiologist (doctor); anesthetist (CRNA) * PLACE of SERVICE: office; hospital; ambulatory center

L04-622 You'll add a modifier to the CPT code to indicate which of these situations applies.

* Modifier -26 indicates the radiology service provided was for the professional component (reviewed and interpreted by the physician). * Modifier -TC indicates the technical component (obtained by the technician but not reviewed or interpreted by the physician).

L04-347 The Cardiovascular procedures that you'll code most often are:

* Pacemaker insertions, repairs, and revisions * Coronary artery bypass grafts (CABGs) * Percutaneous transluminal coronary angioplasties (PTCAs) and stent placements * Cardiac catheterizations

L04-225 Skin replacement surgery (15002-15278)

- A pinch graft (15050) is a small, split-thickness repair. - Autografts are grafts that are taken from the patient's body (Fig. 14-24), whereas allografts (homografts) are grafts that are taken from a human donor. - Acellular dermal replacement (15271-15278) is the use of skin replacement products based on the location and size of repair. - Temporary allografts are also reported with 15271-15278 based on the location and size of repair. - A permanent graft may be placed over the site at a later date to complete the repair process.

L04-299 Introduction codes (30200-30220)

- Injections into the turbinates (30200) are therapeutic injections usually performed to shrink the nasal tissue to improve breathing. - Displacement therapy (30210) is a procedure in which the physician flushes saline solution into the sinuses to remove mucus or pus. - The insertion of a nasal button (30220) is a technique used for a patient who has a perforated septum.

L04-151 Three different categories of Anesthesia:

- Local anesthesia numbs a specific part of the body. - Regional anesthesia suppresses feeling in a wider anatomical area, such as the leg, arm, or face. - General anesthesia is administered in cases that require suppression of the patient's entire nervous system.

L04-503 Molecular Pathology codes

- Tier 1 codes (81105-81383) report services for molecular assays that are more commonly performed. - Tier 2 codes 81400-81408 involve less commonly performed analyses and are arranged by the required level of technical resources and the level of physician interpretation or other qualified health professional. Tier 1 or Tier 2 is reported with 81479 (unlisted molecular pathology procedure).

L04-358 Vascular repairs

- Vein repairs are performed by locating the defective vessel, clamping the vessel off, and bypassing or grafting the defect. - Arteriovenous Fistula category codes (35180-35190) are reported for fistula repair and are divided on the basis of whether the fistula (abnormal passage) is congenital, acquired, or traumatic. - The aneurysm codes often refer to a pseudoaneurysm (false aneurysm), which is an aneurysm in which the vessel is injured and the aneurysm is being contained by the tissue that surrounds the vessel.

L04-128 Attending physician (2)

- legally responsible for the care and treatment provided to a patient. - may be a patient's personal physician or may be a physician assigned to a patient who has been admitted to a hospital through the emergency department. - usually a provider of primary care, such as a family practitioner, internist, or pediatrician, but the attending physician may also be a surgeon or another type of specialist.

L04-129 Attending physician (3)

- member of the academic or medical school staff who is responsible for the supervision of medical residents, interns, and medical school students and oversees the care the residents, interns, or students provide to the patients.

L04-492 The types of ligation:

- tying off the tube with suture material (ligation) - removing a portion of the tube (transection) - blocking the tube with a device, such as a clip, ring, or band (occlusion) Do not use a bilateral procedure modifier (-50) with codes in the Incision category because the code descriptions indicate "tube(s)" or "unilateral or bilateral."

L04-014 0DTJ

0 - Medical and Surgical (the first character is for section) D - Gastrointestinal System (the second character is the body system where the surgery was performed) T - Resection (the third character is for the root operation that was performed) J - Appendix (the forth character is for the body part on which the surgery was performed) Entire appendix removed using open approach. Since there are no special devices or qualifying circumstances for this procedure, the sixth and seventh characters are Z.

L04-627 Radiology Terminology (1)

1 aortography - aorta 2 arthrography - joint 3 cholangiopancreatography - biliary system and pancreas 4 cholangiography - bile ducts 5 cystography - urinary bladder 6 dacryocystography - lacrimal sac or tear duct sac 7 duodenography - duodenum or first part of the small intestine 8 echocardiography - heart or heart walls or neighboring tissues 9 encephalography - subarachnoid space and ventricles of the brain 10 epididymography - epididymis with contrast material 11 hepatography - liver 12 hysterosalpingography - uterine cavity and fallopian tubes 13 laryngography - larynx 14 lymphangiography- lymphatic vessels and node 15 myelography - spinal cord 16 pyelography - ureter and renal pelvis 17 sialography - salivary duct and branches 18 sinography - sinus or sinus tract 19 splenography - spleen 20 urography - any part of the urinary system 21 venography - vein and tributaries 22 vesiculography - seminal vesicles

L04-015 Some additional pointers to keep in mind as you learned assign procedure codes using ICD-10-PCS:

1. Don't get stressed! Understand the logic. If you understand what you need to do in terms of reviewing the record so that you can build your codes. It'll become easier. 2. Think of each character in your code as telling a part of the story. 3. In addition to assigning codes for surgeries, you'll use other sections of ICD1-10-PCS to assign codes for services that don't pertain to operations, such as radiation therapy, imaging, obstetrics, mental health, and substance abuse.

L04-628 Radiographic Terms: Fluoroscopy

1. Fluoroscopy is an x-ray procedure that allows the visualization of internal organs in motion. It uses real-time video images. After x-rays pass through the patient, instead of using film, the images are captured by a device called an image intensifier and converted into light. The light is then captured by a camera and displayed on a video monitor. Fluoroscopy allows the study of the function of the organ (physiology) as well as the structure of the organ (anatomy).

L04-502 The main things to remember when coding from these two subsections are:

1. Identify specific tests 2. Determine if the test was automated (by machine) or nonautomated (manual) 3. Number of tests performed 4. Identify combination codes for similar types of tests 5. Whether the results are qualitative or quantitative 6. Method of testing

L04-559 Steps to accurate coding

1. Identify the main term(s) in the diagnostic statement. 2. Locate the main term(s) in the Alphabetic Index (referred to in this material as the Index). 3. Review any subterms under the main term in the Index. 4. Follow any cross-reference instructions, such as see. 5. Verify the code(s) selected from the Index in the Tabular List (referred to in this material as the Tabular). 6. Refer to any instructional notations in the Tabular. 7. Assign codes to the highest level of specificity. 8. Code the diagnosis until all elements are completely identified.

L04-244 The following tips will help you to choose the most correct code from this subsection:

1. Identify whether the procedure is being performed on soft tissue or bone. 2. Determine whether treatment is for a traumatic injury (acute) or a medical condition (chronic). 3. Identify the most specific anatomic site. 4. Determine whether the code description includes grafting or fixation. 5. Read the code carefully to determine whether it describes a procedure that was on a single site (e.g., each finger). HCPCS modifiers are used to identify the digit treated, such as F6 for right hand, second digit. 6. Check any medical terms you do not understand in a medical dictionary or in the Glossary at the back of the book.

L04-184 CMS RULES The documentation must support that certain services were personally performed by the physician. These include:

1. Pre-anesthesia examination and evaluation 2. Prescription of an anesthesia plan 3. Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence 4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist 5. Monitors the course of anesthesia administration at frequent intervals 6. Remains physically present and available for immediate diagnosis and treatment of emergencies 7. Provides indicated post-anesthesia care (42 C.F.R. 415.110 Conditions for Payment: Medically directed anesthesia services)

L04-102 Examination levels

1. Problem focused: Examination is limited to the affected body area or organ system identified by the chief complaint. 2. Expanded problem focused: A limited examination is made of the affected body area or organ system and other symptomatic or related body area(s)/organ system(s). 3. Detailed: An extended examination is made of the affected body area(s) and other symptomatic or related organ system(s). 4. Comprehensive: This is the most extensive examination; it encompasses a general multi-system examination and should include findings about 8 or more of the 12 organ systems.

L04-644 Radiology Guidelines

1. Professional: describes the services of the physician, including the supervision of the taking of the x-ray film and the interpretation with report of the x-ray films. 2. Technical: describes the services of the technologist, as well as the use of the equipment, film, and other supplies. 3. Global: describes the combination of the professional and technical components (1 and 2).

L04-339 Approaches: Epicardia

1. The epicardial approach involves opening the chest cavity and placing a lead on the epicardial sac of the heart. A pocket is formed in either the upper abdomen or under the clavicle, and the pacemaker generator is placed into the pocket. The wires are then connected to the pacemaker generator and the chest area is closed. Codes for the epicardial process are further divided based on the approach to the heart—thoracotomy, upper abdominal (xiphoid region), or endoscopic.

L04-027 Steps for Accurate Coding

1. Review the medical record to determine the patient's diagnosis. 2. Determine the main term and sub-term in the diagnosis. 3. Look up the diagnosis in the Alphabetic Index. 4. Find the code(s) in the Tabular List 5. Review any instructional notes in the Tabular List and assign your code.

L04-341 The same set of criteria applies to choosing the correct implantable defibrillator codes:

1. Revision or replacement of lead(s) 2. Replacement, repair, removal of components 3. Approach used for insertion or repair A change of batteries in a pacemaker or an implantable defibrillator is a removal of the implanted generator and the reimplantation (insertion) of a new generator. If only the pulse generator is replaced, only the appropriate code for the generator removal/insertion is reported; an additional code for the removal of the generator is not separately reported.

L04-040 Code Structure: The Seven Characters in Specific Locations in a Code

1. Section 2. Body System (on which the surgery was performed) 3. Root Operation (the type of operation performed) 4. Body Part (the specific body part within the body system that required surgery) 5. Approach (the surgical approach that the physician used to perform the surgery) 6. Device (if any) 7. Qualifier (any additional circumstance surrounding the procedure)

L04-223 Component (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.

L04-103 Medical decision making complexity levels (1)

1. Straightforward decision making: Minimal diagnosis and management options, minimal or none for the amount and complexity of data to be reviewed, and minimal risk to the patient of complications or death if untreated.

L04-073 Medical records documentation (1-3)

1. The medical record should be complete and legible. 2. Documentation of each encounter should include the date, reason for encounter, appropriate history and physical examination, review of ancillary services, assessment, and plan of care with provider signature and date. 3. Past and present diagnoses should be accessible to the treating and/or consulting physician.

L04-203 Three final notes on treatment of lesions:

1. The shaving of lesions requires no closure because no incision has been made. 2. Excision includes simple closure but may require more complex closure. If more complex closure is required, follow the notes in the CPT manual to appropriately code for these services. 3. Destruction may be by any method, including freezing, burning, chemicals, etc.

L04-645 CODING SHOT

1. Third-party payment is generally 40% for the professional component, 60% for the technical component, and 100% for the global service. 2. -TC (Technical Component) and -26 (Professional Component) are terms used by third-party payers. When contacting a payer regarding payment of a service, first determine if there is a separate allowance for the -TC and -26.

L04-336 Three things about the service provided to correctly code the pacemaker:

1. Where the electrode (lead) is placed: atrium, ventricle, or both ventricle and atrium 2. Whether the procedure involves initial placement, replacement, upgrade or repair of all components or separate components of the pacemaker 3. The approach used to place the pacemaker (epicardial or transvenous)

L04-045 ICD-10-PCS Coding (2) They are numbered 1 through 7, pertaining to the following:

1. represents where the procedure will be coded from, such as Medical Surgical section, Imaging section, etc. 2. represents the body system or type of procedure, such as the Respiratory System or the Musculoskeletal system. 3. is a specific type of procedure such as incision, excision, removal, transplant, etc. 4. What part of the body will the procedure be done on; an example of this might be bone, lung, thyroid, etc. 5. How will the procedure be performed: Is it being done through an open incision, percutaneously, externally, or through a natural opening? 6. determines if any device is remaining in the body, such as a graft, implant, prosthesis, etc. 7. represents more description that is specific to the procedure.

L04-524 Example—Administration

90471 - Administration service for tetanus 90472 × 2 - Administration service, rubella and diphtheria

L04-629 Radiographic Terms: Magnetic resonance imaging (MRI

2. Magnetic resonance imaging (MRI) is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The magnet creates a strong magnetic field that aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body and produces a faint signal that is detected by the receiver portion of the MRI scanner. The received information is processed by a computer, and an image is then produced.

L04-340 Approaches: Transvenous

2. The transvenous approach involves accessing a vein (subclavian or jugular) and inserting an electrode (lead) into the vein. The pacemaker is affixed by creating a pocket into which the pacemaker generator is placed. The fluoroscopy views the internal structure by means of x-rays. Fluoroscopic guidance is included in 33206-33249. Diagnostic fluoroscopic guidance for diagnostic lead evaluation with lead insertion, replacement, or revision is reported with 76000. Transvenous codes are further divided based on the area of the heart into which the pacemaker is inserted. If the pacemaker electrodes were placed in both the atrium and ventricle, 33208 (dual-lead pacemaker) is reported.

L04-105 Medical decision making complexity levels (3)

3. Moderate-complexity decision making: Multiple diagnoses and management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.

L04-630 3. Radiographic Terms: Tomography

3. Tomography is the process of producing a tomogram, a two-dimensional image of a slice or section, through a three-dimensional object. Tomography achieves this result by simply moving an x-ray source in one direction as the x-ray film is moved in the opposite direction. The tomogram is the picture, tomograph is the apparatus, and tomography is the process.

L04-631 Radiographic Terms: Biometry

4. Biometry is the application of a statistical method to a biologic fact. For example, the application of this science in radiology has resulted in analysis of data, for example, of the effectiveness of radiation used in the treatment of brain tumors—science applied to biology.

L04-106 Medical decision making complexity levels (4)

4. High-complexity decision making: Extensive diagnoses and management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.

L04-074 Medical records documentation (4-6)

4. The reasons for and results of x-rays, lab tests, and other ancillary services should be clear. 5. Relevant risk factors should be identified. 6. The patient's progress and response to treatment, any change in treatment or change in diagnosis, and any patient noncompliance should be documented.

L04-075 Medical records documentation (7)

7. A written plan of treatment should include, when appropriate, treatments and medications, specifying frequency and dosage, any referrals or consultations, patient or family education, and any specific instructions for follow-up care.

L04-076 Medical records documentation (8)

8. Documentation should report the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of the medical decision making.

L04-511 Surgical Pathology subsection codes: LEVEL 1

88300 identifies specimens that normally do not need to be viewed under a microscope for pathologic diagnosis (e.g., a tooth)—those for which the probability of disease or malignancy is minimal.

L04-512 Surgical Pathology subsection codes: LEVEL 2

88302 deals with those tissues that are usually considered normal tissue and have been removed not because of the probability of the presence of disease or malignancy, but for some other reason (e.g., a fallopian tube for sterilization, foreskin of a newborn).

L04-513 Surgical Pathology subsection codes: LEVEL 3

88304 is assigned for specimens with a low probability of disease or malignancy. For example, a gallbladder may be neoplastic (benign or malignant), but when the gallbladder is removed for cholecystitis (inflammation of the gallbladder), it is usually inflamed from chronic disease and not because of cancerous changes.

L04-514 Surgical Pathology subsection codes: LEVEL 4

88305 designates a higher probability of malignancy or decision making for disease pathology. For example, a uterus is removed because of a diagnosis of prolapse. There is a possibility that the uterus is malignant or that there are other causes of disease pathology.

L04-515 Surgical Pathology subsection codes: LEVEL 5

88307 classifies more complex pathology evaluations (e.g., examination of a uterus that was removed for reasons other than prolapse or neoplasm).

L04-516 Surgical Pathology subsection codes: LEVEL 6

88309 includes examination of neoplastic tissue or very involved specimens, such as a total resection of a colon.

L04-077 Medical records documentation (9-10)

9. All entries should be dated and authenticated by provider or provider extender. 10. The CPT and ICD-10-CM codes reported on the insurance claim or billing statement should reflect (support) the documentation in the medical record.

L04-523 Example without counseling

90471 - Administration service for tetanus 90749 - Tetanus toxoid (substance injected, IM) 90472 - Administration service for rubella 90749 - Rubella virus (substance injected, SC) 90472 - Administration service for varicella (may require modifier -59, based on payer guidelines) 90716 - Varicella virus vaccine, split virus (substance injected, SC)

L04-525 Example—Multiple Vaccines

90471 - Administration service for tetanus and diphtheria 90714 - Tetanus and diphtheria toxoids (substances injected, IM) 90472 - Administration service for rubella 90749 - Rubella virus (substance injected, SC)

L04-120 Subsequent observation care.

99224-99226 range. The codes report the physician's services for day 2 to the date of discharge. The code assignment is based on the documented level of at least two of the three key components (history, examination, and complexity of medical decision making). These codes indicate the time the physician typically spends providing the service. (Note that these are resequenced codes.)

L04-447 Meckel's diverticulum and the mesentery

A Meckel's diverticulum is a fairly common congenital pouch on the wall of the small bowel that may contain pancreatic or stomach tissue and may require surgical removal (44800). Removal of the omphalomesenteric duct refers to the embryonic passage that connects an egg sac to the intestine and is included in the code description of 44800.

L04-170 Anesthesia: Physical Status Modifiers (2)

A Qualifying Circumstance is an "Add on" code and a plus sign (+) is used to attach it to the main code. An Add on code can never be used as a primary code and can never be reported alone. These codes are used for more specificity when coding unusual risk factors or circumstances about the patient or the patient's condition.

L04-173 Swan-Ganz catheter

A Swan-Ganz catheter is not a normal service provided during a surgery, so it could be reported using a code from the Medicine section for placement of a flow-directed catheter (93503). Some payers will require modifier -59 (distinct procedural service) be appended to the catheter code if another central line is also placed. Reporting the insertion separately and also adding the insertion time to the anesthesia service would result in double payment for the insertion service.

L04-407 Coding highlights: General

A bone marrow or blood cell transplant is a treatment for some blood diseases, such as leukemia or lymphoma. Bone marrow aspiration (38220) is a procedure in which a sample of the bone marrow is taken by means of a needle that is inserted into the marrow cavity. Bone marrow biopsy (38221) is a procedure in which small pieces of the marrow are obtained by means of a needle or trocar.

L04-435 Branchial cleft

A branchial cleft cyst is a congenital defect that appears as a gill located on the neck. Branchia is Greek for gills, which the cyst resembles.

L04-242 Mastectomy procedures

A breast lesion is often identified as a result of a screening mammogram, and a breast biopsy is then scheduled. If a biopsy is obtained in the operating room and based on the results of the biopsy, a mastectomy is performed, the biopsy is bundled into the mastectomy. Any breast procedure performed on both breasts must be reported as a bilateral procedure (modifier -50).

L04-097 History levels: 1. Problem focused:

A brief history would include a review of the history regarding pertinent information about the present problem or chief complaint. Brief history information would center around the severity, duration, and/or symptoms of the problem or complaint. The brief history does not have to include the past, family, or social history or a review of systems. A brief HPI includes one to three of the eight elements.

L04-429 Cleft palate

A cleft palate may also be present with a cleft lip, and if repair of the palate is performed at the time of the lip repair, the palate repair is reported separately with codes from the 42200 series.

L04-499 Pathology clinical consultations

A clinical pathologist, upon request from a primary care physician, will perform a consultation to render additional medical interpretation of test results. - (80503-80506) can be based on either the level of medical decision making (MDM) or the total time spent on the date of consultation. - If reporting based on MDM, determine whether the level was straightforward (80503), moderate (80504), or high (80505), but also based on two out of the three MDM elements. - Report 80503 for 5-20 minutes of total time, 80504 for 21-40 minutes of total time, and 80505 for 41-60 minutes of total time. Each additional 30 minutes after the initial 60 minutes of total time should be reported with 80506 as an add-on code to 80505 only.

L04-617 Auditory system: (Inner ear) Introduction

A cochlear device implant is a computerized device that restores partial hearing in those who are profoundly hearing impaired. A receiver on the outside of the skin behind the ear picks up sound waves. The receiver is placed over the transmitter, which is surgically implanted under the skin behind the ear. A sound processor is connected to an electrode implanted between the processor and the cochlea, and it receives a signal from the transmitter and transfers the signal to the cochlear nerve. The implantation of the cochlear device is reported with 69930.

L04-561 Combination code

A combination code is a single code used to classify: - Two diagnoses, or - A diagnosis with an associated secondary process (manifestation) - A diagnosis with an associated complication Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs.

L04-034 Combination codes (1)

A combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List.

L04-601 Anterior segment: LENS

A common procedure performed on the lens of the eye is cataract removal. Cataract removal and lens replacements (66830-66990) utilize one of two different approaches or techniques: ■ Extracapsular cataract extraction (ECCE) is the removal of the capsule and is the most common method. It removes the hard nucleus of the lens in one piece and the soft cortex in multiple pieces. The posterior lens capsule is left in place. Report with codes 66982, 66984, 66987, or 66988, depending on the complexity and whether there is endoscopic cyclophotocoagulation. ■ Intracapsular cataract extraction (66983) (ICCE) is the removal of the lens and surrounding lens capsule, which removes the cataract in one piece.

L04-281 Foot and toe repairs

A common procedure performed on the toe is a hallux valgus correction (bunion surgery). Hallux is the great toe and valgus is the angulation of the toe away from the midline.

L04-132 Consultation services (1)

A consultation is a service provided by a physician whose opinion or advice regarding the management or diagnosis of a specific problem has been requested. "Request for consultation" used to be termed "referral"; making a referral means that the referring physician is asking for the advice or opinion of another physician (a consultation). Some third-party payers have chosen to define referral to mean a total transfer of the care of a patient.

L04-300 Removal of a foreign body

A variety of objects are inserted into the various orifices (openings) of the body, and the nose is a common place into which these foreign objects are placed. The code to report an office procedure for the removal of a foreign body from the nose is 30300.

L04-593 Anterior segment: CORNEA (2) Keratoplasty

A keratoplasty is repair of the cornea. Codes 65710-65756 report keratoplasty based on the type of procedure performed and include grafts and preparation of donor material. A penetrating keratoplasty (65730-65755) is the removal of the full thickness of the cornea and replacement with donor cornea. A lamellar keratoplasty (65710) is a procedure in which only a thin layer of the cornea is removed and replaced with donor cornea.

L04-615 Auditory system: (Inner ear) Incision and/or destruction

A labyrinth is a cavelike structure, located in the inner ear. The labyrinth is dominated by two fluid-filled spaces that contain endolymph and perilymph. A labyrinthotomy is a procedure in which the labyrinth is surgically incised and various procedures performed to return the labyrinth to functional condition. Code 69801 is reported for a labyrinthotomy.

L04-616 Auditory system: (Inner ear) Excision

A labyrinthectomy is a procedure in which the incus and stapes are removed. If a transcanal approach is used, report 69905. If a postauricular incision (behind the ear) is used as the approach, report 69910.

L04-312 REPAIR: Laryngoplasty

A laryngoplasty for a laryngeal web is a surgical procedure, usually performed in two stages, for the repair of congenital webbing between the vocal cords. The surgeon removes the webbing and places a spacer between the vocal cords. At a later time, the surgeon will again expose the vocal cords, using the same tracheostomy incision made on the initial procedure, and remove the spacer.

