Coding Chapter 12

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Carpal tunnel decompression surgery is classified in what section

nervous

SHOULD YOU REPORT MODIFIER 58 WHEN A TEMP CAST IS APPLIED AND THE PT LATER UNDERGOES A RESOTRATIVE TX

no

Nasal vestibule

nose's entrance

Xenografts

obtained from another species

report a manipulation code _--

once for any region including multiple regions during the same op session

How many codes are reported for exploration of spinal fusion

only one

There are different codes for an arytenoidectomy done _____ vrs _______

open vrs endoscopic

Classifications based on skin condition

open/ compound, closed/simple

Allogenous

originating in another person

Autogenous

originating in the patient's body

Biopsy codes are not reported for multiple ___ or _____ lesions even if taken from different areas

similar or identical

Closed aka

simple

Codes for the nose range from ______ to _________

simple control of nosebleed to complex surgery

Write the Coding Tip on page 576 in your book!

...

abdomen

...

exploration

...

femur (thigh region) and knee joint

...

foot and toes

...

forearm and wrist

...

hands and fingers

...

leg (tibia and fibula) and ankle joint

...

nothing here

...

nothing here either

...

pelvis and hip joints

...

read example on 566

...

shoulder

...

Modifier ___ can be added if turbinate surgery is performed on both sides

-50

What codes are included in fracture management? Do you report separate codes for any of these?

-Pinning -Open/Closed tx -Application and removal of initial cast or splint -Normal, uncomplicated follow up care (Do not report separate codes for these)

What falls under codes 20100-20103 Penetrating Trauma?

-Surgical exploration and enlargement of the wound -Extension of dissection (to determine penetration) -Debridement -Removal of foreign bodies -Ligation of coagulation of minor subcutaneous and or muscular blood vessels of the tissue, muscle, and or fascia not requiring thoracotomy or laparotomy

3 Methods of closed fracture treatment

-With manipulation/reduction which means realignment -Without manipulation/reduction which means the bones are not realigned and a cast is placed to stabilize -With or without skeletal traction

What are bundled in with the diagnostic endoscopy?

-anesthesia -electrocautery -access to cavities -shaving/debridement

Types include

-direct -indirect -use of operating a microscope -use of fiberoptic scope

Report excision codes for ____ and _______ on muscle or bone

-epiphyseal bar procedures and biopsy

Examples of headings in respiratory

-nose -larynx -lungs and pleura -trachea and bronchi -accessory sinus

What id bundled in with surgical sinus endoscopy?

-sinusotomy -diagnostic endoscopy

Accessory Sinuses

...

Application of casts and strapping

...

Arthrodesis

...

Back and Flank

...

Coding Tip: Closed and Open fractures many not receive the same type of tx. For ex: Closed may receive open tx and open may receive closed tx.

...

ENDOSCOPY/ARTHROSCOPY

...

EXCISION

...

Endoscopy

...

Excision

...

Excision (larynx)

...

Fracture and or Dislocation

...

Fracture and/or dislocation

...

Grafts or Implants

...

Head

...

Head Prosthesis

...

Humerus (upper arm) and elbow

...

INCISION

...

Incision

...

Intro

...

Introduction or Removal

...

Just example

...

Just look at examples

...

Larynx

...

Lung Transplant

...

Lungs and Pleura

...

Manipulation

...

Musculoskeletal System Notes

...

NOTHING IMPORTANT HERE

...

Neck and Thorax

...

Nose

...

Nothing important in this section

...

Nothing important in this section except example

...

Osteotomy

...

Other Procedures

...

Other Procedures:

...

Removal

...

Repair

...

Repair Revision, Reconstruction

...

Repair, Revision, and or Reconstruction

...

Replantation

...

Respiratory System

...

Review the coding tip on page 572 about using codes 30130-30140 with a procedure to gain access to the ethmoid bone

...

Spinal instrumentation

...

Spine (Vertebral Column)

...

Surgical Collapse Therapy: Thoracoplasty

...

Trachea and Bronchi

...

Vertebral Body, Embolization or Injection

...