L04-584 Ocular and Auditory System Coding: Slit lamp

A lighted microscope called a slit lamp is used to examine the eye and locate the foreign body. In the case of eye removals, the physician may remove the inside of the globe of the eye while leaving the sclera and extraocular muscles intact. This procedure is called evisceration. In other cases, the physician may choose enucleation, removing the eye while leaving the structures of the orbit intact. If the physician removes the adnexa, eye, and a portion of the orbit, the procedure is an exenteration.

L04-412 Two categories of codes for lymphadenectomies:

A limited lymphadenectomy (38562-38564) is the removal of the lymph nodes only; A radical lymphadenectomy (38700-38780) is the removal of the lymph nodes, gland(s), and surrounding tissue.

L04-463 Liver: Transplant

A liver transplant is a complex procedure that usually involves the surgical expertise of several physicians and a trained surgical team. The transplant procedure involves obtaining the graft to be transplanted (from a cadaver or living donor), backbench work (special preparation of the graft before transplantation), and transplantation into the recipient.

L04-470 Nephrotomy

A nephrotomy is exploration of the inside of the kidney.

L04-500 Specimen, Block, and Section

A specimen is a sample of tissue from a suspect area; a block is a frozen piece of a specimen; and a section is a slice of a frozen block. A pathologist prepares a specimen by cutting it into blocks and taking sections from the blocks. Each specimen may be reported separately, but each slide from that specimen may not.

L04-137 Nursing facility

A nursing facility is not a hospital but does have inpatient beds and a professional health care staff that provides health care to persons who do not require the level of service provided in an acute care facility.

L04-335 Pacemaker or implantable defibrillator

A pacemaker and implantable defibrillator (33202-33273) are devices that are inserted into the body to electrically shock the heart into regular rhythm. When a pacemaker is inserted, a pocket is made and a generator and lead(s) are placed inside the chest. Sometimes, only components of the pacemaker are reinserted, repaired, or replaced.

L04-348 Pacemaker insertions, repairs, and revisions

A pacemaker ensures that the heart appropriately "keeps pace". Patients may require these pacemaker surgeries: - replacement - revision - battery change - lead adjustment Pacemaker-related surgeries Codes 33202-33275 The key to coding pacemaker: Closely compare the surgery described in the medical record to the code description in code range 33202-33275.

L04-110 There are five types of presenting problems: ■ Minimal

A problem may not require the presence of the physician, but a service is provided under the physician's supervision. A minimal problem is a blood pressure reading, a dressing change, or another service that can be performed without the physician being immediately present.

L04-333 Cardiac tumor

A procedure performed to remove a tumor of the pericardium is reported using a code from the Pericardium category (33016-33050), but if a tumor is removed from the heart, you would select a code from the category Cardiac Tumor (33120, 33130). There are only two tumor-removal codes in the Cardiac Tumor category, one for a tumor that is removed from inside the heart (intracardiac) and one for a tumor that is removed from outside the heart (external). Both procedures are open surgical procedures that involve opening the chest, spreading the ribs, and excising the tumor.

L04-527 Psychiatry

A psychiatrist is a physician who specializes in psychiatry, the practice of diagnosing and treating mental disorders. A psychologist is not a physician but is a qualified specialist in psychiatry. Partial hospitalization refers to a hospital setting in which the patients are in the hospital during the day and return to their homes in the evenings and on weekends.

L04-036 Late effects (sequela) (1)

A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.

L04-428 Rhinoplasty

A rhinoplasty may be required if a nasal deformity has occurred with the cleft lip defect. These defects occur when the muscle, rather than encircling the mouth, attaches to the nose and pulls the nose out of normal position. If a rhinoplasty is performed with a cleft lip repair, the rhinoplasty is reported separately with 30460 or 30462.

L04-417 Sentinel lymph node biopsy

A sentinel lymph node biopsy is bundled into a planned lymphadenectomy and not paid separately.

L04-241 Mastectomies:

A simple or complete mastectomy (19303) is one in which all of the subcutaneous tissue and breast tissue are removed and the nipple and skin may or may not be removed. A modified radical mastectomy (19307) is one in which the breast is removed in addition to the axillary lymph nodes, and the pectoralis minor muscle may or may not be removed. The pectoralis major muscle is not removed in the modified radical mastectomy. A radical mastectomy (19305) is one in which the entire breast is removed in addition to the pectoral muscles and axillary lymph nodes. Code 19306 reports another type of radical mastectomy that includes the internal mammary lymph nodes and is also known as an Urban type operation.

L04-337 Single Pacemaker

A single pacemaker has one lead (atrium or ventricle), a dual pacemaker has two leads (one lead in the right atrium and one in the right ventricle), and a biventricular pacemaker has three leads (one in the right atrium, one in the right ventricle, and one on the left ventricle via the coronary sinus vein).

L04-138 Skilled nursing facility (SNF)

A skilled nursing facility (SNF) is one that has a professional staff that often includes physicians and nurses. The patients of a skilled nursing facility require less care than that given in an acute care hospital, but more care than that provided in a nursing home. Skilled nursing facilities are also called skilled nursing units, skilled nursing care, or extended care facilities. Professional and practical nursing services are available 24 hours a day. skilled nursing facility was previously called an extended care facility. Skilled nursing facilities provide care for individuals of all ages, even though the majority of services are provided to geriatric patients.

L04-406 Coding highlights: Introduction

A splenoportography is an x-ray of the portal and circulatory vessels of the spleen. Code 38200 reports the injection portion of the procedure. The physician makes an incision in the left axilla area and inserts a catheter into the spleen. Radiopaque dye is inserted and x-rays are taken. The physician then removes the catheter and closes the area.

L04-012 Status code

A status code is assigned to indicate that a patient has the sequelae or residual of a past disease or condition or is a current carrier of a disease. A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code.

L04-438 Submucosal injection

A submucosal injection is one that is performed to ease the removal of polyps. Fluid, usually saline, is injected around the polyp and the fluid elevates the polyp to allow for easier excision. Submucosal injection by means of: ■ Esophagoscopy, 43192, 43201 ■ EGD, 43236 ■ Sigmoidoscopy, 45335 ■ Colonoscopy, 45381

L04-212 Subungual hematoma

A subungual hematoma (blood trapped under the nail) is evacuated by puncturing the nail with an electrocautery needle (11740). The trapped blood and fluid are drained by applying pressure to the top of the nail.

L04-306 Therapeutic fracture

A therapeutic fracture of the nasal turbinate is a procedure in which the physician fractures the turbinate bone and then repositions it, under local anesthetic. Repositioning the turbinate(s) often alleviates obstructed airflow caused by enlarged inferior turbinates or a previous fracture that has healed out of alignment and resulted in a deviation of the nose.

L04-572 Thyroid gland incision and excision

A thyroidectomy is the removal of all or part of the thyroid gland. The thyroid gland consist of two lobes, one on each side of the throat, connected by a narrow band of thyroid tissue (isthmus). The term "thyroidectomy" can apply to a total removal of the gland (total thyroidectomy), removal of one or part of one of the lobes (lobectomy), or the isthmus (isthmusectomy). Usually thyroid function tests (blood tests) and thyroid scanning are performed before the procedure. For cases in which thyroid cancer is suspected, a biopsy may also be performed.

L04-562 TIA

A transient ischaemic attack (TIA) or "mini stroke" is caused by a temporary disruption in the blood supply to part of the brain. The disruption in blood supply results in a lack of oxygen to the brain.

L04-361 Transluminal angioplasty

A transluminal angioplasty is a procedure in which a vessel is punctured and a catheter is passed into the vessel for the purposes of widening a narrow or obstructed vessel by inflating a balloon. The category codes 36902, 36905, 36907, and 37246-37249 are divided on the basis of whether the catheter was passed into the vessel by incising the skin to expose the vessel (open) or by passing the catheter through the skin (percutaneous) into the vessel.

L04-353 Vascular families—selective or nonselective placement

A vascular family can be compared to a tree with branches. The tree has a main trunk from which large branches and then smaller branches grow. The same is true with vascular families. A main vessel is the main trunk, and other vessels branch off from the main vessel. Vessels connected in this manner are considered families.

L04-425 Vermilionectomy (40500)

A vermilionectomy (40500) is shaving of the lip. The vermilion zone is the red part of the lips. The surgeon removes an area of tissue and repairs the defect by moving the mucosal surface to reconnect the lip, thereby forming a new vermilion border. There are many services bundled into 40525, such as: ■ 11440-11444 and 11446 (benign lesion excision) ■ 11640-11644 and 11646 (malignant lesion excision) ■ 40500 (vermilionectomy with mucosal advancement) ■ 40510 and 40520 (excision of lip)

L04-458 Virtual colonoscopy

A virtual colonoscopy (VC) (74261, 74262) utilizes x-rays and computer to produce a two- and three-dimensional image of the colon. The VC can also be performed using computed tomography (CT) or magnetic resonance imagining (MRI). Virtual colonoscopy may be performed when a colonoscopy cannot be successfully completed and is used as a technique for screening. Because colonoscopy can more accurately detect colon cancer, virtual colonoscopy may be medically necessary only when colonoscopy cannot be successfully performed or extended to the cecum, to evaluate submucosal abnormalities detected by other imaging studies, or immediately following a failed standard colonoscopy.

L04-064 Abnormal findings

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.

L04-517 Two types of Immunizations

Active immunization is the type given when it is anticipated that the person will be in contact with the disease. Active immunization agents can be toxoids or vaccines. Toxoids are bacteria that have been made nontoxic and when injected, produce an immune response that builds protection against a disease. Passive immunization does not cause an immune response; rather, the injected material contains a high level of antibodies against a disease (e.g., rabies, hepatitis B, tetanus), called immune globulins.

L04-030 Conditions that are not an integral part of a disease process

Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

L04-366 Vascular coding with a common femoral artery approach

After the completion of the service described in 36217, the physician pulls the catheter back into the second-order artery and then manipulates the catheter into another third-order artery (36218), where contrast material is again injected into the artery through the catheter and another arteriography is completed.

L04-571 Endocrine Glands

All endocrine glands are ductless, which means they secrete hormones directly into the bloodstream rather than through ducts leading to the exterior of the body. Exocrine glands send their chemical substances into ducts and then out of the body. Examples of exocrine glands are sweat, mammary, mucous, salivary, and lacrimal (tear ducts).

L04-252 Fractures and dislocations

All fractures and dislocations are reported based on the reason for the treatment. For instance, if a hip replacement (arthroplasty) is performed for medical reasons, such as osteoarthritis, it is reported with 27130, located under the subheading Pelvis and Hip Joint, category Repair, Revision, and/or Reconstruction. The osteoarthritis that caused the breakdown of the bone of the hip requiring repair was the reason for the treatment. If the hip replacement was performed for a fracture, it is reported with 27236, located under the subheading Pelvis and Hip Joint, category Fracture and/or Dislocation.

L04-169 Anesthesia: Physical Status Modifiers (1)

All physical status modifiers start with the letter P followed by a single digit between 1-6. The numerical digit represents the severity of the patient's health status; based on clinical decisions of the anesthesiologist: * P1--normal, healthy * P2--mild systemic disease * P3--severe systemic disease * P4--severe systemic disease, life-threatening * P5--not expected to live w/o surgical intervention * P6--brain dead patient having organs harvested for donor purposes

L04-410 Allogenic, Autologous and Stem cell harvesting

Allogenic is from the same species (human), such as a cadaver, a close relative, or a non-related donor. Autologous bone marrow is collected from the patient, processed, and later transplanted or reinfused into the patient. Stem cell harvesting is the collection of stem cells from the blood system through a process termed apheresis.

L04-476 Renal transplantation

Allotransplantation is the transfer of tissue or an organ between two people who are not related (genetically different).

L04-111 ■ Self-limited

Also called a minor presenting problem, a self-limited problem runs a definite and prescribed course, is transient (it comes and goes), and is not likely to permanently alter health status, or the presenting problem has a good prognosis with management and compliance.

L04-069 Four major objectives guided the development of ICD-10-PCS: (4) Standardized terminology

Although the meaning of a specific word may vary in common usage, ICD-10-PCS should not include multiple meanings for the same term; each term should be assigned a specific meaning, and ICD-10-PCS should include definitions of the terminology.

L04-376 Electrocardiogram (ECG)

An ECG is typically conducted by attaching 10 electrodes (leads) to the patient's chest to monitor 12 areas. The ECG provides a reading of the electrical currents of the heart and is a standard test conducted to detect suspected cardiac abnormalities, such as arrhythmias and conduction abnormalities.

L04-127 Attending physician (1)

An attending physician is a doctor who, on the basis of education, training, and experience, is granted medical staff membership and clinical privileges by a health care organization to perform diagnostic and therapeutic procedures in the facility.

L04-578 Electroencephalograph (EEG)

An electroencephalograph (EEG) is used to monitor currents emanating from the brain and is usually utilized any time a procedure on the brain is performed. Report the EEG service separately from code ranges 95700-95726, 95812-95830, 95955-95957.

L04-357 Embolectomy/thrombectomy

An embolus is a mass of undissolved matter that is present in blood and is transported by the blood. A thrombus is a blood clot that occludes, or shuts off, a vessel. Embolectomy/Thrombectomy codes (34001-34490) are divided based on the artery or vein in which the clot or thrombus is located (e.g., radial artery, femoropopliteal vein), with the site of incision specified in the code description (e.g., arm, leg, abdominal incision).

L04-491 Laparoscopy/hysteroscopy

An increasing number of procedures are being performed by using an endoscope instead of opening the area to complete view. With an endoscopic procedure, usually two or three small incisions are made through which lights, cameras, and instruments may be passed. The surgeon first inserts an instrument into the vagina to grasp the cervix. The laparoscope is then inserted into the abdomen and the uterus and/or ovaries/fallopian tubes are excised.

L04-122 Hospital inpatient services

An inpatient is one who has been formally admitted to an acute health care facility. Note that within the subsection Hospital Inpatient Services, all the subheadings except Hospital Discharge Services are divided on the basis of the three key components of history, examination, and MDM complexity.

L04-139 Intermediate care facility

An intermediate care facility provides regular, basic health services to individuals who do not need the degree of care or treatment provided in a hospital or a skilled nursing facility.

L04-619 Operating microscope

An operating microscope (The operating microscope allows for visualization of minute structures, such as nerve fibers and blood vessels) is used in microsurgical procedures and is reported separately with add-on code 69990, unless the code indicates the inclusion of use of an operating microscope. This does not include magnifying loupes (Magnifying loupes are produced in a range of powers) that are used to enlarge the area being viewed.

L04-569 Pancreas

An organ that is located behind the stomach, and the head of the organ is attached to the duodenum (first section of the small intestine). Although the organ is listed in the heading (Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid Body), the codes for procedures involving the pancreas are located in the Digestive System subsection (48000-48999).

L04- 235 Ostectomy

An ostectomy is the removal of the bone that underlies the ulcer area. The bony prominences are chiseled or filed down to alleviate future pressure. The operative report will indicate if the bone was removed.

L04-611 Auditory system: (External ear) Repair

An otoplasty is a procedure performed for a protruding ear that may or may not include a decrease in the size of the ear. This procedure is usually performed with the use of conscious sedation, which is included in 69300. When an otoplasty is performed bilaterally, modifier -50 is added to code. Reconstruction of the external auditory canal (canalplasty/canaloplasty) may be performed for conditions such as stenosis due to injury or infection (69310) or for a congenital defect (69320). Canaloplasty is bundled into some middle ear repair codes, such as 69631-69646 and not reported separately.

L04-149 Anesthesia and Analgesia

Anesthesia means induction or administration of a drug to obtain partial or complete loss of sensation. Analgesia (absence of pain) is achieved so that a patient may have surgery or a procedure performed without pain.

L04-176 T is for time

Anesthesia services are provided based on the time during which the anesthesia was administered and calculated, in total minutes. The timing is started when the anesthesiologist begins preparing the patient to receive anesthesia and is in constant attendance with the patient, continues through the procedure, and ends when the patient is turned over to the post-anesthesia caregivers. Often, 15 minutes equal a unit, but for some carriers, 1, 10, or 30 minutes equals a unit.

L04-583 Aneurysm, arteriovenous malformation, or vascular disease.

Aneurysms may develop within the brain and require surgical repair. An arteriovenous malformation is a condition in which the arteries and veins are not in the correct anatomic position, usually congenital. Codes to indicate the definitive procedure or repair of these conditions are located in the category Surgery for Aneurysm, Arteriovenous Malformation, or Vascular Disease (61680-61711). These codes are divided on the basis of the approach and method of procedure.

L04-594 Anterior segment: CORNEA (3) Aphakia and Pseudophakia

Aphakia is absence of the lens of the eye, and pseudophakia is the presence of an artificial lens after cataract surgery. These terms are in three of the keratoplasty code descriptions.

L04-346 Coronary artery bypass

Arteries deliver oxygenated blood to all areas of the body, and veins return the blood that is full of waste products. The heart muscle is fed by coronary arteries that encircle the heart. Sometimes the arteries clog to the point that the heart muscle begins to perform at low levels due to lack of blood (reversible ischemia) or actually die (irreversible ischemia).

L04-278 Arthrodesis

Arthrodesis can be performed with another surgical procedure, such as fracture care or a laminectomy. If arthrodesis is performed with a more major procedure, use modifier -51 on the arthrodesis code to indicate multiple procedures were performed. An exception to this rule is when the code is an add-on code, which is exempt from use with modifier -51.

L04-285 Endoscopy/arthroscopy

Arthroscopy is often the treatment of choice for many orthopedic surgical procedures. The incisions are smaller, which decreases the risk of infection and speeds recovery time. Several small incisions are made through which lights, mirrors, and instruments are inserted. When coding arthroscopic procedures of the knee, note the use of basket forceps, which indicates a meniscectomy (meniscus removal) rather than a shaving and debridement. A diagnostic arthroscopy is always included in a surgical arthroscopy.

L04-067 Four major objectives guided the development of ICD-10-PCS: (2) Expandability

As new procedures are developed, the structure of the ICD-10-PCS should allow for incorporation of these new procedures as unique codes.

L04-178 M is for modifying unit

As the name implies, modifying units reflect circumstances or conditions that change or modify the environment in which the anesthesia service is provided. There are two base-modifying factors: qualifying circumstances codes and physical status modifiers.

L04-362 Bypass grafts

As with coronary artery bypass grafting (CABG), you must know the type of grafting material used for vascular bypass grafts (Bypass Grafts 35500-35671). Grafts can be vessels harvested from other areas of the body or they may be made of artificial materials. Codes are chosen on the basis of the type of graft and the specific vessel(s) that the graft is being bypassed from and to. One way to locate the graft codes in the CPT manual index is to reference "Bypass Graft" and then the subterm type (e.g., carotid, subclavian, vertebral).

L04-035 Combination codes (2)

Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.

L04-444 Bariatric Surgery

Bariatric Surgery codes 43770-43775 also report procedures performed for gastric restrictive procedures that are accomplished by placing a restrictive device around the stomach to decrease its functional size.

L04-462 Liver: Biopsy

Biopsy of the liver may be performed percutaneously (47000) using imaging guidance that is reported separately. If the biopsy is performed at the time of a more major procedure, the biopsy is reported with add-on code 47001. A liver biopsy may also be performed as a wedge biopsy (47100) that involves removal, through an incision, of a small fan-shaped section of tissue for examination.

L04-274 Free osteocutaneous flaps (20969-20973)

Bone grafts that include the skin and tissue that overlie the bone. The flap has an arterial pedicle that is attached (anastomosed) to an artery on the recipient site. The surgeon then utilizes the skin, tissue, and bone to reconstruct the defect, using an operating microscope. The codes are divided based on which part of the body the flap is taken from.

L04-239 Breast procedures

Breast procedures (19000-19499) are divided according to category of procedure (e.g., incision, excision, introduction, repair and/or reconstruction). In an incisional biopsy, an incision is made into the lesion and a small portion of the lesion is taken out. In an excisional biopsy, the entire lesion is removed for biopsy. Wire marker used to mark breast lesion. A, Mammography is used to place a preoperative needle used to mark a lesion. B, The wire marker serves as a guide for the surgeon to perform the biopsy.

L04-315 Excision/repair: Bronchoplasty

Bronchoplasty is repair of the bronchus and often involves the use of grafting repair or stents. A chest tube may be left in the area as a drain after the procedure and is not reported separately because it is bundled into the code to report the procedure. A grafting procedure is not bundled into the bronchoplasty code 31770 and is reported separately.

L04-388 Bundle of His recording

Bundle of His recording is a reading taken inside the heart (intracardiac) at the tip of the bundle of His. The bundle of His is also known as the atrioventricular bundle or AV bundle and is the bundle of cardiac muscle fibers that conducts electrical impulses that regulate heartbeats.

L04-364 Vascular injection procedure

Bundled into the vascular injections (36000-36522) are the following items: ■ Local anesthesia ■ Introduction of needle or catheter ■ Injection of contrast media ■ Pre-injection care related to procedure ■ Post-injection care related to procedure Vascular injections bundles do not include the following items: ■ Catheter ■ Drugs ■ Contrast media For items not bundled into the injection procedure, report each item separately.

L04-236 BURNS

Burns are classified as first, second, or third degree based on the depth of the burn. 1ST - Epidermis 2ND - Dermis 3RD - Subcutaneous The documentation should indicate the degree of burn at each location, and the physician should be queried if the degree is not stated. The definition of small is less than 5% of the total body surface area, medium is the whole face or whole extremity, or 5% to 10% of the total body surface area, and large is more than one extremity or greater than 10% of the total body area.

L04-326 Coding highlights

Cardiology is one of the largest subspecialties in medicine, and numerous modern techniques are used to diagnose and treat cardiac conditions. A cardiologist is an internal medicine physician who is specialized in the diagnosis and treatment of conditions of the heart.

L04-350 Coding highlights

Cardiology is one of the largest subspecialties in medicine, and numerous modern techniques are used to diagnose and treat cardiac conditions. A cardiologist is an internal medicine physician who is specialized in the diagnosis and treatment of conditions of the heart. A cardiologist can further specialize in cardiovascular surgical procedures or other treatment and diagnostic specialties.

L04-010 Categories of Z Codes: 1) Contact/Exposure

Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who are suspected to have been exposed to a disease by close personal contact with an infected individual or are in an area where a disease is epidemic. Category Z77, Other contact with and (suspected) exposures hazardous to health, indicates contact with and suspected exposures hazardous to health. Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk.

L04-382 Cardiac catheterization

Catheterization (93451-93572) is an invasive diagnostic medical procedure in which the physician percutaneously inserts a catheter and manipulates the catheter into coronary vessels and/or the heart. A percutaneous method of catheterization called the Seldinger technique, after the inventor of the method. A cardiac catheterization is a study of both the circulation and the movement of the blood of the heart; the physician may inject a dye into the vessel or heart and observe the movement of the dye by means of angiography. The three cardiac catheterization components of catheter placement, injection, and imaging are reported in one combination code.

L04-183 Concurrent modifiers

Certified registered nurse anesthetists (CRNAs) may administer anesthesia to patients under the direction of a licensed physician, or they may work independently. An anesthesiologist may medically direct up to four cases at the same time (concurrently). Medical direction means the directing anesthesiologist is present at the induction and emergence from anesthesia, for all key portions of the procedure, and is immediately available in case of an emergency. The CRNA would be with the patient the entire time.