Wound Exploration- Trauma

...

T1-T2 REPRESENTS ----- INTERSPACESS

1

What is included in the tendon repair codes

1. App. Of immobilization 2. Extension of excision 3. Repair and closure of tendon sheath

2 types of tendons

1. Flexor tendons 2. Extensor tendons

3 bunion procedures

1. Keller procedure 2. Mcbride procedure 3. Mitchell procedure

3 COMPARTMENTS OF A KNEE

1. MEDIAL 2. LATERAL 3. PATELLOFEMORAL

This heading includes codes that are reported when?

1. Replacement procedure performed during or after the period of follow up care 2. Initial service performed without restorative tx or procedure to stabilize or protect a fracture, disocation, etc

Why is precut. Vertebroplasty typically performed?

1. To relieve pain due to vertebral compression fractures 2. To relieve pain due to benign or malignant vertebral lesions

Lung transplants include what components

1. cadaver donor pneumonectomy 2. recipient lung allotransplantation 3. backbench work

C1-C2 AND C2-C3 REPRESENTS --- INTERSPACES

2

T1-T2 REPRESENTS --- SPINAL SEGMENTS

2

There are ___ turbinates on each side of the nasal vestibule

3 (inferior, middle, and superior)

L1-L4 REPRESENTS ---- SPINAL SEGMENTS

4

If a total lung lavage is performed bilaterally what modifier must be added

50

When exploration of spinal fusion is performed in addition to other definitive procedures what modifier must be added to the exploration code

51

When an osteotomy is performed during the same op session as a bone graft report the appropriate code and do not add modifier

51 or 62. Only one surgeon performs the bone grafting

When two surgeons work together to perform an anterior spine osteotomy procedure during the same op session on the same pt and each performs a distinct part of the procedure modifier __ is added to the appropriate procedure codes reported by ea. Surgeon

62

When two surgeons work together to treat distinct parts of open fracture and or dislocation procedures during the same op session and ea. Performs a distinct part of the procedure, mod. --- is added to the procedure codes; however both surgeons must work together a primary surgeons.

62

WHEN 2 SURGEONS COLLABORATE TO PERFORM A SPINAL PROCEDURE DURING THE SAME OP. SESSION ON THE THE SAME PT. AND EACH PERFORMS A DISTINCT PART OF THE PROCEDURE ADD MOD. --- TO THE PROCEDURE CODE REPORTED BY EACH SURGEON.

62 (ALSO ADD TO ADDITIONAL PROCEDURE CODES REPORTED BY EA. SURGEON)

Bone Bank is

allogenous

Severed body part aka

amputation

Percutaneous vertebroplasty involves

A bone cement (hardens in 10 mins) is injected under pressure directly into a fractured vertebra, the cement causes the fragments to congeal and provide stability

What other type of code should be reported with precut. Vertebroplasty

A radiology code for radiological supervision and interpretation

WHEN A PHYSICAN PERFORMS AN INTIAL RESTORATIVE TX AND AN INITIAL CAST IS ALSO APPLIED, THE PHYSICIAN IS RESPONSIBLE FOR PROVIDING

ALL SUBSEQUESNT FRACTURE INJURY CARE,

INSTRUMENTAL CODES ARE REPORTED SEPERATELY IN ADDION TO ---- CODES

ARTHRODESIS

T/F BONE GRAFT CODES ARE REPORTED SEPARETLY IN ADDITION TO ---- CODES

ARTHRODESIS

tibia

largest of the 2 lower leg bones

when arthrodesis is performed with another procedure report ---

an arthrodesis code with mod. 51 and the definitive procedure code

When tx of fractures/dislcoations are performed during a arthrodesis report ___

Appropriate arthrodesis code

When tx of fractures/dislcoations are performed during a bone graft report ___

Appropriate bone graft code (don't add mod. 51 or 62)