L04-230 Cervicoplasty

Cervicoplasty, 15819, is a surgical procedure in which the physician removes excess skin from the neck, usually for cosmetic reasons.

L04-119 Chronic diseases

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

L04-482 Introduction: Injection and Manometric studies

Code 50684 reports an injection procedure performed through an indwelling catheter to determine the status of the renal collecting system. (50686) are tests to measure kidney and ureter flow and pressure.

L04-011 Categories of Z Codes: 2) Inoculations and vaccinations

Code Z23 is for encounters for inoculations and vaccinations. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit.

L04-020 Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

L04-304 Other procedures

Codes (30901-30920) for the control of nasal hemorrhage are located in the Other Procedures category and are often reported. Anterior nasal packing is the application of pressure using packing to the anterior aspect of the nasal cavity, and posterior nasal packing is the application of pressure to the posterior aspect of the nasal cavity. The nasal pack is inserted via the nasal opening. A balloon may be inserted and inflated to further control bleeding. The codes are divided according to the type and extent of control required.

L04-453 Endoscopy: Colonoscopy

Codes 45378-45398 describe procedures in which the endoscope is advanced to the proximal colon (past the splenic flexure) to the cecum or into a portion of the terminal ileum (most distant part of the small intestine). To report colonoscopy procedures, first determine how the procedure was performed: ■ Through a colostomy (44380-44408) ■ Through a colotomy (45399) ■ Through the rectum (45378-45398)

L04-380 Implantable, insertable, and wearable cardiac device evaluations

Codes 93279-93285 are reported per procedure, such as a single, dual, or multiple lead pacemaker or implantable defibrillator programming device evaluation. Codes 93286 and 93287 report periprocedural (shortly before or shortly after) evaluation of a device based on if the device is a pacemaker or an implantable defibrillator. Codes in the 93288-93292 range are reported per procedure and are in-person evaluations of a pacemaker or an implantable defibrillator system based on the type of device and the type of analysis performed. Evaluation of a pacemaker by means of a telephone is reported once in a 90-day period with 93293.

L04-146 Domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services

Codes 99339, 99340 apply to services provided to a patient who is being cared for at home and not enrolled with a home health care agency. These patients are being cared for by family members, health care professionals, and other types of caregivers. The physician's time may be reported if the time was over 15 minutes within a calendar month. Code 99339 reports 15-29 minutes, and 99340 reports 30 minutes or more.

L04-051 Symptoms, signs, and ill-defined conditions

Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as a principal diagnosis when a related definitive diagnosis has been established.

L04-608 Auditory system: (External ear) Excision (1)

Codes for the external ear include biopsy by location of external ear (69100) or external auditory canal (69105), excision of the external ear, either partially or complete (69110, 69120). If the external ear was reconstructed after the excision, report the repair with split thickness autograft codes (15120, 15121) from the Integumentary System based on the square centimeters used in the repair.

L04-026 Selection of ob principal or first-listed diagnosis: 2) Supervision of High-Risk Pregnancy

Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery. For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis. Secondary chapter 15 codes may be used in conjunction with these codes if appropriate.

L04-234 Lips

Codes in the Lips subheading (40490-40799) include the categories of Excision, Repair (Cheiloplasty), and Other Procedures. If the procedure was performed on the skin of the lips, assign a code from the Integumentary System, not a Digestive System code.

L04-580 Craniectomy/craniotomy.

Codes in the category Craniectomy or Craniotomy (61304-61576) describe procedures that deal with incision into the skull with possible removal of a portion of the skull to open the operative site to the surgeon. Assignment of these codes is based on the site and condition (e.g., evacuation of hematoma, supratentorial, subdural, 61312). Only by careful attention to code description can you prevent unbundling surgical procedures and incorrectly report bundled components separately. When craniectomies are performed, it is not uncommon that additional grafting is required to repair the surgical defect caused by opening the skull. These grafting procedures are reported separately, in addition to the major surgical procedure.

L04-130 Observation or inpatient care services (including admission and discharge services)

Codes in this range require that all three of the key components must be at or exceed the level stated in the code description. These codes include both the admission service and the discharge service. This means that the services provided in these other locations are considered when assigning a code from the 99234-99236 range.

L04-006 Codes that describe symptoms and signs

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider.

L04-449 Colon and rectum

Colon and Rectum procedures are reported with codes from the 45000-45999 range. These procedures involve the colon and rectum and employ techniques such as incision, excision, and destruction. Many of the codes are very complex. ■ 45126, Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), or any combination thereof

L04-396 Contrast material

Commonly used with radiology procedures to enhance the image. If the Radiology section code states "with contrast" or "with or without contrast," you will know that the injection of contrast material and the contrast material itself (the substance used for contrasting) are bundled into the code; therefore, you would not report the contrast material or injection separately.

L04-126 Concurrent

Concurrent care is being provided when more than one physician provides service to a patient on the same day for different conditions.

L04-565 Thyroid Gland

Composed of a right and left lobe on either side of the trachea, just below a large piece of cartilage (thyroid cartilage). Two of the hormones secreted by the thyroid gland are T3 (triiodothyronine) and T4 (thyroxine). The thyroid gland normally produces 80% T4 and 20% T3. These hormones are necessary to maintain the normal level of metabolism in the cells of the body. Thyroid Function Tests (TFTs) assess the levels of hormones produced by the thyroid gland. Within the Thyroid Gland subheading in the CPT manual (60000-60300) there are the categories of Incision, Excision, and Removal.

L04-166 Moderate (conscious) sedation (3)

Consciousness is depressed, and the patient may fall asleep but is not unresponsive. Patient will still be able to respond to commands during the procedure. CAUTION Do not confuse conscious sedation with monitored anesthesia care. Conscious sedation is administered by the surgeon or another physician; MAC is provided by an anesthesiologist or CRNA.

L04-196 General subsection

Contains codes for fine needle aspiration biopsies (10004-10021), excluding bone marrow aspirations (see code 38220). The codes are divided based on whether imaging guidance was used during the aspiration, and if so, the type of guidance performed. A fine needle aspiration biopsy is used to withdraw fluid that contains individual cells

L04-108 Contributory factors: ■ Coordination of care

Coordination of care with other health care providers or agencies may be necessary for the care of a patient. In coordination of care, a physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long-term nursing facility.

L04-107 Contributory factors: ■ Counseling

Counseling is a service that physicians provide to patients and their families. It involves discussion of diagnostic results, impressions, and recommended diagnostic studies; prognosis; risks and benefits of treatment; instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education.

L04-199 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.

L04-639 Decubitus

Decubitus positions are recumbent (lying) positions; the x-ray beam is placed horizontally. Ventral decubitus (prone) is the act of lying on the stomach, and dorsal decubitus (supine) is the act of lying on the back. The term "decubitus," generally shortened to "decub," has a special meaning in radiology. The simple act of lying on one's back would be referred to as lying supine, but if a horizontal x-ray beam is used, the position becomes decubitus. The type of decubitus is determined by the body surface the patient is lying on.

L04-227 Dermabrasion

Dermabrasion is used to treat acne, wrinkles, or general keratoses (horny growth) (Fig. 14-29). The skin area is anesthetized by a chemical that freezes the area (a cryogen), and the area is sanded down using a motorized brush. A tattoo can be removed by dermabrasion.

L04-193 Special Reports

Describing the procedure must accompany the claim. According to the CPT manual, "Pertinent information [in the special report] should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service." Unlisted codes are assigned only after thorough research fails to reveal a more specific code.

L04-303 Destruction

Destruction can be accomplished by use of ablation. Ablation is removal, usually by cutting, or cauterization is performed to remove excess nasal mucosa or to reduce inflammation. The destruction codes (30801, 30802) are divided according to the extent of the procedure—superficial or intramural. Intramural is ablation of the deeper mucosa, as compared to superficial ablation, which involves only the outer layer of mucosa.

L04-002 Selection of first-listed condition (2)

Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors.

L04-529 Dialysis

Dialysis is the cleansing of the blood of waste products when it is not possible for the body to perform the cleansing function adequately on its own. Dialysis may be temporary, as in the case of a patient who has acute renal failure from which he or she recovers, or permanent, as in the case of a patient with end-stage renal disease (ESRD) who will not recover without a kidney transplant.

L04-286 Respiratory System Coding

Different types of endoscopies include the following: * Laryngoscopy (The scope is inserted into the larynx.) * Tracheoscopy (The scope is inserted into the trachea.) * Bronchoscopy (The scope is inserted into the bronchus.)

L04-291 DIRECT

Direct in 31515 means that the endoscope is passed into the larynx and the physician looks directly at the larynx through the endoscope. The operative report will indicate whether the procedure was indirect or direct.

L04-118 Uncertain diagnoses

Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," "compatible with," "consistent with," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

L04-381 Echocardiography

Echocardiography (93303-93355) is a noninvasive diagnostic method that uses ultrasonographic images to detect the presence of heart disease or valvular disease. A sliced image is used to detail the various walls of the heart. A transducer is placed on the outside of the chest wall, and it sends sound waves through the chest.

L04-452 Endoscopy: Diagnostic colonoscopy

Endoscopic examination of the colon from rectum to cecum is reported with codes from the 45378-45398 range. The scope is advanced more than 60 cm (more than 23.6 in). The diagnostic colonoscopy codes are divided based on the extent and the purpose of the procedure. The diagnostic stand-alone codes 45300, 45330, and 45378 each have a list of indented procedure codes based on the purpose of the procedure (such as biopsy, foreign body removal, ablation, control of bleeding, etc.).

L04-020 Role of E/M Coding

E/M stands for "evaluation and management." These codes make up the first section of the CPT manual. E/M codes are used broadly for physician services that don't involve surgery. These codes guide the process for translating physician-patient encounters into five-digit CPT codes for billing purposes.

L04-328 Electrophysiology

Electrophysiology (EP) is the study of the electrical system of the heart and includes the study of arrhythmias.

L04-370 Endoluminal imaging

Endoluminal imaging of the coronary vessels can be reported using the two codes 92978 and 92979, depending on the number of vessels being diagnosed.

L04-420 Mediastinum and diaphragm: Excision

Excision codes 39200 and 39220 are based on whether a cyst or tumor was excised. The surgical approach is one in which the surgeon makes the incision just below the nipple line and retracts the rib cage and muscles to expose the thoracic cavity. The cyst or tumor is removed and the incision closed.

L04-450 Endoscopy: Proctosigmoidoscopy

Endoscopic examination of the rectum (proct/o = rectum) and the sigmoid colon (45300-45327). The scope is advanced 6-25 cm (2.4-9.8 in). Code 45300 describes a rigid proctosigmoidoscopy, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). Do not assign 45300 when reported with codes 45303-45327, because these codes report surgical procedures, so the diagnostic service of 45300 is bundled into the surgical procedure.

L04-451 Endoscopy: Sigmoidoscopy

Endoscopic examination of the sigmoid colon may include the descending colon (45330-45350). The scope is advanced 26-60 cm (10.2-23.6 in). A sigmoidoscopy is the examination of the entire rectum and sigmoid colon and may include examination of a portion of the descending colon but stops before reaching the splenic flexure (the turn beneath the spleen that connects the descending to the transverse colon).

L04-288 Endoscopy

Endoscopic procedures may start at one site (such as the nose) and follow through to another site (such as the larynx or bronchial tubes). It is important to choose the code that most appropriately reflects the furthest extent of the procedure.

L04-021 E/M Codes

Evaluation codes describe the initial procedures that were used to create a framework for understanding a patient's condition. Management codes describe the procedures that were used to diagnose and treat specific complaints or problems.

L04-171 Anesthesia: Physical Status Modifiers (3)

Examples of add-on codes include: * +99100 is used for patients that are younger than 1 year or older than 70 years.(Only use this add-on code if there isn't a code to accurately describe the procedure for the patient that is less than 1 year or greater than 70 years.) * +99116 is used for procedures that are complicated by total body hypothermia. * +99135 is used for procedures that are complicated by the utilization of controlled hypotension. * +99140 is used for procedures that are complicated by emergency conditions. This must be specified.

L04-609 Auditory system: (External ear) Excision (2)

Exostosis is a bony growth and when present in the external auditory canal, it is termed "surfer's ear," because it is associated with chronic cold water exposure. An incision is made behind the ear to gain access to the canal, and the bony growth is excised (69140).

L04-268 Grafts (or implants): Fascia lata grafts

Fascia lata grafts are taken from the mid-upper lateral thigh area because the fascia is thickest in this area. Fascia is the fibrous tissue that serves as connective tissue; it may be shaved off with an instrument called a stripper or it may be incised (cut) away. The fascia lata is then used in the repair procedure.

L04-560 Locating a code in the ICD-10-CM

First locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List. It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.

L04-024 Ambulatory surgery

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

L04-023 Preoperative evaluation

For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations.

L04-022 Therapeutic services

For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.

L04-061 Reporting additional diagnoses

For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: - clinical evaluation; or - therapeutic treatment; or - diagnostic procedures; or - extended length of hospital stay; or - increased nursing care and/or monitoring.

L04-025 Selection of ob principal or first-listed diagnosis: 1) Routine outpatient prenatal visits

For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis. These codes should not be used in conjunction with chapter 15 codes.

L04-563 Endocrine system

Format There are nine glands in the endocrine system, but only four are included in the Endocrine subsection (60000-60699) of the CPT manual. The four glands in the Endocrine subsection are: ■ Thyroid (60000-60300) ■ Parathyroid (60500-60512) ■ Thymus (60520-60522) ■ Adrenal (60540-60545, 60650)

L04-566 Parathyroid Glands

Four small oval bodies located on the dorsal aspect (back) of the thyroid gland. These glands secrete parathyroid hormone (PTH). That mobilizes calcium from bones into the bloodstream, which is necessary for the proper functioning of body tissues, especially muscles. Within the Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid Body subsection (60500-60699) there are categories Excision, Laparoscopy, and Other Procedures.

L04-287 FORMAT

Fracture repair, such as that of the nose or sternum, is listed in the Musculoskeletal System subsection, not in the Respiratory System subsection. Procedures that are performed on the throat or mouth are not located in the Respiratory System subsection but instead are located in the Digestive System subsection. The Respiratory System subsection contains some codes that may be considered cosmetic.

L04-150 Types of anesthesia

May be general, regional, local, or monitored anesthesia care (MAC). Moderate (conscious) sedation is not reported with anesthesia codes but rather is reported with Medicine codes. Local anesthesia is usually administered by the surgeon.

L04-049 Surgical Guidelines

General surgery is used to describe operations on a wide range of anatomical systems. These include the respiratory, cardiovascular, lymphatic, auditory, ocular, nervous, and digestive systems, as well as the male and female reproductive systems.

L04-597 Anterior segment: Anterior chamber (3) Goniotomy

Goniotomy (65820) is a surgical procedure that utilizes an instrument called a goniolens. This procedure may be performed for congenital glaucoma, a condition in which the optic nerve at the back of the eye may be damaged and cause a loss of vision, especially peripheral vision. A note following code 65820 directs the coder not to use modifier -63 (procedure performed on infants less than 4 kg) with the code. Codes for severing adhesions or scar tissue from the anterior chamber of the eye are based on the location of the adhesion or scar tissue (65860-65880).

L04-460 Hemorrhoids

Hemorrhoids are a frequent condition of the anus. Hemorrhoids (piles) arise from an inflammation of the venous plexuses (congregation of vessels) around the anus and may be inside or outside of the anal canal.

L04-209 Hidradenitis

Hidradenitis suppurativa. A hallmark of hidradenitis is the double and triple comedone, a blackhead with two or sometimes several surface openings that communicate under the skin.

L04-028 Level of detail in coding

ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth characters and/or sixth characters, which provide greater detail. A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.

L04-013 Assigning a medical and surgical code using the ICD-10-PCS

ICD-10-PCS gives you the first three "building blocks", and then you add the remaining characters to the code for a total of seven characters altogether. Excision means cutting off or cutting out a portion of a body part without replacing it. Resection means cutting off or cutting out all of the body parts.

L04-068 Four major objectives guided the development of ICD-10-PCS: (3) Multiaxial (more than one part).

ICD-10-PCS should have a structure such that each code character has, as much as possible, the same meaning, both within the specific procedure section and across procedure sections.

L04-044 ICD-10-PCS Coding (1)

ICD-10-PCS uses a seven character alphanumerical format consisting of 10 digits, 0-9,and 24 letters: A-H, J-N, and P-Z. Please make a note that the letters O and I are not used in PCS coding to avoid confusion with zero and one.

L04-395 Global service

If a clinic owns its own x-ray equipment and employs a radiologist to interpret the x-rays and write the reports, and also employs the technician who, under the supervision of the radiologist, takes the x-rays, the clinic could report the x-ray service using the appropriate radiology code, with supervision and interpretation in the description and no modifier.

L04-390 Noninvasive physiologic studies and procedures

If a patient has a pacemaker or defibrillator in place, periodic monitoring must occur to ensure that the device is functioning properly. Codes from the Noninvasive Physiologic Studies and Procedures (93701-93790) category and the Implantable, Insertable, and Wearable Cardiac Device Evaluations (93279-93298) category reflect these services. Codes are assigned according to the type of pacemaker (single- or dual-chamber) or implantable defibrillator and whether reprogramming of an existing pacemaker or defibrillator was done.

L04-188 Return to operating room

If a patient is returned to the operating room on the same day for the same or a related procedure, and the same individual is performing the second procedure, report the service with modifier -76. The second service would be reported 00811-AA-76. If that second procedure was performed by another anesthesiologist, the second service would be reported 00811-AA-77.

L04-319 Excision: Pleurectomy (2)

If a pleurectomy is performed as part of another, more major procedure such as the removal of a lung (pneumonectomy), you would not report the pleurectomy separately. Note that after code 32310, pleurectomy, parietal "separate procedure" warns you not to report a pleurectomy if the pleurectomy was performed as a part of a more major procedure.

L04-360 Angioscopy

If an angioscopy of the vessel or graft area is performed during a therapeutic procedure, code 35400, Angioscopy (noncoronary vessels or grafts) during therapeutic intervention, is listed in addition to the procedure code.

L04-057 Uncertain diagnosis

If the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," "compatible with," "consistent with," or other similar terms indicating uncertainty, code the condition as if it existed or was established. Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

L04-189 Pre-anesthetic examination

If the pre-anesthetic examination was provided by an anesthesiologist for a patient who did not undergo surgery, the E/M service would be reported for consideration for reimbursement.

L04-063 Previous conditions

If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.

L04-033 Acute and chronic conditions

If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

L04-258 Dislocations: External technique for relocation of a shoulder (Stimson technique)

If the shoulder was dislocated, the physician might elevate the arm and rotate the humerus while applying pressure to the head of the humerus. Or the patient might lie face down on a table with the arm hanging off the edge while a weight is attached to the hand; the weight is sufficient to pull the arm back into place.

L04-053 Two or more diagnoses

If two or more diagnoses are equally responsible for the outpatient visit, either can be sequenced as the principal diagnosis. The same is applicable in the inpatient setting.

L04-505 Immunology

Immunology codes (86000-86804) report identification of conditions of the immune system caused by the action of antibodies (e.g., hypersensitivity, allergic reactions, immunity, and alterations of body tissue). To report antibody tests for the SARS-CoV-2 coronavirus, use code 86328 for a single-step method immunoassay, with 86769 for the multi-step method. To report quantitative antibody detection, utilize code 86413.

L04-588 Secondary implant(s) procedures (1)

Implants may be placed inside the muscular cone (ocular implant or fake eye) or outside the muscular cone (orbital implant). The ocular implant is the artificial eye, a prosthesis similar to a contact lens that covers the entire surface of the eyeball, while the orbital implant replaces the orbit that was occupied by the eyeball before removal.

L04-402 Aorta and arteries

In Radiology, the Aorta and Arteries subsection (75600-75774) includes codes for aortography excluding the heart—thoracic, abdominal, cervicocerebral, brachial, external carotid, carotid, vertebral, spinal, extremity, renal, visceral, adrenal, pelvic, pulmonary, and internal mammary. The Aorta and Arteries subsection codes are reported with coding components of cardiovascular services.

L04-226 FLAPS

In a delayed graft, a portion of the skin is lifted and separated from the tissue below, but it stays connected to blood vessels at one end. An island pedicle flap contains an artery and vein, and a neurovascular pedicle flap contains an artery, vein, and nerve.

L04-047 Differences between inpatient and outpatient coding

In an inpatient setting, you must be familiar with the inpatient Guidelines so that the coding leads to the correct MS-DRG. Coders do not need to know the formulas for MS-DRGs. A computer program, a grouper, assigns the MS-DRG based on the ICD-10 codes. ICD-10-PCS is the inpatient procedural coding system. In the inpatient setting, ICD-10-PCS are assigned instead of CPT or HCPCS codes.

L04-001 Selection of first-listed condition

In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.

L04-054 Comparative or contrasting conditions

In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

L04-489 In Vitro fertilization

In vitro fertilization means to fertilize an egg outside the body. The codes in the In Vitro Fertilization category describe several methods that are used in modern fertility practice. Third-party payers often do not pay for the fertility treatments.

L04-480 Kidney index locations

Incision - 50080-50081, 50120-50135 Excision - 50200-50230 Renal Transplantation - 50320, 50340, 50360, 50365 Introduction - 50382-50390, 50432-50435 Laparoscopy - 50545-50547, 50549 Endoscopy - 50551-50561, 50570-50580 Other Procedures - 50590, 50592 The third-party payer may require reporting modifiers -RT and -LT rather than modifier -50.

L04-198 Incision and drainage

Incision and Drainage (I&D) codes (10040-10180) are divided according to the condition for which the I&D is being performed. Also included under this heading is a puncture aspiration code (10160), which describes inserting a needle into a lesion and withdrawing the fluid (aspiration).

L04-206 Mucous membranes

Included in the Biopsy codes are codes for biopsies of mucous membranes. A mucous membrane is tissue that covers a variety of body parts, such as the tongue and the nasal cavities.

L04-202 Closure of excision sites

Included in the codes for lesion excision is the direct, primary, or simple closure of the operative site. Excision is defined as a full thickness (through the dermis) excision of a lesion and a simple closure is nonlayered closure. Closures can also be intermediate or complex (greater than layered). The local anesthesia is included in the excision codes. Any closure other than a simple closure can be reported separately with lesion excision.

L04-290 INDIRECT

Indirect in 31505 means that the physician used a tongue depressor to hold the tongue down and view the epiglottis (the lid that covers the larynx) with a mirror. The patient vocalizes (says "ah") and the physician can then view the vocal cords.

L04-123 The subsection of Hospital Inpatient Services: Initial hospital care

Initial Hospital Care codes are used to report the initial service of admission to the hospital by the admitting physician. Only the admitting physician can report the Initial Hospital Care codes. These codes reflect services in any setting (office, emergency department, nursing home) that are provided in conjunction with the admission to the hospital.

L04-266 Insertion of wires or pins

Insertion of wires or pins to repair a bone (20650) is a procedure often used by orthopedic physicians. The procedure is performed using a local or general anesthetic. The bone is drilled through with a power drill and pins and/or wires are placed through the holes in the bone and allowed to emerge through the skin on each side of the bone. This may sound painful, but actually, the procedure is used to allow well-aligned healing, as well as alleviate pain.