Spine procedures are sometimes followed by ___ and may include ___, and ____

Arthrodesis, bone grafts, and instrumentation

Incision contains just one code for ________

Arthrotomy, temporomandibular joint

Arthrodesis aka

Artificial ankylosis

Wagstaff-LeFort fracture

an avulsion of the fibula

Osteogenesis

Bone growth

C

CERVICAL

Spine codes classify procedures performed on the __,___ and ____spine

Cervical, thoracic, and lumbar spine

Mitchell procedure

Complex, double cut osteotomy through the neck of the first metatarsal

ARTHROSCOPY

VISUAL EXAM OF THE INSIDE OF A JOINT

The shoulder heading has codes for procedures on the ---, ---, ---, ----, ---, and ----

Clavicle, scapula, humerus head/neck, sternoclavicular joint, scrominoclavicular joint, and should joint

Osteotomy includes ____, -----, and ----- so separate codes are not needed.

Corpectomy, discectomy, and laminectomy

ENDOSCOPIC AND ARTHROSCOPIC PROCEDURES ARE --- OR ---

DIAGNOSTIC OR SURGICAL

------ IS PROBABLY THE MOST COMMON TYPE OF PROCEDURE PERFORMED

DX KNEE ARTHROSCOPY

ENDOSCOPY

VISUAL EXAM OF THE INTERIOR OF A BODY CAVITY OR ORGAN

McBride procedure

Distal soft tissue release that corrects soft tissue deformity at the mtp joint

What happens when major blood vessels need repaired via thoractomy or laparotomy?

Do not report the -otomy code. Report the repair code

Codes for injections are based on ________

anatomic site

T or F Regardless of tumor size, you use the same code.

False! This use to be true. Our book is wrong though.

________ management codes are found throughout the musculoskeletal system subsection.

Fracture

Open Fracture Treatment

Fracture site is surgically opened

How is the Musculoskeletal System subsection arranged?

From head to toe according to body area

Patients who are candidates for precut. Vertebroplasty?

Functional disability and severe pain in which pain meds and support braces don't resolve

arthrodesis performed for reasons other than to correct spinal deformity is classified according to ---

anatomical approach

The codes for procedures in the humerus heading is performed on the

Humerus, elbow, and head/neck of the radius and olecranon process

WHEN AN ARTHRODESIS IS PERFORMED IN ADDITION TO ANOTHER PROCEDURE REPORT THE ARTHRODESIS CODE _______ AND USE MODIFIER ---

IN ADDITION TO THE OTHER PROCEDURE, AND USE MOD. 51 ON THE ARTHRODESIS CODE

Graft aka

Implant

An osteotomy is an

Incision into the bone

Osteotomy codes differentiate btw --- and --- approaches

anterior and posterior

When a simple, intermediate, or complex repair of wound is performed without enlargement of wound area, extension of dissection to determine penetration, debridement, removal, or foreign body then what do you report?

Just the repair code from the integumentary system

L

LUMBAR

Colpoclesis aka

LeFort procedure which involves the surgical repair of a uterine prolapse or a vaginal vault prolapse

PROCEDURES S ON THE BONES, MUSCLES, AND TISSUE OF THE SPINAL COLUMN IS CLASSIFIED IN THE --- SECTION

MUSCULOSKELETAL

Spinal osteotomy involves

Making incisions in vertebral bone to remove pieces or wedges of bone to correct a deformity

mtp joint

Metatarsophalangeal joint

PROCEDURES PERFORMED ON THE NERVES AND SPINAL CORD IS CLASSIFIED IN THE --- SECTION

NERVOUS

SHOULD YOU REPORT A CODE FOR THE APPLICATION OF A CAST, SPLINT, OR STAPPING DEVICE WITH THE INITIAL RESTORATIVE TX

NO , THE FIRST ONE IS INCLUDED IN THE TX OF FRACTURE/DISLOCATION CODE

SHOULD YOU REPORT AN E&m CODE AT THE TIME OF CASTING

NO, UNLESS SIGNIFICANT IDENTIFIABLE FURTHER SERVICES WERE PROVIDED AT THE TIME OF THE CASTING

a wedge resection may be performed on what part of the lung?

any part of a diseased lung

When osteotomy is performed during same op session as a spinal instrumentation report the --- code but do not add modifier ----.

appropriate, 51

if 2 surgeons perform a procedure that also includes spinal instrumentation can both surgeons report it?

No only one surgeon performs a spinal instrumentation so do not add a modifier 62 as well

Do you add a modifier 50 to a total laryngectomy with bilateral neck dissection?

No. The larynx is a single organ. You need to code a total laryngectomy with dissection and then an extra radical neck dissection code. Ex: 31365 and 38720-59

When should you add modifier 51 to the spinal instrumentation code?

Only when its performed during same op session as other definitive procedures

Internal Fixation often called

Open reduction with internal fixation or ORIF

Clinically requires an injury with sufficient force to penetrate skin, subcutaneous tissue, muscle , and or bone

Open/Compound

Internal Fixation Device

Pins, screws, and or plates are inserted through or within the fracture area to stabilize and immobilize the injury

What does the nose heading include?

Procedures performed on the nose, nasal septum, intra nasal tissue, etc

The manipulation setting contains codes for reporting _____ manipulation which requires anesthesia

TMJ

WHEN ONE PHYSICIAN APPLIES A CAST SPLINT, OR STRAPPING DEVICE AS INITIAL TX OF A FRACTURE OR DISLOCATION AND A DIFFERENT PHYSICIAN LATER PERFORMS RESTORATIVE TX REPORT

TX OF FRACTURE FROM THE MUSCULOSKELETAL SYSTEM

What do you do if an incision of soft tissue abscess is performed and it is located in deeper tissues than those associated with the integumentary system?

Report 20005 for the incision and drainage of a soft tissue abscess, sub fascia, which involves the soft tissue below the deep fascia (the physician thoroughly debrides and irrigates the affected area, examines underlying tissue and bone for signs of infection, removes dead bone or tissue, and closes the site)

Deep abscesses aka

SUBFASCIAL

It is important to differentiate btw ____ and ____

Segments and interspaces

Keller procedure

Simple resection of the base of the proximal phalanx with removal of the medial eminence

Closed Fracture Treatment

Site is not opened or exposed

Extensor tendons

Straightn the fingers

Do not code separately sutures stables or steri strips in the back and flank section

T

T

THORACIC

If osteotomy is performed during same op session as an arthrodesis simply report --- and --

The appropriate code and the 51 modifier attached

When tx of fractures/dislocations are performed during a spinal implementation report

The appropriate code but don't add mod. 62

When spinal instrumentation is performed during the same op session as the exploration of spinal fusion what must you report?

The appropriate instrumentation code

What subheadings are included under Lung and Pleura?

The regular headings on pg 570 like incision, excision, etc plus two extra headings. (Lung transplant and Surgical collapse therapy)

T or F The accessory sinuses heading contains unique coding guidelines for endoscopy procedures.

True

T or F When the control of nosebleed is performed during a procedure, it is considered integral and is not reported separate.

True

There are separate codes for harvested grafts. T/F

True

WHEN IS AN ENDO/ARTHROSCHOPY CONSIDERED DIAGNOSTIC

WHEN IT IS PERFORMED TO VISUALIZE AN ABNORM. OR DETERMINE EXTENT OF DISEASE

When a procedure for inferior turbinate surgery, nasal endoscopy, and septoplasty occur then code

a code for each because they are all separate (with appropriate modifier)

Lung transplants include the 3 components how is a code assigned to these?

a code is assigned to each by the physician who performed the component

Arthrocentesis

a procedure done to puncture the joint for fluid removal or medication injection

Interdental wiring

a stabilization procedure that involves the insertion of wires between teeth

femur

long bone of the thigh

Where are CPT guidelines related to the the subsections located?

at the beginning of the section

Prosthesis

created for rehab patients who have facial, oral, or other anatomic deficiencies that require an artificial ear, eye, or nose or an intraoral obturator

How is the Respiratory system arranged?

according to body area from nose to lungs

percutaneous needle biopsy

long needle inserted through the skin and into other tissue to obtain tissue for diagnostic evaluation