L04-383 Intracoronary brachytherapy

Intracoronary brachytherapy is the use of radioactive substances as a therapy for in-stent restenosis of a coronary vessel. The stent reopens the vessel so blood can once again flow without obstruction.

L04-371 Intracoronary stent placement

Intracoronary stent placement (92928, 92929) is performed using a catheter to reinforce a coronary vessel that has collapsed or is blocked. The placement of the stent is usually accomplished with radiographic guidance which is included. The codes are divided on the basis of whether more than one coronary vessel was cleared of obstruction and had a stent placed within it.

L04-549 Therapeutic, prophylactic, and diagnostic injections and infusions

Intravenous infusions are reported with 96365-96368 and are divided based on the time and type of infusion. The initial infusion is reported with 96365 (up to 1 hour), and each additional hour (over 30 minutes) is reported with 96366. the initial infusion is listed first and the sequential infusion (add-on code 96367) is listed second. There are times when more than one infusion is provided at the same time, which is a concurrent infusion. A concurrent infusion is when there is one site and two lines infusing at the same time. Subcutaneous and intramuscular injections are reported with 96372 in addition to a code to report the substance injected. Intra-arterial (96373) and intravenous push (96374/96375/96376) are reported with therapeutic, prophylactic, and diagnostic injection codes.

L04-311 Introduction: Intubation

Intubation is the establishment of an airway. The intubation represented in 31500 is provided on an emergency basis at such time as the patient experiences respiratory failure or the occurrence of an inadequate airway. The other Introduction code (31502) is for the replacement of a previously inserted tracheotomy tube.

L04-351 Invasive

Invasive is entering the body—breaking the skin—to make a correction or for examination. An example of an invasive cardiac procedure is the removal of a tumor from the heart. Invasive cardiology procedures are also called interventional procedures.

L04-222 Three types of repair: Complex

Involves complicated wound closure including revision, debridement, extensive undermining, stents or retention sutures, and more than layered closure (13100-13160).

L04-368 Other therapeutic services and procedures

It is within the Other Therapeutic Services and Procedures subheading (92920-92998) that you locate many commonly assigned cardiovascular codes, such as cardioversion, infusions, thrombolysis, placement of catheters and stents, atherectomy, and angioplasty. Division of the codes is based on method (balloon, blade), location (aorta or mitral valve), and number (single or multiple vessels).

L04-495 Drug assay

Laboratory Presumptive Drug Class Screening (80305-80307) is performed to identify the presence or absence of a drug. Testing that determines the presence or absence of a drug is qualitative (the drug is either present or not present in the specimen).

l04-479 Laparoscopy and Endoscopy

Laparoscopic nephrectomies and pyeloplasty are also reported with codes from the Laparoscopy category and are based on the extent of the procedure. Endoscopy codes (50551-50580) are frequently reported for kidney procedures, because these types of procedures are less invasive than the open procedures and are often performed in an outpatient setting.

L04-483 Laparoscopy

Laparoscopic ureter codes 50947 and 50948 report the placement of a ureteral stent, which may be performed in conjunction with or without cystoscopy. The stent is placed because of an obstruction of the ureterovesical junction (UVJ). The surgeon laparoscopically repositions the ureter on the bladder and then by means of the cystoscope places the ureteral stent.

L04-309 LARYNGOTOMY

Laryngotomy is an incision that is made over the larynx (thyrotomy) to expose the larynx to view. A laryngotomy can also be performed for diagnostic purposes, without a surgical procedure being performed. The codes from the two categories differ, depending on the purpose of the procedure. The Laryngotomy category codes describe procedures in which the surgeon performs a thyrotomy (incision of the larynx through the thyroid cartilage) for the purpose of exposing the larynx.

L04-334 Transmyocardial revascularization

Laser transmyocardial revascularization describes a procedure in which areas of cardiac ischemia (reversible muscle damage) are exposed to a laser beam to create holes in the surface of the heart. This procedure can be performed alone, as the only surgical procedure performed (33140), or at the time of another open cardiac procedure (add-on code 33141).

L04-037 Late effects (sequela) (2)

Late effects codes are not located in a separate chapter in the Tabular. You report late effects when the acute phase of the illness or injury has passed but a residual remains. The residual is reported first and then the late effects code is assigned to indicate the cause of the residual condition. An example would be scars (residual) that remain after a severe burn (cause).

L04-637 Lateral

Lateral positions are side positions. When the patient's right side is closest to the film, it is called right lateral. When the patient's left side is closest to the film, it is called left lateral. The use of these various positions allows the physician to view the body from a variety of angles.

L04-017 ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit

List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the provider.

L04-160 Each type of anesthesia will be covered in depth, but generally speaking: Monitored Anesthesia Care (MAC)

MAC is provided by an anesthesiologist or CRNA. The patient is monitored, and if necessary, sedation is provided; even general anesthesia.

L04-248 CLOSED TREATMENT: Manipulation

Manipulation is attempted reduction, which is an attempt to maneuver the bone back into proper alignment. The physician may bend, rotate, pull, or guide the bone back into position.

L04-221 Three types of repair: Intermediate

Requires closure of one or more layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure. You can report intermediate closure (12031-12057) when the wound has to be extensively cleaned, even if the closure was a single-layer (simple) closure.

L04-260 Median sternotomy

Median sternotomy was performed because of the position of the entrance wound and the suspicion of cardiac injury. Palpation of the left hemidiaphragm revealed a defect and indicated laparotomy.

L04-507 Microbiology

Microbiology codes (87003-87999) report the study of microorganisms and include bacteriology (study of bacteria), mycology (study of fungi), parasitology (study of parasites), and virology (study of viruses).

L04-613 Auditory system: (Middle ear) Excision

Middle ear excision procedures include antrotomy (simple mastoidectomy, 69501), mastoidectomy (complete, modified radical, or radical, 69502-69511), polyp removal (69540), and tumor removal (69550-69554).

L04-614 Auditory system: (Middle ear) Repair

Middle ear repair procedures include revision mastoidectomies based on the extent of the procedure. A cholesteatoma is a benign growth of skin in an abnormal location, in this case in the middle ear. The two major divisions in the tympanoplasty codes are with or without removal of the mastoid bone (mastoidectomy). The ossicular chain is the bones of the ear that include the malleus (hammer), incus (anvil), and stapes (stirrup). The chain may be eroded and repaired as a part of a tympanoplasty (69632 or 69642).

L04-297 Nasal polyps (2)

Modifier -50 (bilateral) is assigned when the polyps are removed from both the left and right sides of the nose. The codes for excision or destruction of lesions inside the nose are divided based on the approach—internal or external. Usually, if the approach to the procedure is external, you are referred to the Integumentary System subsection to locate the correct code; but the nasal lesion excision/destruction codes can be assigned for either an external or an internal approach to a lesion.

L04-172 Anesthesia: Physical Status Modifiers (4)

Modifier after the anesthesia code. * Modifier AA represents the anesthesiologist. * AD—Medical supervision by anesthesiologist performing greater than four concurrent cases. * G8—Monitored anesthesia (MAC) used for deep complex complicated invasive procedures. * G9—Monitored anesthesia of patient with history of severe cardiopulmonary condition. * QK—Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. * QS—Monitored anesthesia care service. * QX—Certified RN (CRNA) with medical direction by a physician. * QY—Medical direction of one CRNA by an anesthesiologist. * QZ—CRNA service without medical direction by a physician.

L04-585 Myringotomy and Tympanostomy

Myringotomies and tympanostomies are often performed on children to treat dysfunction of the eustachian tube. Myringotomy involves making an incision into the tympanic membrane and reinflating the eustachian tube, while tympanostomy involves inserting a tube to drain fluid from the ear. Myringotomies are assigned to codes 69420 and 69421. Tympanostomies are assigned to codes 69433 and 69436.

L04-612 Auditory system: (Middle ear) Myringotomy and tympanostomy

Myringotomy is the incision into the tympanic membrane (69420, 69421) and reinflation of the eustachian tube. Tympanostomy is the insertion of a small plastic or metal tube (PE [pressure equalization] tube) that allows the fluid to drain (69433, 69436). Code 69424 is unilateral, so if the tubes were removed bilaterally, add modifier -50.

L04-296 Nasal polyps (1)

Nasal polyps develop and mature, causing nasal obstruction. The physician removes the polyps, usually with a snare. The excision of nasal polyps is reported with one of two codes (30110 and 30115). The difference between the codes is the extent of the excision. Code 30110 reports a simple polyp excision that would usually be performed in the office, whereas 30115 reports a more extensive polyp excision that would usually be performed in a hospital setting.

L04-292 NOSE

Nose subheading are reported by physicians who specialize in treating conditions of the nose (otorhinolaryngologist; ear, nose, and throat specialists), but there are also many codes in the subheading that are more widely used.

L04-535 The definitions of the terms "new" and "established" patient are the same as those used in the E/M section.

New patient: One who has not received professional service from the physician, or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years. Established patient: One who has received professional services from the physician, or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.

L04-352 Noninvasive

Noninvasive services and procedures—not breaking the skin—are usually performed for diagnostic purposes. Usually, performing these procedures does not require entering the body; rather, they are diagnostic tests that can be performed from outside the body.

L04-397 Contrast material: CODING SHOT

Not all contrast material can be reported separately! Oral or rectal contrast is considered a part of the procedure and is not reported separately. Intravenous, intra-arterial, or intrathecal (fluid-filled space between the layers of tissue covering the brain and spinal cord) injection of contrast material can be reported separately if the code description does not refer to inclusion of contrast material.

L04-590 Removal of foreign body

Note the extensive list of parenthetical notes preceding 65205. The removal codes are for foreign bodies that are located in the external eye or the intraocular eye. A slit lamp is a low-powered microscope with a high-intensity light source that focuses the light as a long narrow beam (slit) and is used to examine eyes. Note that the only difference between 65220 and 65222 is whether a slit lamp is or is not utilized.

L04-329 Nuclear cardiology

Nuclear Cardiology is a diagnostic specialty that plays a very important role in modern cardiology. Nuclear cardiology uses radioactive radiologic procedures to aid in the diagnosis of cardiologic conditions. When reporting nuclear cardiology services, HCPCS Level II codes will often also be reported. - "A" codes report radiopharmaceuticals; - "G" codes report the procedures and procedures combined with the supplies, radiopharmaceuticals, and drugs; - "J" codes report the drugs; - "Q" codes report contrast agents.

L04-641 Oblique (1)

Oblique views refer to those obtained while the body is rotated so it is not in a full anteroposterior or posteroanterior position but somewhat diagonal. Oblique views are termed according to the body surface on which the patient is lying. The left anterior oblique (LAO) position is depicted in Fig. 24-8, H with the patient's left side rotated forward toward the table. The patient is lying on the left anterior aspect of his or her body. The right anterior oblique (RAO) position has the patient on his or her right side rotated forward toward the table.

L04-119 Initial observation care

Observation admission can be reported only for the first day of the service.

L04-015 History of

Often, the patient record states that there is a "history of" a disease: for example, "history of type 2 diabetes mellitus without complications." This does not mean that the patient no longer has diabetes mellitus but that the patient's medical history includes diabetes mellitus. You would not assign a Z code to indicate a previous history of diabetes mellitus but instead would assign the code for the current disease of diabetes mellitus (E11.9).

L04-624 Mammography

One of the most common types of radiological procedures you'll code is mammography. A mammography exam may be unilateral (performed on one breast) or bilateral (performed on two breasts). It may also be a screening mammography for a preventive breast exam. Assign code 77065 for a unilateral mammography, 77066 for a bilateral mammography, and 77067 for a screening mammography.

L04-468 Kidney abscess

Open drainage of a perirenal or renal abscess (50020) reports the drainage of a kidney abscess or the surrounding kidney tissue.

L04-604 Ocular adnexa: Orbit (2)

Orbitotomy performed with a bone flap and with a lateral approach is reported with codes 67420-67450. The codes for a transcranial orbitotomy are located in the Nervous System subsection (61330-61333). Within the Orbit subheading there is also a code (67415) for fine needle aspiration of the orbital contents, and it is usually performed as a biopsy method for an orbital mass.

L04-115 Direct face-to-face and unit/floor time

Outpatient visits are measured as direct face-to-face time. Direct face-to-face time is the time a physician spends directly with a patient during an office visit obtaining the history, performing an examination, and discussing the results. Inpatient time is measured as unit/floor time and is used to describe the time a physician spends in the hospital setting dealing with the patient's care.

L04-387 Pacing and Recording

Pacing is the regulation of the heart rate. A cardiac pacemaker is a permanent pacer; but the pacing referred to in the EP codes is a temporary pacing done in an attempt to stabilize the beating of the heart. Recording is a record of the electrical activity of the heart taken by means of an ECG. Recording services are reported with codes in the range of 93600-93603, and pacing services are reported with codes 93610 and 93612.

L04-596 Anterior segment: Anterior chamber (2) Paracentesis

Paracentesis is the removal of fluid. When a physician performs paracentesis of the anterior chamber of the eye, a needle is inserted into the anterior chamber and fluid is withdrawn. The fluid may be withdrawn for diagnostic purposes (65800) or for therapeutic purposes (65810-65815). If an injection procedure is also performed, report 66020 or 66030.

L04-234 Pressure ulcers

Pressure ulcers are also known as decubitus ulcers or bedsores. Pressure ulcers are located on areas of the body that have bony projections, such as the hips and the area above the tailbone. Pressure on these areas causes decreased blood flow, and sores form. Pressure ulcers commonly occur in patients who are unable to change position or have devices that prevent mobility (splints, casts).

L04-195 Surgical package

Payment is made for a package of services and not for each individual service provided within the package. The surgical package contains the components of: ■ Preoperative visits ■ Intraoperative services ■ Complications following surgery ■ Postoperative visits ■ Supplies ■ Miscellaneous service—dressing changes, catheter removal, etc.

L04-332 Pericardium

Pericardiocentesis (33016) is a procedure in which the surgeon withdraws fluid from the pericardial space by means of a needle inserted percutaneously into the space. Ultrasound guidance is included in 33016, but only when performed.

L04-389 Peripheral arterial disease rehabilitation

Peripheral arterial disease (PAD) rehabilitation sessions (93668) last 45 to 60 minutes; these are rehabilitative physical exercises done either on a motorized treadmill or on a track to build the patient's cardiovascular endurance. The physician services are not included in the PAD codes; rather the physician services are reported with an additional Evaluation and Management (E/M) code.

L04-531 Peritoneal dialysis

Peritoneal dialysis (90945, 90947) involves using the peritoneal cavity as a filter. The dialysis fluid is then drained from the peritoneal cavity. Peritoneal dialysis is reported on the basis of each day the service is provided. Some patients learn how to perform dialysis for themselves. Dialysis teaching codes are located under Other Dialysis Procedures.

L04-070 Three factors of E/M codes: 1. Place of service

Place of service explains the setting in which the services were provided to the patient. Codes vary depending on the place of the service. Places of service can be a physician's office, hospital, emergency department, nursing home, and so on.

L04-210 Podiatrists and Debridement

Podiatrists are physicians who specialize in the care of the foot; as such, these physicians use this category of codes extensively. Debridement (11720) is a more complex service—the manual cleaning of up to five nails—and it includes the use of various tools, cleaning materials/solutions, and files.

L04-598 Anterior segment: Anterior chamber (4) Posterior synechiae and Anterior synechiae

Posterior synechiae are adhesions of the iris to the lens of the eye, and anterior synechiae are adhesions of the iris to the cornea. Severing of the adhesions is performed using either laser (66821) or incisional technique.

L04-471 Nephrolithotomy

Procedures include removal of calculus (50060), secondary surgical operation for calculus (50065), procedures complicated by congenital kidney abnormality (50070), and removal of a staghorn calculus (50075). The staghorn calculus (Fig. 20-2) is shaped like a deer antler and can become large and create extensive obstruction. If the calculus involves the renal pelvis and at least two calyces, it is classified as a staghorn calculus. These types of stones account for about 30% of stones reported and are usually associated with urinary infections.

L04-634 Proximal and distal

Proximal and distal are directional body references that mean closest to (proximal) or farthest from (distal) the trunk of the body.

L04-301 Repair category (30400-30630) are the plastic procedures: Rhinoplasty

Rhinoplasty is a procedure to reshape the nose internally, externally, or both. The codes are divided based on the extent (minor, intermediate, major), on whether the septum was also repaired (septoplasty), and on whether the procedure was an initial or secondary procedure. Secondary procedures are those that are performed after an initial procedure.

L04-186 What is the difference between modifiers QX and QY?

QX: Indicates medical direction of a CRNA by a physician and is appended to the CRNA portion of the charge. QY: Indicates medical direction by an anesthesiologist of one CRNA and is appended to the physician portion of the charge.

L04-393 Supervision and Interpretation

Radiology codes often contain the statement "supervision and interpretation." Supervision is the radiologist's overseeing of the technician who is performing the procedure or indicates that the radiologist is performing the procedure himself/herself. Interpretation is the summary of the findings, also known as the final report, and the radiologist or cardiologist may do this portion of the service.

L04-625 Radiology

Radiology is the branch of medicine that uses radiant energy to diagnose and treat patients. The term originally referred to the use of x-rays to produce radiographs but is now commonly applied to all types of medical imaging. A physician who specializes in radiology is a radiologist. Radiologists can provide services to patients independent of or in conjunction with another physician of a different specialty.

L04-162 Each type of anesthesia will be covered in depth, but generally speaking: Regional anesthesia

Regional anesthesia uses injection to target the nerves of the area being treated.

L04-263 Removal and Injection codes

Removal codes located in the Introduction or Removal category (20520-20525) report the removal of a foreign body lodged in muscle or tendon. Recall that the Integumentary System removal codes describe foreign bodies lodged in the skin. Injection codes in this category report injections made into a tendon, ligament, or ganglion cyst (cystic tumor). An example of the use of these injection codes would be a corticosteroid injection as a ganglion cyst treatment.

L04-466 Six areas of the urinary system

Renal pelvis Kidney Ureters Bladder Urethra Urethral meatus

L04-431 Repair Tongue formula

Repair (41250-41252) of the tongue is reported based on the size of the repair: ■ 2.5 cm or less ■ Over 2.6 cm In addition to the size, the tongue repair codes are also based on the location of the repair: ■ Floor of the mouth and/or anterior two-thirds of tongue ■ Posterior one-third of tongue If the length of the repair is stated in inches, the measurement must be converted to centimeters. One inch equals 2.54 cm, and the formula for conversion is: ■ Centimeters × 0.3937008 = inches ■ Inches × 2.54 = centimeters If the repair is stated in millimeters (mm) the conversion to centimeters is: ■ 1 millimeter = 0.1 centimeter

L04-454 Cold biopsy

Report 45380 (colonoscopy with biopsy(ies)) when a "cold biopsy" is performed. A cold biopsy is generally accepted to mean the use of forceps to grasp and remove a small piece of tissue without the application of cautery.

L04-446 Resection

Resection of the intestine means taking out a portion of the intestine and either joining the remaining ends (anastomosis) directly or developing an artificial opening (exteriorizing) through the abdominal wall. The artificial opening (stoma) allows for the removal of body waste products as with the colostomy. Openings to the outside of the body are named for the part of the intestine from which they are formed—colostomy is an artificial opening from the colon, ileostomy from the ileum, gastrostomy from the stomach, and so forth.

L04-416 CMS RULES: Sentinel node biopsy

Sentinel node biopsy may be indicated in breast carcinoma and is eligible for Medicare reimbursement when the following conditions are met: 1. Clinical Stage I and II carcinoma of the breast with no palpable lymph nodes in the axilla, and 2. If a second sentinel node is excised from a different lymphatic chain through a separate incision at the same operative session, report the appropriate CPT code for the second incision and append the -59 modifier. Examples of payable diagnosis codes: C50.-, C50.029-C50.929

L04-302 Repair category (30400-30630) are the plastic procedures: Septoplasty

Septoplasty is rearrangement of the nasal septum. This procedure is commonly performed due to a deviated septum. CAUTION: Do not use a septoplasty code if the operative report indicates that only a resection of the inferior turbinate(s) was performed. The resection of the inferior turbinate(s) is reported with 30140 and is not a procedure performed on the septum. The septoplasty code, 30520, is reported when the nasal septum is resected. There is a note enclosed in parentheses following both codes—30140 and 30520—that cautions you to use the correct code, depending on whether the turbinate or the septum was resected.

L04-055 Original treatment plan not carried out

Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.

L04-367 Cardiovascular coding in the medicine section

Services in the Cardiovascular subsection of the Medicine section (92920-93799) can be either invasive/noninvasive or diagnostic/therapeutic. The invasive treatments are not a matter of cutting open the body so the surgeon can view it, as was the case in the Cardiovascular subsection of the Surgery section, but are invasive in that there is an incision into or a puncture of the skin.

L04-433 Palate and uvula

Services to the palate (roof of mouth) and uvula (pendulous structure at the back of the throat) are reported with codes 42000-42299. Code 42145 describes a palatopharyngoplasty (palate and pharynx repair) procedure and has limited medically indicated reasons for the surgical procedure.

L04-207 Skin tags

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. Scissoring is often used for tissue column lesions. Closure is achieved by using sutures or an aluminum chloride solution. In ligature strangulation, a thread is tied at the base of the lesion and left there until the tissue dies. The lesion then drops off.

L04-545 Sleep studies

Sleep studies in newborns are performed by pediatric pulmonologists. Sleep studies are the monitoring of a patient's sleep for 6 or more hours. The studies include the tracing (technical component) and the physician's review, interpretation, and report (professional component). If a physician performs only the professional component, modifier -26 is reported.

L04-224 Adjacent tissue transfer or rearrangement

Some of them are Z-plasty, W-plasty, V-Y plasty, rotation flaps (Fig. 14-21), and advancement flaps. These procedures are various methods of moving a segment of skin from one area to an adjacent area, while leaving at least one side of the flap (moved skin) intact to retain some measure of blood supply to the graft.

L04-363 Vascular access

Some treatments are administered through the blood by means of vascular access. For instance, in patients receiving hemodialysis, arteriovenous fistulas may be created for dialysis treatments. This means that an artificial connection is made between a vein and an artery, allowing blood to flow from the vein through the graft for dialysis (cleansing of waste products) and then be returned to the artery.

L04-039 Laterality

Specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

L04-163 Each type of anesthesia will be covered in depth, but generally speaking: Spinal and epidural anesthesia

Spinal anesthesia is administered into the cerebral spinal fluid or epidural area of the spine that corresponds with the area being treated. Spinals are generally used for procedures below the waist. Epidural catheters are often placed to facilitate administration of medication into the spinal region.

L04-282 Application of casts and strapping

Strapping is used to exert pressure on a body part to give it more stability, and is used in the treatment of sprains, strains, and dislocations. Splints are made of wood, cloth, metal, or plastic and are used to immobilize, support, or protect a body part, thereby allowing rest and healing. The removal of the cast, strapping, or splint is included in each of the Application of Casts and Strapping codes.

L04-374 Stress tests (ST)

Stress tests are performed to assess the adequacy of the amount of oxygen getting to the heart muscle (at rest and during exercise) and thus indicate the presence or absence of heart disease. The ST segment dips. QRS complex and T waves are related to the contraction of the ventricles. Indications of heart disease during a stress test are chest pain and lengthened ST segments.