Classification based on position of fracture line

longitudinal, transverse, oblique, spiral. and stellate

tibial plateau

lower portion of femur that articulates with the tibia

What modifiers do you add to endoscopy codes?

lt and rt or -50

Closed reduction of a fracture is the same as

manipulation

Codes for tx of fractures and joint injuries are classified according to type of _________ and ________

manipulation and stabilization

according to cpt a therapeutic wedge resection requires attention to ____ and ______

margins and complete resection of the diseased lung (even when a more extensive resection is performed during a later operative episode)

Femoral Neck

based on location

Flexor tendors

bend fingers

Report excision codes for surgery performed on ___ and ___ of the face or scalp

bone and soft tissue

the knee is comprised of

bones, cartilage, ligaments, and tendons

Conchae defined

bony plates covered by spongy mucosa with curved margins

LeFort III

brings the entire midface forward, from the upper teeth to just above the cheekbones

LeFort I

brings the lower midface forward (from the level of the upper teeth) to just above the nostrils

Closed fracture

broken bones do not protrude and there are no open wounds Ex: burns, deep abrasions, involvement of subcutaneous requiring debridement and skin contusions

Open fracture

broken bones that can be seen through an open wound or protruding through the skin

hallus valgus repair codes are reported to correct

buniuons

if you report manipulation of the spine without anesthesia report a code from the ___ section

medicine

define pleura

membrane that envelops the lungs and lines the walls of the pleural cavity

LeFort I, II, and III are _____ bilateral fractures of facial bones that contain large, unstable fragments

complex

Open aka

compound

Turbinates are aka

conchae

ligaments

connective tissue that connects bone to bone and control stability of the knee

What type of sedation is a pt usually under when precut. Vertebroplasty is being performed

conscious sedation

Extensive shaving and debridement should be reported ______

separate with a -51

bunions

caused by bone inflammation and swelling and result in medical deviation and axial rotation of the first mtp joint

Pathological

caused by weakness from disease

Musculoskeletal System

classifies procedures performed on bones, cartilage, joints, ligaments, muscles, and tendons (including casting and strapping)

Respiratory System

classifies procedures performed on the nose , accessory organs, sinuses, larynx, trachea, bronchi, lungs, and pleura

Types of injury codes include

closed and open fractures and joint injuries

Examples of types of fractures

closed, open, percutaneous

What do the neck and thorax headings include?

codes for procedures performed on soft tissues of the neck and thorax

What does the larynx heading contain?

codes for procedures performed on the epiglottis and larynx and inside the trachea

What does the accessory sinus heading contain?

codes for procedures performed on the maxillary, frontal, ethmoid, and spheroid sinuses

define brushing

combing the mucous lining of the traches or bronchus with a bronchial brush to collect cells

Subglottic stenosis

narrowing of the airway below the vocal cords, adjacent to the cricoid cartilage

When a surgical endoscopy of accessory sinuses is performed, and evaluation of ________ is also performed as part of the procedure

nasal access regions (diagnostic endoscopy)

what does the routine fiberoptic bronchoscopy usually inspect other than the bronchus

nasal cavity, pharynx, and larynx

What do musculoskeletel system notes include ?

definitions of fractures and clarify that the type of fracture does not necessarily correspond to the type of TX provided

Head prosthesis codes

describe professional services that involve designing and preparing a prosthesis for a patient

pneumonolysis

division of tissues that attach the lung to the wall of the chest cavity

what tool is used to perform an endoscopy of the trachea or bronchus

either a flexible fiberoptic scope or a rigid scope with or without cell washings or brushing

Do not code a laryngoscopy separately when it is performed as part of an emergency or nonemergency _______

endotracheal tube

The middle turbinate is part of the _________

ethmoid bone (so if the middle turbinate is removed during ethmoidectomy, a code for the removal is integral)