L04-220 Three types of repair: Simple

Superficial wound repair (12001-12021) that involves epidermis, dermis, and subcutaneous tissue and requires only simple, one-layer suturing. If the simple wound repair is accomplished with tape or adhesive strips, the charge for the closure is included in the E/M service code and would not be reported separately with a repair code. The repair codes are for suture closure.

L04-448 Appendix

Surgical procedures of the appendix may be accomplished by means of Open procedures: ■ 44900, open I&D of abscess ■ 44950, open surgical appendectomy Percutaneous procedures: ■ 49406, percutaneous image-guided I&D of abscess Laparoscopic procedures: ■ 44970, laparoscopic appendectomy There are two other codes to report appendectomy procedures. ■ 44955, appendectomy performed at the time of a major procedure for an indicated purpose ■ 44960, appendectomy when appendix has ruptured or there is generalized peritonitis

L04-558 The TNM Classification System

T stands for the primary tumor N stands for lymph nodes M stands for metastasis T refers to the tumor size: the higher the number, the larger the tumor.

L04-378 Telephonic transmission

Telephonic transmission of an external patient-activated electrocardiogram records irregular rhythms. The readings can then be sent to the physician by means of a telephone to transmit the information, which is subsequently printed for the physician's review. Third-party payers usually restrict the payment of telephonic transmissions to one every 30 days. The codes 93268-93272 are divided on the basis of the component(s) that were provided.

L04-318 Excision: Pleurectomy (1)

The Excision category contains codes for pleurectomy, biopsy, pneumonocentesis, removal, and reconstructive lung procedures. Pleurectomy is a procedure in which the physician opens the chest cavity to full view. With the chest open and the ribs spread apart by a rib spreader, the parietal pleura is removed. The parietal pleura lines the mediastinum and body walls.

L04-632 Planes

Terminology referring to planes of the body and the positioning of the body is often used in the Radiology section. A position is how the patient is placed during the x-ray examination (such as lying down or standing up), and a projection is the path of the x-ray beam.

L04-174 B is for base unit

The ASA publishes a Relative Value Guide® (RVG), which contains codes for anesthesia services and the base unit value for each anesthesia code. Anesthesia is paid based on: • Base units + • Time units + • Modifying units (if allowed) × conversion factor

L04-426 Abbe-Estlander (40527

The Abbe-Estlander (40527, also known as Abbe flap or cross flap) is a reconstructive procedure in which a graft is taken from a portion of the lip and the non-defective area above the lip is used to repair the area of defect.

L04-330 Cardiovascular coding in the surgery section

The Cardiovascular System subsection (33016-37799) of the Surgery section contains diagnostic and therapeutic procedure codes that are divided on the basis of whether the procedure was performed on the heart/pericardium or on arteries/veins. The Heart and Pericardium subheading (33016-33999) contains codes for procedures that involve the repair of the heart and coronary vessels, such as placement of pacemakers, repair of valve disorders, and graft/bypass procedures.

L04-548 Central nervous system assessments/tests

The Central Nervous System Assessments/Tests codes (96105-96146) identify psychological testing, speech/language (aphasia) assessment, developmental progress assessments, and thinking/reasoning status examination (neurobehavioral).

L04-606 Conjunctiva

The Conjunctiva subheading includes Incision and Drainage (68020, 68040), Excision and/or Destruction (68100-68135), Injection (68200), Conjunctivoplasty (68320-68340), and the Lacrimal System (68400-68850). Conjunctivoplasty (68326-68328) involves reconstruction of the cul-de-sac with a conjunctival graft or rearrangement. Lacrimal System procedures include incision, excision, repair, and probing. The most common procedure performed is nasolacrimal duct probing generally due to an obstruction and reported with 68810 or 68811.

L04-345 Coronary artery anomalies

The Coronary Artery Anomalies category (33500-33507) contains codes to report the services of repair of the coronary artery by various methods, such as graft, ligation (tying off), and reconstruction. Do not unbundle the codes and report the endarterectomy or angioplasty separately.

L04-509 Cytopathology and cytogenic studies

The Cytopathology subsection codes (88104-88199) report the laboratory work performed to determine whether cellular changes are present. Cytopathology may also be performed on fluids that have been aspirated from a site to identify cellular changes. Cytogenetic Studies (88230-88299) include tests performed for genetic and chromosomal studies.

L04-261 EXCISION

The Excision category (20150-20251) codes are for the biopsies of muscle and bone. The codes are divided based on the type of biopsy (muscle, bone), the depth of the biopsy (superficial, deep), and, in some codes, the method of obtaining the biopsy (e.g., percutaneous needle). A percutaneous biopsy, as represented in 20206, differs in that the area is not opened to the physician's view.

L04-586 Eye and ocular adnexa

The Eye and Ocular Adnexa subsection (65091-68899) includes the subheadings Eyeball, Anterior Segment, Posterior Segment, Ocular Adnexa, and Conjunctiva. There are the typical incision, excision, repair, and destruction categories but also some that are unique. CODING SHOT: Remember to use modifier -50 (bilateral procedure) when the procedure is performed on both eyes. Modifiers -RT and -LT may be assigned for bilateral procedures of anatomic sites that are in pairs; i.e., eyes, breasts, legs, arms, etc.

L04-605 Ocular adnexa: Eyelids

The Eyelids subheading includes procedures performed by incision, excision, destruction, and tarsorrhaphy (suturing the eyelids together). There are also codes to report eyelid repair and reconstruction. Eyelid repairs include entropion (inward turning, 67921-67924) and ectropion (outward turning, 67914-67917) HCPCS modifiers are added to the procedure code to indicate the specific eyelid: ■ -E1 - upper left eyelid ■ -E2 - lower left eyelid ■ -E3 - upper right eyelid ■ -E4 - lower right eyelid

L04-088 2. History of Present Illness (HPI) (2)

The HPI may include the elements identified in the following example: Location: thoracic spine (site on body) Quality: burning, throbbing (characteristics) Severity: on a scale of 1 to 10, an 8 (intensity) Duration: 3 days (how long is an episode or how long has the problem existed) Timing: throughout the day, continuously, at night, in the morning, etc., the frequency (when does it occur) Context: when bending over (under what circumstances does it occur) Modifying factors: better when lying down (what circumstances make it better or worse) Associated signs and symptoms: weakness (what else is present that relates to chief complaint)

L04-343 Heart (including valves) and great vessels

The Heart (Including Valves) and Great Vessels category (33300-33335) contains codes to report the services of repair of cardiac wounds, exploratory (including foreign body removal), and insertion of graft of the aorta or great vessels. The codes are reported with or without cardiopulmonary bypass. Suture repair of the aorta or great vessels (33320-33322) is reported with or without shunt or cardiopulmonary bypass.

L04-401 Heart

The Heart subsection (75557-75574) of the Radiology section contains codes that report cardiac magnetic resonance imaging (MRI) of the heart. An MRI is the use of radiation to show the body in a cross-sectional view. MRI may include the use of injectable dyes (radiographic contrast) to aid in imaging. Other MRI codes are located throughout the Radiology section according to the body part being imaged, but the codes in the Heart subsection are just for cardiac MRIs.

L04-504 Hematology and coagulation

The Hematology and Coagulation subsection contains codes (85002-85999) based on the various blood-drawing methods and tests. A blood count is used to measure the kind and number of cells in the blood, such as red and white blood cells. It is a commonly used test to detect various abnormalities in the blood. Blood counts can be manual or automated, with many variations of the tests.

L04-521 Immunization administration for vaccines/toxoids

The Immunization Administration subsection codes (90460-90474) are reported in conjunction with the Vaccines, Toxoids subsection codes (90476-90749). Immunization reporting requires two codes: one to report the administration and one to report the substance administered. A variety of administration methods are utilized to deliver the vaccine/toxoid: percutaneous, intradermal, subcutaneous, intramuscular, intranasal, or oral. The administration codes are divided based on the method of administration and in some codes, the patient age, when administered with physician counseling.

L04-197 Integumentary system

The Integumentary System are for procedures performed on the skin, nails, breasts, hair, sebaceous glands, sweat glands, and other areas of the integumentary system. The subsection Integumentary contains the subheadings: ■ Skin, Subcutaneous, and Accessory Structures ■ Nails ■ Pilonidal Cyst ■ Introduction ■ Repair (Closure) ■ Destruction ■ Breast

L04-485 Intersex surgery

The Intersex Surgery subsection (55970, 55980) is located before the Female Genital Surgery subsection and contains only two codes: one for a surgical procedure to change the sex organs of a male into those of a female and one to change the sex organs of a female into those of a male. The procedure for changing male genitalia into female genitalia involves removing the penis but preserving the nerves and vessels intact. These tissues are used to form a clitoris and a vagina. The urethral opening is shifted to be in the position of that of a female. The surgical procedure for changing the female genitalia into male genitalia involves a series of procedures that use the genitalia and surrounding skin to form a penis and testicle structures into which prostheses are inserted.

L04-316 Lungs and pleura

The Lungs and Pleura subheading (32035-32999) includes a wide range of codes to report procedures such as thoracentesis, thoracotomy, and pneumonostomy, in addition to lung transplants and plastic procedures.

L04-243 Musculoskeletal system

The Musculoskeletal System subsection is formatted by anatomic site, such as General, Head, and Neck. The other subheadings are further divided by anatomic site, procedure type, condition, and description. They usually include: ■ Incision ■ Excision ■ Introduction or Removal ■ Repair, Revision, and/or Reconstruction ■ Fracture and/or Dislocation ■ Arthrodesis ■ Amputation

L04-065 Present on admission (POA)

The Present on Admission (POA) indicator distinguishes between conditions that develop during a particular hospital stay and those conditions present at the time of admission.

L04-179 Base-modifying factors: Qualifying circumstances

The Qualifying Circumstances codes begin with 99 and are considered add-on codes, which means that the codes can never be reported alone but must be used in addition to another code to provide additional information. A Qualifying Circumstances code is reported in addition to the anesthesia procedure code.

L04-175 CMS's base units

The RVG is not a fee schedule (a list of charges for services) but instead compares anesthesia services with each other. A team of physicians with expertise in anesthesiology developed the comparisons and assigned numerical values to each service, termed the base unit value.

L04-392 Cardiovascular coding in the radiology section

The Radiology section of the CPT manual used to contain combination codes that included both the professional and technical components in one code.

L04-587 EYEBALL: Removal of eye (1)

The Removal of Eye category contains codes to report evisceration, which is removal of the contents of the globe while leaving the extraocular muscles and sclera intact (65091, 65093); enucleation, which is removal of the eye while leaving the orbital structures intact, (65101-65105); and exenteration, which is removal of the eye, adnexa, and part of the bony orbit (65110-65114).

L04-484 Reproductive system procedures

The Reproductive System Procedures subsection (55920) is located after the Male Genital System subsection and consists of only one code. Code 55920 reports the placement of needles or catheters into the pelvic organs and/or genitalia (except prostate) for the subsequent interstitial radioelement application (brachytherapy). A Heyman capsule indicated in the parenthetical statement following 55920 directs the coder to 58346 when reporting Heyman capsule insertion. A Heyman capsule was a method of manual loading that was used in the early days of brachytherapy.

L04-191 Introduction to the surgery section

The Surgery section is the largest in the CPT manual. The codes range from 10004 to 69990. Surgery is divided into subsections. Most Surgery subsections are defined according to medical specialty or body system (e.g., integumentary or respiratory). Within the Surgery section, some of the more complex subsections are the Integumentary, Musculoskeletal, Respiratory, Cardiovascular, Digestive, and Female Genital subsections.

L04-331 Heart and pericardium

The Surgery section, Cardiovascular System subsection, Heart and Pericardium subheading (33016-33999) contains procedures that are performed both percutaneously and through open surgical sites. There are always many revisions and additions in this subheading each year to reflect the many advances in this important specialty.

L04-506 Transfusion medicine

The Transfusion Medicine subsection codes (86850-86999) report tests performed on blood or blood products. Tests include screening of blood for antibodies, Coombs testing, autologous blood collection and processing, blood typing, compatibility testing, and preparation of and treatments performed on blood and blood products.

L04-259 Wound exploration

The Wound Exploration codes (20100-20103) report traumatic wounds that result from a penetrating trauma (e.g., gunshot, knife wound). Wound Exploration codes include basic exploration and repair of the area of trauma. If the wound does not require enlargement, you would report a code from the Integumentary System, Skin Repair codes. If, however, the wound is more severe than a Wound Exploration code would indicate, the repair code would come from the specific repair by anatomic site codes.

L04-007 Z codes

The Z codes are assigned to report these types of encounters and capture the story accurately. Sometimes the Z code will be the first-listed code, and sometimes the Z code will be a supplemental code.

L04-591 Repair of laceration

The repair codes are assigned to report laceration repair based on where the laceration is located (conjunctiva, cornea, and/or sclera). Code 65286 reports the application of tissue glue for a perforation of the eyeball.

L04-228 Abrasion

The abrasion codes (15786, 15787) report the use of abrasion to remove a lesion, such as scar tissue, a wart, or a callus. This technique is often used to remove areas of sun-damaged skin. The first abraded lesion is reported with 15786, and each additional four or fewer lesions are reported with 15787.

L04-595 Anterior segment: Anterior chamber (1)

The anterior chamber of the eye is a fluid-filled (aqueous humor) space, located behind the cornea and in front of the iris. The categories of Incision (65800-65880), Removal (65900-65930), and Introduction (66020-66030) are for procedures performed on the anterior chamber of the eye.

L04-582 Approach and Definitive Procedures

The approach procedure (61580-61598) is the method used to obtain exposure of the lesion (e.g., anterior cranial fossa, middle cranial fossa, posterior cranial fossa). The approach procedure is the anatomical location. The definitive procedure (61600-61616) is what was done to the lesion (e.g., biopsy, excision, repair, resection).

L04-004 Codes from a00.0 through t88.9, Z00-Z99, U00-U85

The appropriate code(s) from A00.0 through T88.9, Z00-Z99 and U00-U85 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. The Guidelines state that it is acceptable to use any of the codes throughout the entire Tabular List to identify the reason(s) for an outpatient visit including the use of Z codes. Z codes are used more frequently in the outpatient setting. It is important to code all the conditions or problems that are being managed during an encounter.

L04-265 Arthrocentesis (2)

The arthrocentesis codes are divided according to whether the joint is small (finger, toe), intermediate (ankle, elbow), or major (shoulder, hip). Note that while the shoulder is a major joint, the acromioclavicular joint, which is a part of the shoulder, is only an intermediate joint. Codes are also divided by with or without guidance. Lidocaine, Marcaine, and so forth, when used as anesthetics, are not reported separately. Any injected therapeutic drug such as a steroid is reported separately using a HCPCS J code (drug code).

L04-279 Segmental instrumentation

The attachment of a fixative device at each end of the area being repaired and at least one other attachment in the spinal area being repaired. Spinal instrumentation is used to stabilize the spinal column in some repair procedures.

L04-344 Cardiac valves

The category Cardiac Valves (33361-33478) has subcategory codes of aortic, mitral, tricuspid, and pulmonary valves. The procedures listed are similar for each valve; some are a little more extensive than others. Code descriptions vary depending on whether a cardiopulmonary bypass (heart-lung) machine was used during the procedure. The cardiopulmonary bypass is a resource-intensive procedure that requires a heart-lung machine to assume the patient's heart and lung functions during surgery.

L04-359 Aneurysm repair

The category Direct Repair of Aneurysm or Excision (Partial or Total) and Graft Insertion for Aneurysm, Pseudoaneurysm, Ruptured Aneurysm, and Associated Occlusive Disease (35001-35152) contains aneurysm repair codes that are divided according to the type of aneurysm and the vessel the aneurysm is located in (subclavian artery, popliteal artery). The aneurysm is formed by the dilation of the wall of an artery; it is filled with fluid or clotted blood. During repair, the aneurysm is located, and clamps are placed above and below it. The section containing the aneurysm is then removed or bypassed.

L04-573 Central nervous and peripheral nervous systems.

The central nervous system includes the brain and spinal cord. The peripheral nervous system contains 12 pairs of cranial nerves and 31 pairs of spinal nerves. The peripheral nervous system is divided into the somatic nervous system, autonomic nervous system, and the enteric nervous system. The somatic nervous system coordinates body movements and receives external stimuli and is under conscious control. The autonomic nervous system is divided into the sympathetic (responds to stress), parasympathetic (constricts pupils, slows heartbeat, dilates blood vessels, stimulates digestion), and enteric divisions (manages digestion) and is not under conscious control.

L04-600 Anterior segment: Iris, ciliary body

The ciliary body is located behind the iris (colored part of the eye) and produces aqueous humor. The smooth muscle of the ciliary body attaches to the lens. An iridectomy is usually performed for removal of a lesion (66600) or as a treatment for glaucoma (66625, 66630) by creation of an opening to drain aqueous humor. If the iridotomy/iridectomy is performed by means of laser, report the procedure with 66761. If an iridoplasty is performed by means of photocoagulation, report the procedure with 66762.

L04-165 Moderate (conscious) sedation (2)

The code descriptions for the Moderate (Conscious) Sedation codes include the term "intraservice time." Intraservice time begins with the administration of the sedation agent, requires continuous face-to-face attendance by the physician, and ends when the personal contact by the physician ends. Moderate or conscious sedation methods are much less invasive than anesthesia services that provide the complete loss of consciousness.

L04-494 Organ or disease-oriented panels

The codes in the Organ or Disease-Oriented Panels subsection (80047-80081) are grouped according to the usual laboratory work ordered by a physician for the diagnosis of or screening for various diseases or conditions.

L04-553 Physical medicine and rehabilitation

The codes in the Physical Medicine and Rehabilitation subsection (97010-97799) are reported by a physician or therapist. The subsection includes codes for different modalities of treatments (e.g., traction, whirlpool, electrical stimulation) as well as various types of patient training (e.g., functional activities, gait training, massage). An orthotic is a support, splint, or brace used to align a body part, such as an elbow brace (L3702-L3766). A prosthetic is a replacement, such as a breast prosthesis (L8000-L8039).

L04-541 Noninvasive vascular diagnostic studies

The codes in this subsection (93880-93998) report procedures that are conducted to study veins and arteries other than the heart and great vessels. These studies use the same devices as are used in heart and great-vessel echocardiography, except that the divisions are based on the location of the vein or artery being studied.

L04-540 Home and outpatient international normalized ratio (inr) monitoring services

The codes report anticoagulant services using Warfarin/Coumadin. Anticoagulants inhibit coagulation of the blood and are prescribed to patients with various thromboembolic disorders. Patients on this medication are monitored by means of blood tests and adjustments are then made in the blood thinner dosage if the physician determines the clotting levels are not ideal. Codes 93792 and 93793 report the training for INR monitoring and the anticoagulant management for a patient taking warfarin; both codes are reported home or outpatient place of service.

L04-237 Destruction

The codes report destruction of lesions by means other than excision. Destruction codes state "any method" and are divided according to type of lesion (benign or malignant).

L04-493 Pathology/Laboratory

The collection of the specimen is reported separately from the analysis of the test. The laboratory and pathology reports in the patient medical record will describe the method by which the test was performed.

L04-427 Cheiloplasty (lip repair) Two types of Repair codes:

The full-thickness repairs are based on the extent of the repair, for example, vermilion only (40650), up to half of the vertical height of the lip (40652), and over one-half of the vertical height of the lip (40654, complex repair). A cleft lip is a congenital defect in which the muscle and tissue of the lip did not close properly.

L04-592 Anterior segment: CORNEA (1)

The cornea is the transparent part of the eye. The cornea may be the site of a superficial lesion that is completely removed and reported with 65400. If only a portion of the corneal lesion was removed for pathology analysis, report the service as a biopsy with 65410.

L04-432 Dentoalveolar structures

The dentoalveolar structures are the bone (osseous) and soft structures of the mouth that anchor the teeth.

L04-552 Special dermatological procedures

The dermatology codes (96900-96999) are usually reported by a dermatologist who provides services to a patient in an office on a consultation basis. The dermatology codes for special procedures would typically be reported in addition to an E/M code. The dermatologist conducts a history and examination and treats the patient with ultraviolet light (actinotherapy).

L04-422 Diaphragm

The diaphragm is the wall of muscle that separates the thoracic and abdominal cavities. The codes in the Diaphragm subheading (39501-39599) are repair codes. Repairs are usually for a hernia or laceration. Diaphragm codes are located in the CPT manual index under "Diaphragm."

L04-419 Mediastinum and diaphragm: Incision

The difference between the mediastinotomy codes (39000, 39010) is the surgical approach. The approach can be either cervical (neck area), across the thoracic area (transthoracic), or sternum. A mediastinotomy is performed by making an incision next to the breastbone for the purposes of exploration, drainage, removal of a foreign body, or biopsy.

L04-181 CONVERSION FACTOR

The dollar value of each unit. Each third-party payer issues a list of conversion factors. The lists vary with geographic location because the cost of practicing medicine varies from one region to another. The conversion factor for the locale is multiplied by the number of units for the procedure.

L04-385 Electrical conduction system of the heart

The electrical conduction system of the heart, which begins with the sinoatrial node (SA), known as the heart's pacemaker. The sinoatrial node sends impulses to the atrioventricular (AV) node, which in turn passes the impulses to the bundle of His, and finally on to the Purkinje fibers to stimulate the muscle tissues of the ventricles of the heart to contract. Lesions or diseases involving these structures along the electrical conduction pathway underlie many of the disturbances of cardiac rhythm.

L04-078 Medical decision making (MDM)

The elements of Medical Decision Making (MDM) remove the focus of adding up tasks and now focus on the elements that affect the management of a patient's condition that include the number and complexity of problems addressed, amount and/or complexity of data reviewed, and risk of complications and/or morbidity or mortality of patient management.

L04-098 2. History levels: 2. Expanded problem focused:

The expanded problem focused history does not have to include the past, family, or social history. This history would center around specific questions regarding the system involved in the presenting problem or chief complaint.

L04-607 Auditory system: (External ear) Incision.

The external ear may be the site of an abscess or hematoma, and the incision and drainage may be simple (69000) or complicated (69005). If the abscess drained is within the auditory canal, report the service with 69020. Be careful when reporting 69020 as it can be bundled into a major procedure and not reported separately.

L04-294 INCISION (2)

The insertion and removal of the tube and/or gauze and any required sutures and/or anesthesia are bundled into the code, so you should not report these services separately. You should report any additional supplies over and above those usually used for the procedure by using the Medicine section code for supplies, 99070, or a HCPCS code, as directed by the third-party payer.

L04-542 Allergy and clinical immunology

The first is Allergy Testing, which describes allergy testing by various methods (percutaneous, intracutaneous, inhalation) and the type of tests (allergenic extracts, venoms, biologicals, food). The number of tests must always be specified for reporting purposes because for most of these codes, payment is made per test. The second subheading is Ingestion Challenge Testing (95076, 95079). Code 95076 reports the initial 120 minutes of testing time and 95079 reports each additional 60 minutes. The third subheading is Allergen Immunotherapy and the codes specify three types of services: Injection only, prescription and injection, provision of antigen only.

L04-356 Vascular families

The first order is the main artery in a vascular family, the second order is the branch off the main artery, the third order is the next branch off the second order, and so on. Appendix L of the CPT manual is a listing of the vascular families based on the starting point of the aorta.

L04-579 Skull, meninges, and brain: Punctures, twists, or burr holes.

The first two categories of codes are Injection, Drainage, or Aspiration (61000-61070) and Twist Drill, Burr Hole(s), or Trephine (61105-61253) that deal with conditions that may require holes or openings be made into the brain to relieve pressure, insertion of monitoring devices, placement of tubing, injection of contrast material, or to drain a hemorrhage. A ventricular puncture (61020-61026) requires a puncture through the top portion of the skull, while a cisternal puncture (61050, 61055) is an approach at the base of the skull. Twist or burr holes are made through the skull, which leaves the skull intact except for the small openings (holes).

L04-423 Format of the Digestive System subsection

The format of the Digestive System subsection (40490-49999) is divided according to anatomic site and procedure. Included in this subsection are codes for sites beginning with the mouth and ending with the anus. Also included are those internal organs that aid in the digestive process, including the pancreas, liver, and gallbladder.

L04-464 Biliary tract

The gallbladder is connected to the liver and the small intestine by the biliary tract. The tract can be the site of conditions such as calculi and tumor that may obstruct the flow of bile. A choledochotomy is an incision into the biliary tract, and a cholecystostomy is the formation of a stoma between the abdominal wall and the gallbladder. An injection procedure may be necessary to determine if the biliary tract is obstructed. Stents may be placed in the obstructed biliary tract to open the area (47538-47540). Drainage catheters may also be changed (47536) or removed (47537).

L04-085 History.

The history is the subjective information the patient tells the physician based on the four elements of a history—chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family, and social history (PFSH). The history contains the information the physician needs to appropriately assess the patient's condition. Not all histories have all elements. Ancillary staff (nurses, physician assistants, and so forth) are allowed to document some of the history, such as chief complaint and past, family, and social histories, but the physician must authenticate the entries (physician must evaluate the form and indicate in the medical record that the form has been reviewed).

L04-013 External cause index

The index classifies environmental events (tornadoes, floods), circumstances, and other conditions as the cause of injury and other adverse effects alphabetically. The External Cause codes are never reported as a first-listed diagnosis. Rather these codes are reported to clarify injury or adverse effects.

L04-445 Intestines (except rectum)

The large intestine is about 5 feet long with a wider diameter than the small intestine. The small intestine is about 30 feet long. The Intestine codes 44005-44799 exclude codes to report services for the anus and rectum. Endoscope codes are available for procedures depending on how far down (through the mouth) or up (through the anus) the scope is passed. To choose the correct endoscopy, identify the farthest extent to which the scope was passed and then the procedure(s) performed.

L04-643 Oblique (3)

The last two terms that describe projections are tangential and axial. Tangential is the position that allows the beam to skim the body part, which produces a profile of the structure of the body, the axial projection, which is any projection that allows the beam to pass through the body part lengthwise.

L04-080 Various levels of E/M service

The levels of service are based on key components (history, examination, and medical decision making complexity) and contributory factors (counseling, coordination of care, nature of presenting problem, and time). The components contain a great deal of information that you need to know before you learn about factors.

L04-140 Long-term care facility

The long-term care facility describes health and personal services provided to ill, aged, disabled, or mentally handicapped individuals for an extended period of time. Other types of facilities are better described as skilled or intermediate care facilities.

L04-411 Lymph nodes and lymphatic channels

The lymphatic system is a transportation system that takes interstitial fluids, proteins, and fats through the lymphatic channels and back to the bloodstream. Stations along the lymphatic system are called lymph nodes. The nodes fight disease when lymphocytes from the nodes produce antibodies.

L04-557 Salivary glands

The major salivary glands are the largest and most important salivary glands. They produce most of the saliva in your mouth. There are three pairs: the parotid, submandibular, and sublingual glands.

L04-418 Mediastinum

The mediastinum is the area between the lungs. The Mediastinum subheading of the Mediastinum and Diaphragm subsection (39000-39599) of the CPT manual is divided by procedures and includes incision, excision, and endoscopy.

L04-576 Meninges

The meninges consists of three layers of connective membranes that surround the brain and spinal cord. The outermost membrane of the meninges is the dura mater, which is a thick, tough membrane that contains channels by which blood enters the brain tissue. The subdural space is located below the dural membrane and contains multiple blood vessels. The second layer around the brain and spinal cord is the arachnoid membrane. The third layer of the meninges and the one closest to the brain and spinal cord is the pia mater.

L04-238 Mohs micrographic surgery

The method is named after the physician who pioneered the basic microscopic technique, Frederic Mohs, MD. The microscope is used during the surgical procedure to view the lesion and assess its invasion by a single physician acting in two separate and distinct capacities—surgeon and pathologist. Mohs micrographic surgery is especially useful in cases of large tumors.

L04-618 Auditory system: (Inner ear) Temporal bone, middle fossa approach

The middle fossa approach is used by surgeons to excise acoustic neuromas, to decompress the facial nerve (proximal temporal), and repair nerves in the vestibular labyrinth. The codes in the Temporal Bone, Middle Fossa Approach subheading report removal of the vestibular nerve (69950), relief of pressure (decompression) of the facial nerve and/or repair (69955), decompression of the internal auditory canal (69960), and removal of tumors of the temporal bone (69970).

L04-386 Programmed stimulation.

The physician may also stimulate the heart to induce arrhythmia by means of a catheter attached to a pacing device that sends electrical impulses to various sites within the heart. A protocol (a set order) for the placement of the catheter is a programmed stimulation.

L04-365 Catheter insertion

The needle has a guidewire attached to it, and when the needle is withdrawn, the guidewire is left inside the artery. The guidewire can then be manipulated into the particular artery. Once the guidewire is in the correct artery, a catheter is threaded into place over the guidewire and into the first-order brachiocephalic artery. The catheter is manipulated through the second-order artery and arrives at the third-order artery, where contrast material is injected into the artery through the catheter and an arteriography is completed.

L04-465 Pancreas

The pancreas is located behind (posterior to) the stomach and produces enzymes and hormones. The pancreas may become inflamed (pancreatitis) and require the placement of drains to remove the excess fluid.

L04-101 Examination

The patient has presented the physician with the subjective information regarding the complaint or problem in the history portion of the encounter; now the physician will do an examination of the patient to provide objective information, "hands-on" (those findings observed by the physician) about the complaint or problem. The physician then documents the objective findings in the patient record.

L04-551 Photodynamic therapy

The photodynamic therapy services (96567-96574) are codes reported in conjunction with the bronchoscopy or endoscopy services. An agent is injected into the patient that remains in premalignant cells longer than in the normal cells. After the agent has dissipated from the normal cells, the patient is exposed to laser light. The agent absorbs the light and the light produces oxygen, destroying the premalignant cells.

L04-099 3. History levels: Detailed:

The physician focuses on a chief complaint, obtains an extended history of the present problem (four or more of the eight elements), an extended review of systems, and a pertinent PFSH. The system review in this history is extended, which means that positive responses and pertinent negative responses relating to multiple organ systems should be documented.

L04-321 Thoracentesis (1)

The preferred method of accomplishing a thoracentesis is by having the patient sit with arms supported. Local anesthesia is administered, a needle is inserted between the ribs, and fluid is withdrawn. Thoracentesis is performed to withdraw fluid from the pleural space that has accumulated as a result of a variety of conditions, such as congestive heart failure, pneumonia, tuberculosis, or carcinoma.

L04-049 Selection of principal diagnosis (1)

The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner.

L04-050 Selection of principal diagnosis (2)

The principal diagnosis is sequenced first in inpatient coding. In an outpatient setting, the term first-listed condition is used in lieu of the term principal diagnosis and is used to indicate the main reason for the visit. The terminology "principal diagnosis" refers only to an acute care setting and is used in conjunction with the MS-DRG payment scheme; "first-listed diagnosis" refers only to outpatient settings.

L04-114 ■ High severity

The risk of complete sickness (morbidity) without treatment is high to extreme, there is a moderate to high risk of death without treatment, or there is a strong probability of severe, prolonged functional impairment.

L04-112 ■ Low severity

The risk of complete sickness (morbidity) without treatment is low, there is little or no risk of death without treatment, and full recovery without impairment is expected.

L04-113 ■ Moderate severity

The risk of complete sickness (morbidity) without treatment is moderate, there is moderate risk of death without treatment, and an uncertain prognosis or increased probability of impairment exists.

L04-599 Anterior segment: Anterior sclera

The sclera is the white, fibrous outer layer of the eyeball and the anterior sclera is the front part of the eye. The anterior sclera may be the site of lesions that are excised (66130) by incision of the conjunctiva to gain access to the lesion. Depending on the size of the lesion, the area of the sclera may not require sutures.

L04-180 Base-modifying factors: Physical status modifiers

The second type of modifying unit used in the Anesthesia section. These modifiers indicate the patient's condition at the time anesthesia was administered and identify the level of complexity of the services provided to the patient. The physical status modifier is not assigned by the coder but is determined by the anesthesiologist and documented in the anesthesia record. The physical status modifier begins with the letter "P" and contains a number from 1 to 6.

L04-208 Shaving of epidermal or dermal lesions

The shaving of a lesion (11300-11313) can be performed by using a scalpel blade or other sharp instrument. Anesthesia and cauterization (electrocautery or chemical cautery) to control bleeding are included in the lesion-shaving codes. If more than one lesion was removed, you would add modifier -51 (multiple procedures) to any codes after the first code.

L04-581 Surgery of skull base.

The skull base is the area at the base of the cranium where the lobes of the brain rest. When lesions are located within the skull base, it often takes the skill of several surgeons working together to perform surgery dealing with these conditions. The procedures located in the category Surgery of Skull Base (61580-61619) are very involved, taking many hours to complete. The procedures are divided on the approach procedure, the definitive procedure, and the reconstruction/repair procedure.

L04-575 Spinal cord

The spinal cord is a column of nerve tissue extending from the medulla oblongata to the second lumbar vertebra. Located at the end of the spinal cord is the cauda equina (a group of nerve fibers found below the second lumbar vertebra of the spinal column). The cauda equina carries all the nerves that affect the lower part and limbs of the body and serves as the pathway for impulses going to and from the brain.

L04-404 Coding highlights: Spleen

The spleen is composed of lymph tissue and is located in the left upper quadrant of the abdomen. The spleen is easily ruptured and may result in massive hemorrhage. The spleen initiates an immune response, filters, removes bacteria from the bloodstream, and destroys worn out blood cells. Codes in the subheading Spleen (38100-38200): - excision, repair, laparoscopy, introduction Codes in the Excision category are based on the type of splenectomy: - - - total, partial, or total for extensive disease The splenectomy (total and partial) carries the designation "(separate procedure)" behind the code description (38100, 38101).

L04-532 End-stage renal disease

The subheading (End Stage Renal Disease Services) deals with dialysis of an ongoing nature. The 90951-90966 codes reflect all services included in treating a patient with ESRD and are listed according to patient age (e.g., younger than 2 years of age, 2-11 years of age) and number of visits (1, 2-3, 4+) per month. Dialysis services are reported as a monthly fee. Dialysis is usually performed in an outpatient setting at a hospital or other outpatient dialysis facility. The physician services are reported based on the type of dialysis the patient is receiving, the complexity of the service, and the number of visits the physician provides to the patient.

L04-405 Coding highlights: Laparoscopy

The surgical laparoscopy codes (38120, 38129) always include a diagnostic laparoscopy if one is performed. Report a diagnostic laparoscopy with 49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).

L04-488 Tandems and Ovoid

The tandems and/or vaginal ovoid are internal implants that contain a radioactive substance and are often used in the treatment of cervical cancer. The tandems and/or vaginal ovoid are internal implants that contain a radioactive substance and are often used in the treatment of cervical cancer The tandems and/or vaginal ovoids are internal implants that contain a radioactive substance and are often used in the treatment of cervical cancer

L04-394 Two components (parts) in a code with supervision and interpretation in the description:

The technical component is the equipment and the technician who actually provides the service. The professional component is the interpretation of the results and the writing of a report about the results. Both components are not necessarily done by the same organization. Let's take an x-ray as an example of a service and see how you report the components.

L04-415 Regions of neck lymph nodes

The term "complete neck dissection" in code 38720 is the same as radical neck dissection. During a complete or radical neck dissection, the lymph nodes in all five regions are resected (removed). The suprahyoid neck dissection is a variation of the modified radical neck dissection and is reported with 38700. Staging is determining the grade or level of a neoplasm based on a common grading system, such as the TNM (tumors, nodes, and metastases).

L04-194 Separate procedure

The term "separate procedure" does not mean that the procedure was the only procedure that was performed; rather, it is an indication of how the code can be assigned. Procedures followed by the words "separate procedure" (in parentheses) are considered minor procedures that are reported only when they are the only services performed or when they are performed with another major procedure but at a different site or unrelated to the major procedure.

L04-262 General introduction or removal

The term "sinus" refers to a cyst or abscess inside the body with a tract (known as a fistula) connecting to another surface—internal (to the gut) or external (to the skin). The infection is treated by injecting an antibiotic or other substance into the sinus by way of the sinus tract. Other methods that may be used in treatment of the sinus tract are the incision or opening of the tract (fistulotomy) to promote healing or excision (fistulectomy) of the tract.

L04-251 Fractures

The treatment method used—open or closed—depends on the type and severity of the fracture. A closed fracture may receive either closed, open, or percutaneous fixation, whereas a more complicated compound fracture usually requires an open treatment to provide internal fixation (e.g., wires, pins, screws).

L04-338 Approaches

The two approaches that are used when inserting a pacemaker are epicardial (on the heart) and transvenous (through a vein), and the codes are divided according to the surgical approach.

L04-192 Unlisted procedures

The unlisted codes identify procedures or services throughout the Surgery section for which there is no CPT code. If a Category III code is available for the unlisted service you are reporting, you must use the Category III code, not the unlisted Category I code. Reimbursement for Category III codes will vary by payer.

L04-430 Vestibule of mouth

The vestibule of the mouth is also known as the buccal cavity and is part of the oral cavity. Codes for the Vestibule of Mouth (40800-40899) do not include codes for services of the Tongue and Floor of Mouth (41000-41599) or Dentoalveolar Structures (41800-41899).

L04-496 Therapeutic drug assays

Therapeutic drug assays are performed to help the physician monitor the level of medication in the patient's system or to monitor the patient's compliance. If the drug is not listed, it is possible that quantitative analysis may be listed under the methodology (e.g., immunoassay, radioassay). The drugs are listed by their generic names, not their brand names.

L04-621 Radiology Coding

There are a variety of radiology procedures that may be coded in the outpatient setting, including fluoroscopy, magnetic resonance imaging (MRI), tomography, diagnostic imaging, radiologic guidance procedures, mammography, bone and joint studies, nuclear medicine, and radiology oncology.

L04-434 Salivary gland and ducts

There are three salivary glands (parotid, submandibular, and sublingual).

L04-305 LIGATION

There are times when neither cauterization nor packing will control a nasal hemorrhage, and ligation of the bleeding artery is required. Ligation of ethmoidal arteries involves opening the upper side of the nose and locating and tying the ethmoid artery. Ligation of the internal maxillary artery is performed to gain control of nasal hemorrhage by locating and ligating the maxillary artery.

L04-421 Mediastinum and diaphragm: Endoscopy

There are two mediastinoscopy codes (39401, 39402), and the procedure includes any biopsy performed during the procedure. The procedure is performed by making a small incision above the sternum. The scope is inserted through the incision for exploration (and/or biopsy).

L04-550 Chemotherapy administration

There are two other sets of codes used to report chemotherapy services: Hydration (96360-96361) and Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (96365-96379). Included (not reported separately) with chemotherapy infusion or injection codes 96401-96549 are the following: 1. Use of local anesthesia 2. IV start 3. Access to indwelling intravenous, subcutaneous catheter, or port 4. Flush at the conclusion of infusion 5. Standard tubing, syringes, and supplies 6. Preparation of the chemotherapy agent(s)

L04-066 Four major objectives guided the development of ICD-10-PCS: (1) Completeness

There is a unique code for all substantially different procedures. Previously, procedures performed on different body parts, using different approaches or of different types, were sometimes assigned the same code.

L04-620 EYEBALL: Removal of eye (3)

These codes do not report skin grafting to the orbit. When the operative report indicates skin grafting, report the service separately with codes from the Integumentary System (15120/15121 or 15260/15261). If the eyelid was repaired deeper than skin level, refer to the reconstruction codes 67930/67935 (partial or full thickness repair).

L04-185 Additional modifiers that define the types of providers involved in anesthesia

These modifiers are not CPT modifiers but HCPCS modifiers and further define the anesthesia services provided. Anesthesia modifiers are always placed first after the CPT anesthesia code. These anesthesia modifiers are pricing modifiers and are listed first to ensure correct reimbursement.

L04-038 Reporting same diagnosis code more than once

This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code. If the medical documentation indicates that the patient has two different conditions that are both included in one diagnosis code, report the diagnosis code only once.

L04-373 Cardiography and cardiovascular monitoring services

This category (93000-93278) of the Cardiovascular System subsection contains frequently assigned codes, such as those for electrocardiograms and heart monitoring, which are certain to be used in most office practices, even if the practice does not include a cardiologist. The Cardiography subheading codes report electrocardiographic procedures such as stress tests.

L04-109 Contributory factors: ■ Nature of presenting problem

This is the foundation of the level assigned. The presenting problem is the patient's chief complaint or the situation that leads the physician to determining the level of care necessary to diagnose and treat the patient. The CPT describes the presenting problem as a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.

L04-100 4. History levels: Comprehensive:

This is the most complex of the history types: the physician documents the chief complaint, obtains an extended history of the present problem, does a complete review of systems, and obtains a complete PFSH.

L04-543 Endocrinology

This subsection contains only codes used to report glucose monitoring (95249-95251). Continuous glucose monitoring is a procedure in which a probe is inserted subcutaneously and attached to a monitor that is worn by the patient.

L04-322 Thoracentesis (2)

Thoracentesis may also be performed to insert a chest tube as an indwelling method of draining the accumulated fluid in the pleural space (pleural effusion). Local anesthesia is administered, and a small incision is made through the skin, fat, and muscle.

L04-317 Incision: Thoracotomy

Thoracotomy involves making a surgical incision into the chest wall and opening the area to the view of the surgeon. This is a major surgical procedure during which the patient is under general anesthesia. The codes are divided according to the reason for the procedure, such as biopsy, control of bleeding, cyst removal, foreign body removal, or cardiac massage. The insertion of a chest tube is bundled into the thoracotomy codes.

L04-216 Repair component

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.

L04-369 Thrombolysis

Thrombolysis, as described in 92975, is a percutaneous procedure in which the physician inserts a catheter into a coronary vessel and injects contrast material into the vessel to further enhance the visualization of a blood clot.

L04-116 Total time spent with a patient

Time was not included in the CPT manual before 1992 but was incorporated to assist with the selection of the most appropriate level of E/M services. Time has changed as of 2021, reporting total time performing face-to-face and non-face-to-face services for the same date of service.

L04-570 Carotid Body

Tissue rich in capillaries that act as receptors located near the bifurcation (splitting into two) of the carotid arteries as illustrated in Fig. 22-2. The receptors monitor arterial oxygen content and pressure. Tumors that develop in the carotid body may be excised and the service reported with 60600 or 60605.

L04-314 Excision/repair: Tracheoplasty

Tracheoplasty involves the surgical repair of a damaged trachea. The repair may involve reconstruction of the trachea by the use of grafts or splints formed from cartilage taken from other areas of the body or by the use of prostheses. The codes are divided according to the approach used (cervical or thoracic) and the extent and type of repair.

L04-313 Incision: Tracheostomy

Tracheostomy is the most common procedure reported with codes from the Incision category. A tracheostomy can be planned or performed as an emergency procedure. A planned tracheostomy is usually performed when there is a need for prolonged ventilation support. Code 31603 is assigned for an emergency transtracheal tracheostomy, and 31605 is assigned for an emergency cricothyroid membrane tracheostomy. These codes represent two different approaches to establishing an airway.

L04-255 Traction definitions are as follows:

Traction is the application of pulling force to hold a bone in alignment. Skeletal traction is the use of internal devices, such as pins, screws, or wires. The devices are inserted into the bone through the skin, with ends of the pins, screws, or wires sticking out through the skin, so traction devices can be attached. Skin traction involves strapping, elastic wrap, or tape that is fastened to the skin or wrapped around the limb. Weights are then attached to apply force to the fracture.

L04-298 Turbinates

Turbinates' are the bones on the inside of the nose. These bones are shaped like a spiral shell and humidify, warm, and filter the air. These bones are referred to as the nasal conchae. The turbinates' are divided into three sections—inferior, middle, and superior.

L04-642 Oblique (2)

Two more oblique views are left posterior oblique and right posterior oblique. In the left posterior oblique (LPO) view, the patient is rotated so that the left posterior aspect of his or her body is against the table. The right posterior oblique (RPO) view has the patient with the right side rotated back

L04-052 Two or more interrelated conditions

Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

L04-399 Coding for the cardiologist

Two physicians, a cardiologist and a radiologist from different facilities, perform an angiography of the brachiocephalic artery (first order) using contrast material. ■ Cardiologist placing the catheter: 36215, Surgery section

L04-398 Contrast material coding:

Two physicians, a cardiologist and a radiologist from the same facility, perform an angiography of the brachiocephalic artery (first order) using contrast material. Access was the right femoral artery. The coding is as follows: ■ Cardiologist placing the catheter: 36215, Surgery section ■ Radiologist performing the angiography: 75710, Radiology section ■ Supply of the contrast material: 99070, Medicine section, or HCPCS Level II code (such as A4641, Radiopharmaceutical, diagnostic)

L04-567 Adrenal Glands (suprarenal)

Two small glands situated one on top of each kidney. There are two parts to each gland, the cortex (outer portion) and the medulla (inner portion). The cortex secretes the hormones corticosteroids, and the medulla secretes the hormones catecholamines.

L04-520 Codes in the Immune Globulins subsection are categorized according to the:

Type of immune globulin (rabies, hepatitis B, etc.) ■ Method of injection (IM, IV, SC, etc.) ■ Type of dose (full dose, mini-dose, etc.)

L04-201 Lesion excision and destruction

Types of treatment include paring (peeling or scraping), shaving (slicing), excision (cutting removal), and destruction (ablation). To code these procedures properly, you must know the site, number, and size of the excised lesion(s), as well as whether the lesion is malignant or benign.

L04-147 Home services

Under certain circumstances, health care services can also be provided to patients in their homes. Home visits and interactions must be strictly for the patient's benefit, thus careful documentation of a patient's need is important. Note that there is a statement about typical time located under the code description in the paragraph that begins, "Usually, the presenting problem(s) is . . . " Never report a code based on time unless at least 50% of the time was spent on counseling or coordinating care.

L04-603 Ocular adnexa: Orbit (1)

Under the subheading Orbit are codes for orbitotomy and fine needle aspiration. The orbitotomy codes are divided based on the approach and if a bone flap was or was not placed. Orbitotomy that is performed without a bone flap and with either a frontal or transconjunctival approach is reported with codes 67400-67414.

L04-602 Ocular adnexa: Extraocular muscles

Under the subheading of Ocular Adnexa are codes for strabismus surgery, which corrects muscle misalignment. The codes are divided based on repair of vertical (67314, 67316) or horizontal (67311, 67312) muscles and are reported by the number of muscles repaired. Vertical muscles move the eye up and down, while the horizontal muscles move the eye side to side.

L04-501 Urinalysis, molecular pathology, and chemistry

Urinalysis codes are for nonspecific tests performed on urine. Chemistry codes are for specific tests performed on material from any source (e.g., urine, blood, breath, feces, sputum).

L04-161 Each type of anesthesia will be covered in depth, but generally speaking: General anesthesia

Used for cases that require deep sedation, such as open heart surgery or complicated abdominal surgery. The patient is usually intubated. The patient is in a deep state of sedation and is not arousable or able to communicate or follow commands.

L04-372 Valvuloplasty

Valvuloplasty can also be performed by inserting a catheter percutaneously. The procedure opens a blocked valve by using a balloon, which is inflated to clear the blockage. Codes 92986-92990 are divided based on the valve being repaired.

L04-021 Patients receiving diagnostic services only

When a diagnostic service is provided to a patient during an encounter, the reason for the service is the diagnosis stated in the medical record, or when no diagnostic statement is available, report the primary reason the patient presented for the service. Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

L04-016 Observation stay

When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses. The two categories of Z codes that report observation are Z03 and Z04. These observation codes are reported only as the first-listed diagnosis for medical observation for suspected conditions and conditions ruled out.

L04-058 Admission Following Medical Observation

When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.

L04-059 Admission Following Post-Operative Observation

When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

L04-003 Outpatient surgery

When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.

L04-219 Repair (closure) Repair factors:

When reporting integumentary wound repair, the following three factors must be considered: 1. Length of the wound in centimeters 2. Complexity of the repair 3. Site of the wound repair Remember length, complexity, and site.

L04-056 Complications of surgery and other medical care

When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.

L04-029 Integral conditions

When the signs or symptoms are due to a diagnosed condition, the signs or symptoms are not reported separately. If the signs or symptoms are not due to a diagnosed condition, the signs and symptoms should be reported. This may require the coder to query the physician regarding the reporting of signs and symptoms that may or may not be routinely associated with a disease process.

L04-349 Coronary artery bypass grafts (CABGs) address blockages in the heart that restrict blood flow.

With a CABG, the physician: - takes a healthy blood vessel. - attaches the healthy blood vessel above and below the clogged artery. - enables the healthy blood vessel to carry the blood previously carried by the clogged artery. The clogged artery is "bypassed" and the blood is now transported by the healthy blood vessel.

L04-589 Secondary implant(s) procedures (2)

With some implants, the muscles are attached to the implant to enable the artificial eye to move and thus appear more natural. The codes in the 65125-65155 range report a subsequent implantation of ocular implants based on the type of service provided with the implant, such as grafting or attachment of muscles to implant. Removal of an ocular implant is reported with 65175. Orbital implant insertion is reported with 67550 and removal with 67560.

L04-610 Auditory system: (External ear) Removal of foreign body

With the shape of the ear, it is easy to see how foreign bodies and cerumen (earwax) can become lodged in the external ear. When a foreign body is removed from the ear, the code reported is based on whether general anesthesia was or was not used (69200, 69205). Ear lavage (69209) is the unilateral removal of impacted cerumen (ear wax) using irrigation/lavage. Removal of the cerumen with instrumentation is reported with 69210 (if bilateral then append with modifier -50). You may not report 69209 on the same day as code 69210. NOTE: Medicare does not allow modifier -50 for CPT codes 69209 and 69210.

L04-295 EXCISION

Within the Nose subheading, the Excision category (30100-30160) contains a wide range of procedures that describe removal of tissue from the nose. When two procedures are completed during the same surgical session, the most complex procedure is sequenced first. The biopsy code (30100) reports a biopsy that is performed intranasally; but if the procedure was for a biopsy of the skin outside of the nose, you assign a biopsy code (11102-11107) from the Integumentary System.

L04-277 Spinal instrumentation and fixation

Within the subheading Spine (Vertebral Column) (22010-22899), services are often based on the cervical (C1-C7), lumbar (L1-L5), and thoracic (T1-T12) spinal areas. Of special note in the CPT manual is that the C1 is often referred to as the atlas and C2 is referred to as the axis.

L04-554 Active wound care management

Wound management codes are based on nonselective or negative pressure procedures. Nonselective debridement is that in which healthy tissue is removed along with necrotic tissue. The tissue is gradually loosened with water (hydrotherapy). Loosened tissue may be cut away with sharp instruments. Nonselective debridement is usually done over the course of several visits.

L04-008 Use of Z Codes in Any Healthcare Setting

Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis.

L04-014 Circumstances to assign Z codes

Z codes are most often assigned in the outpatient settings, that is, ambulatory care centers, physicians' offices, and outpatient departments of hospitals.

L04-009 Z Codes Indicate a Reason for an Encounter

Z codes are not procedure codes. A corresponding procedure code must accompany a Z code to describe any procedure performed.

L04-443 Roux-en-Y (RNY)

a Y-shaped surgical connection in which the intestine is detached from its original origin and reattached so as to bypass a part of the stomach and the entire duodenum (first part of the small intestine). Roux-en-Y term is used in several code descriptions, such as 43621 (total gastrectomy with Roux-en-Y reconstruction) and 43644 (laparoscopic gastric restriction, with gastric bypass and Roux-en-Y gastroenterostomy).

L04-087 The four elements of a history: 2. History of Present Illness (HPI) (1)

a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. The HPI must be documented in the medical record by the physician.

L04-086 The four elements of a history: 1. Chief Complaint (CC)

a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words.

L04-490 Hysterosalpingography

a diagnostic procedure to test the patency (unblocked) of the fallopian tubes. Saline or contrast material is injected into a tube (58340). Catheterization and introduction (58340) of saline or contrast material through the cervix and uterus and into the fallopian tubes (hysterosalpingography) is performed by a physician to identify blockage or abnormalities of the fallopian tubes.

L04-246 OPEN TREATMENT

a fracture is made when a surgery is performed in which the fracture is exposed by an incision made over the fracture and the fractured bone is visualized. to immobilize the nose. Open treatment is used when the fracture is opened (exposed to the external environment). In this instance, the fracture (bone) is open to view and internal fixation (pins, screws, etc.) may be used.

L04-214 Pilonidal cyst

a pilonidal cyst or sinus are 11770-11772. A pilonidal cyst is located in the sacral area and is most often caused by an ingrown hair. A cyst larger than 2 cm is considered complicated and requires more extensive excision and closure. A complicated excision is very extensive and usually requires reconstructive surgical repair.

L04-264 Arthrocentesis (1)

a procedure commonly used in the treatment of joint conditions. The area over the involved joint is injected with anesthetic, a needle is inserted into the joint, and fluid is withdrawn. Arthrocentesis is aspiration of a joint, and the codes to report such a service are in the range of 20600-20611.

L04-408 Bone marrow harvesting (38230)

a procedure in which a larger amount of bone marrow is aspirated from a donor by means of a large aspiration needle. The marrow is then transplanted into the recipient patient.

L04-323 Surgical collapse therapy; thoracoplasty: Thoracoplasty

a procedure in which a portion of the internal skeletal support is removed to treat a condition in which pus chronically collects in the chest cavity (chronic thoracic empyema). The procedure is major and requires extensive resecting of the membrane that lines the chest cavity. Note that code 32905, thoracoplasty, refers to "all stages." The subsequent stages are for the removal of the packing and are bundled into the surgical code.

L04-308 SINUSOTOMY

a procedure in which the physician enlarges the passage or creates a new passage from the nasal cavity into a sinus. This procedure is usually performed due to chronic sinus infection; the procedure improves sinus drainage. The codes are divided according to the extent of the procedure.

L04-250 CLOSED TREATMENT: Closed treatment with manipulation

a procedure in which the physician has to reduce (put back in place) a fracture. Code 21320 describes a closed treatment of a nasal bone fracture with manipulation and stabilization. This code is correctly reported when a patient has a displaced nose that requires manipulation to return it to the normal position. The physician would then apply external and/or internal splints to immobilize the nose.

L04-249 CLOSED TREATMENT: Closed treatment without manipulation

a procedure in which the physician immobilizes the bone with a splint, cast, or other device but without having to manipulate the fracture into alignment. Code 25500 describes a closed treatment of a radial shaft fracture without manipulation.

L04-272 Monitoring of interstitial fluid pressure (20950)

a procedure in which the physician inserts a device into the muscle compartment to measure the pressure changes within the muscle. Increased pressure in the muscle due to accumulation of fluid causes the blood supply to be compromised.

L04-439 EGD (esophagogastroduodenoscopy)

a procedure performed to examine the esophagus, stomach, duodenum, and sometimes the jejunum for signs of bleeding, tumors, erosion, ulcers, or other abnormalities. EGD code 43259 is assigned when an endoscopic ultrasound examination is performed. As stated in the parenthetical note immediately following CPT code 43259, the radiological supervision and interpretation is NOT reported separately with 76975.

L04-324 Pneumonolysis

a procedure that is performed to separate the inside of the chest cavity from the lung to permit the lung to collapse. This procedure was originally used as a treatment for tuberculosis but is now used in the evaluation of pleural diseases, debridement of chronic emphysema, and as a treatment for emphysematous blebs, in addition to other therapeutic treatments.

L04-469 Nephrostomy

a procedure used to decompress the renal system by means of the insertion of a catheter into the kidney while leaving the other end of the catheter outside the body to temporarily drain the kidney.

L04-117 Observation

a status used for the classification of a patient who does not have an illness severe enough to meet acute inpatient criteria and does not require resources as intensive as an inpatient but does require hospitalization for a short period of time.

L04-478 Pyeloplasty

a surgical procedure for an obstruction of the ureteropelvic junction (UPJ), which connects the renal pelvis to the ureter. A complicated pyeloplasty (50405) includes all of the procedures in the simple pyeloplasty, as indicated by the placement of the semicolon in 50400. (Note that the semicolon is after the term "splinting," which means that all the terms that precede the semicolon are included in the code description for the indented code 50405.)

L04-325 Pneumothorax injection (32960)

a therapeutic procedure in which the surgeon inserts a needle into the pleural cavity and injects air into the pleural cavity. The pressure in the thoracic cavity is increased and the lung partially collapses. This procedure is sometimes performed to treat tuberculosis. A chest tube may be inserted into the space for further injections of air. You would not report the insertion of the chest tube separately, as the insertion is bundled into the procedure code.

L04-164 Moderate (conscious) sedation (1)

a type of sedation that can be provided by a surgeon or the surgeon's staff while the surgeon is performing a procedure; it provides a decreased level of consciousness that does not put the patient completely to sleep. CODING SHOT Moderate (conscious) sedation codes are only reported when the physician performing the procedure administers the sedation and an independent trained observer assists.

L04-342 Subcutaneous cardiac rhythm monitor

also known as a cardiac event recorder or a loop recorder. Codes 33285 and 33286 involve surgical insertion into and removal from a subcutaneous prepectoral pocket. The recorder senses the heart's rhythms, and when the patient presses a button, the device records the electrical activity of the heart. The recording can assist the physician in making a diagnosis of a hard-to-detect rhythm problem. Codes are divided on the basis of whether the device was implanted or removed.

L04-229 Chemical peels

also known as chemexfoliation, are treatments in which a chemical is applied to the skin and then removed. The treatment is used for cosmetic purposes, such as smoothing the wrinkles around the mouth or removing liver spots (lentigines). The chemical peel codes (15788-15793) are divided according to whether the peel is on the face or not on the face, in addition to the depth of the peel (epidermal or dermal).

L04-441 Endoscopic retrograde cholangiopancreatography (ERCP, 43260-43278)

an endoscopic procedure of the pancreatic ducts, hepatic ducts, common bile ducts, duodenal papilla, and/or gallbladder (hepatobiliary system) and is performed primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (due to trauma or surgery), disease of the liver, and cancer.

L04-089 The four elements of a history: 3. Review of Systems (ROS (1)

an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.

L04-391 Ambulatory blood pressure monitoring (93784-93790)

an outpatient procedure that is conducted over a 24-hour period by means of a portable device worn by the patient. There is a code for the total procedure—including recording, scanning, analysis, and interpretation/report—and there are codes for each of the individual components—recording only, analysis only, and interpretation/report only.

L04-187 Unlisted anesthesia code

an unlisted procedure code is available and is located under the Other Procedures subsection in the Anesthesia section. When there is no CPT code to indicate the anesthesia services, the unlisted Anesthesia code (01999) may be reported.

L04-310 Radical neck dissection

as referred to in the codes for laryngectomy, is the removal not only of the larynx but also of lymph glands and/or other surrounding tissue. Many of the codes in the Larynx subheading, Excision category are divided according to whether radical neck dissection was or was not performed.

L04-159 Local anesthesia

can be accomplished by means of application of an anesthetic agent (such as lidocaine) placed directly on the area involved (topical anesthesia) or local infiltration through subcutaneous injection of an anesthetic agent. Lidocaine can be subcutaneously injected. A postdural puncture headache is a blood patch, also known as an epidural blood patch (EBP). A blood patch procedure is when a cerebrospinal fluid leak is closed by means of an injection of the patient's blood into the epidural space at or near the area of the dural puncture that was accessed during spinal anesthesia.

L04-289 Thoracotomy and Thoracoscopy

code 32141 describes a thoracotomy with "resection-plication (removal/shortening) of bullae (blisters); includes any pleural procedure, when performed." Code 32655 describes a surgical thoracoscopy with resection-plication of bullae; includes any pleural procedures when performed.

L04-270 Grafts (or implants): Spine surgery

codes 20930-20938 report the obtaining and shaping of the tissue, whether from the patient (autograft) or from a donor (allograft). The obtaining and shaping of the spine graft material is reported in addition to reporting the implantation procedure, which is the primary procedure (definitive procedure), unless the description of the major procedure includes a graft.

L04-121 Observation or Inpatient Care Services

codes 99234-99236, have a very specific purpose: to report services for a patient who is admitted to and discharged from observation or inpatient status on the same day. All the services provided to the patient—same-day office services, observation care, and discharge—are bundled into one code from the 99234-99236 range.

L04-436 Tonsillectomy and adenoidectomy

commonly reported surgical procedures (42820-42836). The tonsils are two glands located at the back of the throat, and the adenoids, are located behind the nose and above the soft palate (roof of mouth) and cannot be visualized without a mirror or scope. The selection of the correct code is based on if: ■ Only the tonsils are removed ■ Only the adenoids are removed ■ Both the tonsils and adenoids are removed ■ The patient is under 12 years of age, or age 12 or over

L04-218 Subcutaneous hormone pellet implantation

commonly used for the insertion of a hormone in a time-release capsule into the buttocks of women requiring hormone replacement therapy after menopause. The implantation area is anesthetized and the pellet is inserted through a tube. The pellet is completely absorbed into the system and does not need to be removed, as does a contraceptive capsule.

L04-144 Other nursing facility services

contains only one code, 99318, and reports the annual nursing facility assessment provided by the physician.

L04-538 Comprehensive service (92004, 92014)

describes a general evaluation of the complete visual system. The comprehensive services constitute a single service that may be performed at different sessions but is reported only once.

L04-537 Intermediate ophthalmological service (92002, 92012)

describes an evaluation of a new or existing condition complicated with a new diagnosis or management problem not necessarily relating to the primary diagnosis.

L04-254 Percutaneous skeletal fixation

describes fracture treatment that is neither open nor closed. In this procedure, the fracture is not open to view, but fixation (e.g., pin, screw) is placed across the fracture site, usually under x-ray imaging. Areas of bones, are important to know when identifying the location of a fracture.

L04-273 Bone grafts (20955-20962)

identified by the site from which the graft is obtained. When the bone grafts are removed, the small blood vessels remain attached to the graft. The graft is then inserted and the blood vessels are attached to vessels in the area of implant, using an operating microscope. The use of the operating microscope (69990) is included in the code descriptions for 20955-20962. "(Do not report 69990 in addition to codes 20955-20962)."

L04-257 Dislocations: Digital nerve block

if a finger was dislocated and the bone did not protrude through the skin, the physician may administer a digital block and apply gentle traction until the finger realigns. A splint would then be applied to keep the finger immobile for about 3 weeks.

L04-133 Consultation services (2)

if a patient is referred by physician A to physician B, physician A is expecting physician B to evaluate and treat (assume care for) the patient for the condition for which the patient is being referred. The services of physician B would then not be reported using consultation codes. On the other hand, if physician A makes a request for a consultation to physician B, it is expected that physician B will provide physician A with his or her advice or opinion and that the patient will return to physician A for any necessary treatment. Physician B would then report his or her services using consultation codes.

L04-623 Global service

in which the hospital owns the radiology equipment, hires technicians to obtain the x-ray, and hires physicians who review and interpret the x-ray—doesn't require a modifier.

L04-293 INCISION (1)

incision of a nasal abscess (30000, 30020) are divided on whether the abscess is on the nasal mucosa or the septal mucosa. If a nasal abscess is approached from the outside of the nose (external approach), you would assign a code from the Integumentary System subsection; but if the approach is from the inside of the nose (internal approach), you would assign a code from the Respiratory System subsection. The medical record will describe the approach to the procedure.

L04-269 Grafts (or implants): Tissue grafts

include obtaining of the fat, dermis, paratenon (loose connective tissue from the tendon compartment), and other tissue types.

L04-217 Implantable contraceptive capsules

inserted under the skin by means of a small incision on the upper arm. A capsule is effective for a number of years; at the end of that time, it must be removed. Performed by a gynecologist, the capsules are usually inserted through a non-biodegradable drug delivery implant.

L04-155 Some of the more commonly used anesthesia terms: Regional anesthesia

interrupts the sensory nerve conductivity in a region of the body and is produced by a field block (forming a wall of anesthesia around the site by means of local injections) or nerve block (injection of the area close to the site). Nerve block is also known as block, block anesthesia, or conduction anesthesia.

L04-158 General anesthesia

is a state of unconsciousness that is accomplished by the use of a drug or combination of drugs administered intramuscularly, rectally, intravenously, or by inhalation.

L04-156 Some of the more commonly used anesthesia terms: Patient-controlled analgesia (PCA)

is a system that allows the patient to administer an analgesic drug such as morphine to control pain. A device is attached to a pump holding the drug and the patient can depress a handheld button to administer a dose of the drug. PCA is considered a hospital service and not generally reported by a physician.

L04-153 Some of the more commonly used anesthesia terms: Endotracheal anesthesia

is accomplished by insertion of a tube into the nose or mouth, and passing the tube into the trachea for ventilation.

L04-154 Some of the more commonly used anesthesia terms: Epidural anesthesia

is the injection of an anesthetic agent into the epidural spaces between the vertebrae, also known as peridural, or epidural block.

L04-487 There are two labia:

labia minora and labia majora. A partial vulvectomy (less than 80%) pertains to leaving at least 20% of the vulvar area.

L04-568 Thymus Gland

located behind the breast bone, in front of the heart, and is involved in maturation (development) of the immune system. Thymectomy is removal of the thymus and is usually performed by cutting through the breast bone, similar to heart surgery.

L04-640 Recumbent

means lying down. Thus, right lateral recumbent means the patient is lying on the right side, and left lateral recumbent means the patient is lying on the left side. In the ventral decubitus position, the patient is positioned prone and the x-ray beam comes into the patient from the right side and exits on the left. In the left lateral decubitus position, the patient is lying on the left side with the beam coming from the front and passing through to the back (anteroposterior). When the patient is positioned on his or her back (dorsal decubitus) and the x-ray beam comes into the left side of the patient, the positioning is dorsal decubitus, but the view obtained is a right lateral (because the right side is closest to the film).

L04-355 Selective catheter placement

means the catheter must be moved, manipulated, or guided into a part of the venous or arterial system, passed into a branch of the aorta or access vessel, and then advanced farther through the vessel to enter any of the vascular families (that is, into the branches), generally under fluoroscopic guidance.

L04-354 Nonselective catheter placement

means the catheter or needle is placed directly into an artery or vein (and not manipulated farther along) or is placed only into the aorta from any approach and not advanced any farther.

L04-633 Prone

means the patient is lying on his or her anterior (front), but the entrance and exit of the x-ray beam are not specified.

L04-473 Percutaneous nephrolithotomy (nephrolithotripsy)

more invasive method of treating kidney stones and usually is performed with ultrasound. An incision is made over the kidney, a probe is inserted, and shock waves pulverize the stone. Electrohydraulic or mechanical lithotripsy may be used instead of shock waves, but the use of shock waves is the most common method. The lithotripsy is reported separately (50590 lithotripsy or 52353 cystourethroscope with lithotripsy). Percutaneous nephrostolithotomy (PCNL) or a pyelostolithotomy is a procedure to remove kidney stones.

L04-240 Partial mastectomy (19301)

one in which only a portion of the breast tissue is removed. If an axillary lymphadenectomy is performed with a partial mastectomy, report the service with 19302. A partial mastectomy is also known as a lumpectomy, segmentectomy, or tylectomy.

L04-247 CLOSED TREATMENT

performed when the physician repairs the fracture without directly visualizing the fracture. Closed Treatment: This terminology is used to describe procedures that treat fractures by one of three methods: (1) without manipulation, (2) with manipulation, or (3) with or without traction.

L04-409 Transplantation and cellular infusions (38240-38243)

procedures in which hematopoietic cells, obtained from bone marrow, peripheral blood apheresis, or umbilical cord blood, are infused into the patient. Code 38242 represents allogenic infusion. The preparation and storage of the cells prior to transplantation or infusion are reported with 38207-38215.

L04-157 Spinal or intraspinal anesthesia

refers to anesthesia produced by an injection of local anesthetic into the subarachnoid space around the spinal cord.

L04-467 Retroperitoneal

refers to that area located behind (retro to) the peritoneum (lines the abdominal walls and covers most of the organs) that is located in the abdominal cavity.

L04-375 Holter monitor

similar to an electrocardiogram (ECG) Leads are attached to the chest and to a cassette machine. The monitor converts the ECG readings to sound, and the sound is converted back to an ECG reading when completed. The reading is then sped up to hundreds of times faster than normal by computers. Any reading that varies from a normal reading will be identified. The Q, R, and S waves are related to the contraction of the ventricles of the heart. The QRS waves and heartbeats can be monitored by Holter monitors. Cardiac arrhythmias can be identified using the Holter monitor process.

L04-547 F-wave

studies assess motor nerve function along the entire extent of that nerve. An impulse generated at the stimulating electrode travels up the motor nerves to the motor neuron cell bodies in the spinal cord. Parameters are what are being measured during a sleep test.

L04-267 External fixation (Ilizarov multiplane)

the application of a device that holds a bone in place, but unlike internal fixation, the device is placed on the outside of the body and pins or wires are placed into the bone from the outside. External fixation is used primarily in cases of limb fracture, major pelvic disruption, osteotomy, arthrodesis, bone infection, and bone lengthening.

L04-280 Nonsegmental instrumentation

the application of the fixative device at each end of the area being repaired. For example, if the repair was of T10, the rod may be attached at T7 and T12.

L04-475 EXCISION: Ablation

the cutting away or erosion of tissue. Code 50250 reports ablation of a kidney lesion by means of cryosurgery (use of subfreezing temperatures) and is usually performed with ultrasonic guidance.

L04-256 Dislocations: Vertebral and subglenoid dislocations

the displacement of a bone from its normal location in a joint, and the treatment of the dislocation injury is to return the bone to its normal location (anatomic alignment) by a variety of methods.

L04-005 Accurate reporting of ICD-10-CM diagnosis codes

the documentation should describe the patient's condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. It is acceptable for symptoms and signs to be reported if no definitive diagnosis has been established by the provider.

L04-546 Polysomnography

the measurement of the brain waves during sleep but with the added feature of recording the various stages of sleep (i.e., excited, relaxed, drowsy, asleep, or deep sleep). During each of these stages, the rate and amplitude (height) of the brain waves are measured and compared with normal ranges. Certain neurologic conditions may be identified by the degree to which brain waves vary from normal ranges.

L04-213 Onychocryptosis (ingrown toenail)

the most common condition of the great toe. The nail grows down and into the soft tissue of the nail fold, causing extreme pain and often infection. Treatment for severe cases is a partial onychectomy (removal of the nail plate and root). The toe is anesthetized and a portion of the nail plate and root is removed (11750). The nail will not grow back where the base has been removed.

L04-307 Accessory sinuses: Incision

the nasal sinuses can be washed (lavage) with a saline solution introduced through a cannula (hollow tube) to remove infection. The Incision category code 31000 describes lavage of the maxillary sinus. Lavage can be performed on both the maxillary and the sphenoid sinuses. If the lavage is of the sphenoid sinus, you report 31002. Use modifier -50 (bilateral) when the lavage is performed on both the left and right maxillary sinuses.

L04-276 Computer-assisted surgical navigation (20985)

the use of navigational assistance in musculoskeletal procedures. The code is listed in addition to the code for the primary procedure.

L04-636 Posteroanterior (PA)

the posteroanterior (PA) position, the patient has his or her back (posterior) located closest to the machine, and the beam travels through the patient from back to front.

L04-528 Biofeedback

the process of giving a person self-information. The information can be used by patients to gain control over physiologic processes, such as blood pressure, heart rate, or pain. Biofeedback training is often incorporated in individual psychophysiologic therapy.

L04-474 EXCISION: Nephrectomy

the removal of a kidney, either partial or radical (total). A radical nephrectomy includes removal of the fascia and surrounding fatty tissue, regional lymph nodes, and the adrenal gland. The nephrectomy codes (50220-50240) are based on the complexity and extent of the procedure. Nephrectomies can also be performed by means of a laparoscope (50543, 50545-50548), based on whether the procedure was partial, radical, or donor, and whether the procedure included a partial or total ureterectomy.

L04-530 Hemodialysis

the routing of blood and its waste products to the outside of the body where it is filtered. After the blood is cleansed, it is returned to the body. Hemodialysis codes (90935 and 90937) are reported for each day the service is provided. The codes in the hemodialysis category are based on the number of times the physician evaluates the patient during the procedure.

L04-211 Avulsion

the separation and removal of the nail plate (11730, 11732), preserving the root so the nail will grow back. An anesthetic is administered, the nail is lifted away from the nail bed, and a portion or all of the nail plate is removed.

L04-486 Vulvectomy

the surgical removal of a portion of the vulva. Usually a vulvectomy is performed to treat a malignant or premalignant lesion.

L04-481 EXCISION: Bladder cuff

the tissue that connects the ureter to the bladder, and the excision of the bladder cuff is only reported if it is the only procedure performed during the surgical session.

L04-320 Pneumonocentesis

the withdrawal of fluid from the lung by means of an aspirating needle. Air or gas in the pleural cavity is known as pneumothorax and occurs when the lung is traumatically ruptured or an emphysematous bulla ruptures. The codes for the removal of the lung are based on how much of the lung is removed—segmentectomy for one segment, lobectomy for one lobe, bilobectomy for two lobes, total pneumonectomy for an entire lung—as well as on the extent of the procedure and the approach.

L04-472 Extracorporeal shock wave lithotripsy (ESWL)

used to be performed with a machine in which the patient was submersed in a fluid. The procedure is performed under general anesthesia in an operating room with a built-in ESWL machine.

L04-379 Cardiovascular stress test

used to evaluate and diagnose chest pain, to screen for heart disease, to evaluate irregular heart rhythms, and to investigate many other cardiovascular abnormalities. The patient is placed on a treadmill or a stationary bicycle and ECG leads are attached. The patient then exercises until he or she reaches maximal (220 minus age) or submaximal (85% of maximal) heart rate. During certain intervals, recordings are taken by means of ECG, heart rate, and blood pressure of the patient.

L04-275 Electrical or ultrasound stimulation (20974-20979)

used to promote healing. Low-voltage electricity or ultrasound is applied to the skin, and both are often used in the treatment of fractures.

L04-060 Admission from outpatient surgery

• If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. • If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. • If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.

L04-253 Fracture codes are reported with a 7th character to indicate whether the fracture care was:

■ Initial or a subsequent encounter ■ Open or closed Fractures are divided based on whether the fracture is pathological (occurred in an area of weakness) or traumatic (due to injury). Open means the fracture has broken through the bone cortex and the bone has been exposed to air (elements). Closed means the fracture is not exposed to air. ■ Healing was routine or delayed ■ Nonunion

L04-413 The codes are divided based on the extent of the procedure:

■ 38570 reports retroperitoneal lymph node biopsy, single or multiple. ■ 38571 reports a bilateral total pelvic lymphadenectomy. ■ 38572 also reports a bilateral total pelvic lymphadenectomy and includes the single or multiple biopsy of the periaortic lymph node. ■ 38573 also reports a bilateral total pelvic lymphadenectomy, while including periaortic lymph node biopsy, washing, and biopsies for both the peritoneum and diaphragm, along with omentectomy. ■ 38589 reports unlisted laparoscopic procedures. A surgical laparoscopy always includes a diagnostic laparoscopy and is therefore not unbundled and reported separately.

L04-440 The services are performed during the same endoscopic session and are reported as:

■ 43245 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) [e.g., balloon, bougie]) ■ 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple)

l04-437 Dilation procedures may use fluoroscopy (74360) but do not include endoscopy:

■ 43450, dilation of the esophagus, by unguided sound or bougie (cylinder), single or multiple passes ■ 43453, dilation of the esophagus, over guidewire ■ 43460, esophagogastric tamponade, with balloon (Sengstaken type) (A balloon is placed into the esophagus and inflated to stop bleeding.)

L04-459 CMS RULES When reporting the CT colonography service for Medicare patients, report:

■ 74261-74262 (Computed tomographic [CT] colonography, diagnostic, including image postprocessing; without contrast and with contrast material(s), including non-contrast images, if performed) NOTE: 74263 (Computed tomographic [CT] colonography, screening, including imagine postprocessing) is not a covered Medicare service (Pub 100-03, Transmittal 105, August 7, 2009).

L04-442 The codes do not include the radiological supervision and interpretation, so when performed, report:

■ 74328 (biliary ductal system) ■ 74329 (pancreatic ductal system) ■ 74330 (biliary and pancreatic ductal systems)

L04-177 The recorded time on all records must be the same:

■ Anesthesia record ■ CRNA, anesthesiologist, or resident billing slip ■ Time on all documents submitted to insurance company The start time on the anesthesia record should match the time reported on the claim form.

L04-167 Anesthesia providers may be a(n):

■ Anesthesiologist ■ Certified registered nurse anesthetist (CRNA) ■ Anesthesiologist's assistant (who may not work without oversight of anesthesiologist) ■ Resident (cannot bill if the case is performed without the participation of another anesthesia provider) ■ Student registered nurse anesthetist (billing is based on specific rules for each payer depending on the payer's definition of medical direction)

L04-283 You can report the Application of Casts and Strapping codes only when the physician:

■ Applies an initial cast, strapping, or splint for stabilization prior to definitive treatment by another provider. ■ Applies a subsequent cast, strapping, or splint. ■ Treats a sprain or fracture and does not expect to provide any other type of restorative treatment.

L04-284 The subheading Application of Casts and Strapping is divided into three major categories:

■ Body and Upper Extremity ■ Lower Extremity ■ Removal or Repair (provided by a physician other than the one who initially applied it) The subcategories of Body/Upper Extremity and Lower Extremity are: ■ Casts ■ Splints ■ Strapping—Any Age The codes in all subcategories are divided primarily according to the location of the cast, splint, or strapping on the body—head, hand, extremity—and often on the type—Minerva, Velpeau, static (nonmovable), dynamic (movable).

L04-091 Review of Systems (ROS (3) For the purposes of an ROS, the following systems are recognized:

■ Cardiovascular Chest pain, rheumatic fever, tachycardia, palpitation, high blood pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis ■ Respiratory Chest pain, wheezing, cough, dyspnea, sputum (color and quantity), hemoptysis, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, last chest radiograph (note: also shortness of breath) ■ Gastrointestinal Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowel habits, diarrhea, constipation, indigestion, food intolerance, flatus, hemorrhoids, jaundice

L04-574 BRAIN

■ Cerebrum—largest part of the brain. ■ Cerebral hemispheres—paired halves of the cerebrum. Each hemisphere is subdivided into four major lobes named for the cranial (skull) bones they overlie: Frontal Parietal Occipital Temporal ■ Cerebellum—posterior part of the brain that coordinates the voluntary muscle movements and maintains balance. ■ Cerebral cortex—outer region of the cerebrum (gray matter). ■ Fissure—groove in the surface of the cerebral cortex. ■ Medulla oblongata—part of the brain located just above the spinal cord that controls breathing, heartbeat, and blood vessel size. ■ Ventricles—reservoirs in the interior of the brain filled with cerebrospinal fluid. The following structures connect the cerebrum with the spinal cord: ■ Cerebellum ■ Pons (part of brain stem) ■ Medulla oblongata (part of brain stem)

L04-062 General rules for other (additional) diagnoses

■ Clinical evaluation; or ■ Therapeutic treatment; or ■ Diagnostic procedures; or ■ Extended length of hospital stay, or ■ Increased nursing care and/or monitoring

L04-522 Report each dose administered—single or combination with the appropriate administration code.

■ Codes 90460-90461 report immunization administration for patients through age 18 and for which counseling has been provided to the patient's family regarding the vaccine/toxoid. Report 90460 for each vaccine administered. For vaccines with multiple components (combined vaccines), report 90460 in conjunction with 90461 for each additional component in the vaccine. ■ Codes 90471-90474 report immunizations at which the physician did NOT provide counseling for patients of any age, including patients through age 18.

L04-577 Neurological diseases of this area are classified as:

■ Congenital ■ Degenerative, movement, and seizure ■ Infectious ■ Neoplastic ■ Traumatic ■ Vascular

L04-083 Of the following categories/subcategories, two of the three key components must be met or exceeded before the code may be assigned:

■ Subsequent Observation Care, New or Established Patient ■ Subsequent Hospital Care, New or Established Patient ■ Subsequent Nursing Facility Care, New or Established Patient ■ Domiciliary Care, Rest Home (e.g., Boarding Home), or Custodial Care Services, Established Patient ■ Home, Established Patient

L04-090 3. Review of Systems (ROS (2) For the purposes of an ROS, the following systems are recognized:

■ Constitutional symptoms - Usual weight, recent weight changes, fever, weakness, fatigue ■ Eyes (Ophthalmologic) - Glasses or contact lenses, last eye examination, visual glaucoma, cataracts, eyestrain, pain, diplopia, redness, lacrimation, inflammation, blurring ■ Ears, Nose, Mouth, Throat (Otolaryngologic) - Ears: hearing, discharge, tinnitus, dizziness, pain Nose: head colds, epistaxis, discharges, obstruction, postnasal drip, sinus pain Mouth and Throat: condition of teeth and gums, last dental examination, soreness, redness, hoarseness, difficulty in swallowing

L04-071 2. Type of service

■ Consultation is a written or verbal request from one provider/physician to another to obtain an opinion and/or advice about a diagnosis or management options. ■ Admission is attention to an acute illness or injury that results in admission to a hospital. ■ Newborn care is the evaluation and determination of care management of a newly born infant. ■ Office visit is a face-to-face encounter between a physician and a patient to allow for primary management of the patient's health care status.

L04-626 The Radiology section of the CPT manual is divided into subsections:

■ Diagnostic Radiology (Diagnostic Imaging) ■ Diagnostic Ultrasound ■ Radiologic Guidance ■ Breast, Mammography ■ Bone/Joint Studies ■ Radiation Oncology ■ Nuclear Medicine

L04-536 Testing may include the following types of measures:

■ External examination, ophthalmoscopy, and biomicroscopy ■ Visual acuity (clarity of vision) ■ Basic sensorimotor examination (tests sensory and motor coordination) ■ Confrontation visual fields (peripheral vision) ■ Tonometry (intraocular pressure) ■ Evaluation of complete visual system ■ May include mydriasis (excess dilation of pupil) for ophthalmoscopy ■ Initiation of diagnosis and treatment programs

L04-096 Past, Family, and Social History (PFSH) (3)

■ Family history is a review of medical events in the patient's family that includes significant information about: The health status or cause of death of parents, siblings, and children Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review Diseases of family members that may be hereditary or place the patient at risk Three of the elements of a history (HPI, ROS, and PFSH) are included to varying degrees in all patient encounters. The degree or level of HPI, ROS, and PFSH is determined by the chief complaint or presenting problem of the patient.

L04-461 Hemorrhoids are classified into four degrees depending on severity:

■ First degree may bleed but do not protrude outside of the anal canal. ■ Second degree protrudes outside of the anal canal occasionally but retracts spontaneously. ■ Third degree protrudes outside the anal canal more often and must be manually placed back into the anal canal. ■ Fourth degree protrudes outside the anal canal but cannot be manually placed back into the anal canal. Fourth degree hemorrhoid may be strangulated or thrombosed.

L04-457 HCPCS colorectal screening codes:

■ G0104 flexible sigmoidoscopy ■ G0105 colonoscopy on individual at high risk ■ G0106 alternative to G0104, screening sigmoidoscopy, barium enema ■ G0120 alternative to G0105, screening colonoscopy, barium enema ■ G0121 colonoscopy on individual not meeting criteria for high risk ■ G0122 colorectal cancer screening, barium enema

L04-092 Review of Systems (ROS (4) For the purposes of an ROS, the following systems are recognized:

■ Genitourinary Urinary: frequent or painful urination, nocturia, pyuria, hematuria, incontinence, urinary infection Genito-reproductive: male—venereal disease, sores, discharge from penis, hernias, testicular pain or masses; female—age at menarche and menstruation (frequency, type, duration, dysmenorrhea, menorrhagia; symptoms of menopause), contraception, pregnancies, deliveries, abortions, last Papanicolaou smear ■ Musculoskeletal Joint pain or stiffness, arthritis, gout, backache, muscle pain, cramps, swelling, redness, limitation in motor activity

L04-081 Key components

■ History ■ Examination ■ Medical decision making The key components of history, examination, and medical decision making reflect the clinical information that is recorded by the physician in the patient's medical record. Key components are present in every patient case except counseling encounters. History and exam are no longer considered key components for these codes but are considered "medically appropriate." Key components enable you to choose the appropriate level of service.

L04-455 Some endoscopic biopsy highlights:

■ If a single lesion is biopsied, but not entirely removed, only a biopsy code would be assigned. ■ If a biopsy is obtained and the lesion is also excised, only the excision of a lesion code would be reported. ■ If a biopsy and excision were performed, it would be appropriate to report the biopsy if taken from a lesion other than the lesion that was excised. The CPT code for the excision will sometimes state "with or without biopsy," in which case you would not report the biopsy separately.

L04-498 To code the components of Evocative/Suppression Testing consider the following:

■ If the physician supplied the agent, report the supply using 99070 from the Medicine section or a HCPCS code. ■ If the physician administered the agent, report the infusion or injection with codes 96365-96379 from the Medicine section. ■ If the test involved prolonged attendance by the physician, report the service with the appropriate E/M code.

L04-518 The first three subsections in the Medicine section are:

■ Immune Globulins, Serum or Recombinant Products ■ Immunization Administration for Vaccines/Toxoids ■ Vaccines, Toxoids

L04-082 According to the E/M Guidelines, the following categories/subcategories must meet or exceed the stated level of the key components:

■ Initial Observation Care, New or Established Patient ■ Initial Hospital Care, New or Established Patient ■ Office or Other Outpatient Consultations, New or Established Patient ■ Observation or Inpatient Care Services, New or Established Patient ■ Inpatient Consultations, New or Established Patient ■ Emergency Department Services, New or Established Patient ■ Initial Nursing Facility Care, New or Established Patient ■ Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services, New Patient ■ Home Services, New Patient

L04-327 Coding from three sections

■ The Surgery section contains codes for cardiovascular surgical procedures. ■ The Medicine section contains codes for nonsurgical cardiovascular services. ■ The Radiology section contains diagnostic studies or radiologic visualization codes.

L04-093 Review of Systems (ROS (5) For the purposes of an ROS, the following systems are recognized:

■ Integumentary (skin and/or breast) Skin: rashes, eruptions, dryness, cyanosis, jaundice, changes in skin, hair, or nails** Breast: lumps, dimpling, nipple discharge** ■ Neurologic (neurological) Faintness, blackouts, seizures, paralysis, tingling, tremors, memory loss ■ Psychiatric Personality type, nervousness, mood, insomnia, headache, nightmares, depression ■ Endocrine Thyroid trouble, heat or cold intolerance, excessive sweating, thirst, hunger, or urination, blood sugar levels ■ Hematologic/Lymphatic Anemia, easy bruising or bleeding, past transfusions ■ Allergic/Immunologic Sneezing, itching eyes, rhinorrhea, nasal obstruction, or recurrent infections

L04-048 A procedure is considered to be significant if it:

■ Is surgical in nature ■ Carries a procedural risk ■ Carries an anesthetic risk ■ Requires specialized training to perform

L04-125 A general rule of thumb for subsequent hospital services is as follows:

■ Level 1 The patient is recovering and improving. ■ Level 2 The patient has a minor complication or inadequate response to the current therapy. ■ Level 3 The patient is unstable, has a significant complication, or has developed a new problem. Note that there is no comprehensive history or comprehensive examination level in the codes in the Subsequent Hospital Care subheading because the comprehensive level of service would have been provided at the time of admission. Also note that only two of the three key components must be met or exceeded to assign a subsequent hospital code.

L04-072 3. Patient status

■ New patient is one who has not received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years. ■ Established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years. ■ Outpatient is one who has not been formally admitted to a health care facility or a patient admitted for observation. ■ Inpatient is one who has been formally admitted to a health care facility.

L04-477 Backbench work is the work involved in preparation for the transplant surgery and includes:

■ Open organ retrieval from a deceased (50300) or living (50320) donor; laparoscopic organ retrieval from a living (50547) donor. ■ Standard preparation based on deceased (50323) or living (50325) donor. As a part of this preparation the surgeon may perform additional surgery on the organ, such as venous, arterial, or ureteral anastomosis (50327-50329). ■ Allotransplantation service reported with 50360 (without nephrectomy) or 50365 (with nephrectomy) with modifier -50 added for a bilateral procedure.

L04-094 The four elements of a history: 4. Past, Family, and Social History (PFSH) (1)

■ Past history is the patient's past experience with illnesses, operations, injuries, and treatments that includes significant information about: Prior major illnesses and injuries Prior operations Prior hospitalizations Current medications Allergies (e.g., drug, food) Age-appropriate immunization status Age-appropriate feeding/dietary status

L04-456 Code G0105 reports a screening colonoscopy on a patient at high risk; which means the patient has a:

■ Personal history of colorectal cancer (Z85.038, Z85.048) ■ Personal history of adenomatous polyps (Z86.010) ■ Inflammatory bowel disease, including Crohn's disease, and ulcerative colitis ■ A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyposis (Z80.0, Z83.71) ■ Family history of adenomatous polyposis (Z83.71) ■ Family history of nonpolyposis colorectal cancer (Z80.0)

L04-400 Coding for the radiologist

■ Radiologist performing the angiography: 75710, Radiology section ■ Supply of the contrast material: 99070, Medicine section, or a HCPCS Level II code (such as A4641, Radiopharmaceutical, diagnostic) If the radiologist is at the same facility as the equipment, you report 75710 (angiography). If the angiography was performed at the hospital and the radiologist from a clinic read the angiography, the radiologist would report 75710-26 and the hospital would report 75710-TC.

L04-079 Time includes performing the following activities, when performed by the physician or other qualified health care professional:

■ Reviewing documentation/results prior to appointment ■ Obtaining and/or reviewing separately obtained history ■ Counseling and education to the patient, family, and/or caregiver ■ Ordering medications, tests, and/or procedures ■ Referring and/or communicating with other health care professionals ■ Documentation of clinical information in the electronic or other health record ■ Independently interpreting results and communicating results to the patient, family, and/or caregiver ■ Coordination of care

L04-095 Past, Family, and Social History (PFSH) (2)

■ Social history is an age-appropriate review of past and current activities that includes significant information about: Marital status and/or living arrangements Current employment Occupational history Military history Use of drugs, alcohol, and tobacco Level of education Sexual history Other relevant social factors

L04-245 Many Musculoskeletal System Excision codes to report tumor excision are based on if the tumor is of the:

■ Subcutaneous soft tissue tumors (below the skin but above the deep fascia) ■ Fascial or subfascial soft tissue tumors (within or below deep fascia, but not involving bone) ■ Radical resection of soft tissue tumors (subcutaneous or subfascial but with wide margins, appreciable vessel exploration, and/or repair/reconstruction of nerves) ■ Radical resection of bone tumors (wide margins, appreciable vessel exploration, and/or repair/reconstruction of nerves and complex bone repair/reconstruction)

L04-414 The lymph nodes of the neck are named based on the anatomical location:

■ Submental and submandibular nodes are located at the chin area and beneath the body of the mandible. ■ Upper jugular nodes are divided in two groups and are located at the mandibular angle and the front of the sternocleidomastoid muscle. ■ Middle jugular nodes are located between the hyoid bone and the cricoid cartilage. ■ Lower jugular nodes are located between the cricoid cartilage and the clavicle. ■ Posterior triangle nodes are divided into two groups. ■ Upper visceral nodes are located by the hyoid bone. ■ Superior mediastinal nodes are located between the left and right common carotid arteries.

L04-152 The American Society of Anesthesiologists (ASA) defines the practice of anesthesiology as dealing with but not limited to the following:

■ The management of procedures for rendering a patient insensible to pain and emotional stress during surgical, obstetrical, and other diagnostic or therapeutic procedures. ■ The evaluation and management of essential physiologic functions under the stress of anesthetic and surgical manipulations. ■ The clinical management of the patient unconscious from whatever cause. ■ The evaluation and management of acute or chronic pain. ■ The management of problems in cardiac and respiratory resuscitation. ■ The application of specific methods of respiratory therapy. ■ The clinical management of various fluid, electrolyte, and metabolic disturbances.

L04-5647 The Endocrine System subsection (60000-60699) includes two subheadings of:

■ Thyroid Gland ■ Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid Body

L04-182 Multiple procedures

■ When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code that represents the highest base value unit procedure is reported. The time reported is the combined total for all procedures. ■ Assign the code for procedure of highest base value unit. ■ Indicate cumulative start/stop time for all surgical procedures performed.