Back and Flank only contains ______

excision

Do not report a biopsy code in addition to an _______

excision , destruction, or other type of removal during the same op session

Skeletal traction

exerts a pulling force on the affected limb to realign bone or joint

Stellate usually found in

fingers and toes

Stabilization

fixation or immobilization

pleural effusion

fluid in the pleural cavity prevents the lung from fully expanding which makes it difficult to breathe

define cell washing

flushing fluid into an area and removing the fluid using aspiration technique to collect cells

Gastrocnemious

from the calf

Tensor fascia lata

from the thigh

Fascia lata tissue is harvested from _________ or _____

gastrocnemius fascia or tensor fascia lata

Classification based on bone condition

green stick, comminuted, Compression, impacted

External fixation device

hardware is inserted through bone and skin and held rigid with cross braces outside of the body

the femur articulates with the

hip bone, tibia, and patella

Why are artenoidopexy and arytenoidectomy performed?

improve breathing

bone graft procedure are reported ___ to the arthrodesis codes

in addition

Where are unique coding instructions for Musculoskletal and Respiratory Systems located?

in the notes below headings or codes

define recipient lung allotransplantation

include transplantation of a single or double lung allograft and care of the recipient

Turbinate excision and submucous resection codes are typically reported for ________ turbinate surgery.

inferior

therapeutic pneumothorax

injection of air into the pleural space

Introduction and removal codes are reported for what?

injection procedures, removal of foreign bodies, insert and application of surgical hardware, arthrocentesis, and aspirations

percutaneous pleural biopsy involves

inserting a long needle through skin into the chest wall to obtain pleural tissue w/out direct visualization of the pleura

What do diagnostic endoscopy codes include?

inspection of the interior of the nasal cavity and its meatus,turbinates, and sphenoethmoid recess

define cadaver donor pneumonectomy

involved harvesting the allograft and preserving the allograft with cold preservation solution and cold maintenance

define backbench work

involves preparing the cadaver donor lung allograft prior to lung transplantation and dissecting allograft from surrounding soft tissues to prepare the pulmonary venous/atrial cuff, pulmonary artery, and bronchus

Dislocation

joint injury

What is coded if a sinusotomy is performed in conjunction with a sinus endoscopy

just one code to include both

If a physician is performing a surgical endoscopy; however, it fails and the physician must switch to an open procedure what should you code?

just the open procedure

if a diagnostic endoscopy of the trachea and bronchi is performed at the same time a surgical endoscopy is being performed what do you report as your code?

just the surgical endoscopy

what is an example of a hinge joint

knee

Closed and open fractures may receive __________ tx

per cutaneous skeletal fixation

Surgical Injections

performed by inserting a needle directly into a joint or tendon sheath, trigger point, or ganglion cyst to aspirate fluid or inject medications

Open nasal surgical approach

performed by making an incision into skin or tissues inside the nasal cavity

Surgical sinus endoscopy

performed through the nose, using a fiber-optic endoscopy

Internal fixation device is less ____ than wiring

permanent

What do CPT codes located in the Head category include?

procedures performed on the skull, facial bones, and temporomandibular joint (TMI)

What do respiratory guidelines do?

provide instructions for the selection of appropriate codes Example: approach

pneumoncentesis?

puncture of pleural space with a transthoracic needed to drain fluid or to obtain material for dx study

LeFort II aka

pyramidal fracture

Excision includes

radical resection of tumor, partial and total excision of ribs, costotransversectomy, osteotomy of sternum, sternal debridement, and radical resection of sternum

LeFort I, II, or III procedures

reconstruction of the face

Harvested cartilage tissue is often used for _________

reconstruction purposes

Manipulation aka

reduction

wedge resection

removal of a portion of lung that is less than a segment

lobectomy

removal of a single lobe

segmentectomy

removal of one segment of a lobe

total pneumonectomy

removal of the entire lung

extrapleural resection of ribs is the

removal of the ribs

External device is always _______

removed (after fracture is healed)

Harvesting

removing tissue for transplantation

Tendon tissue is harvested for the purpose of _____

repairing another tendon

What do you do when a physician performs sinus endoscopy with partial ethmoidectomy and septoplasty?

report a code for each procedure because 2 distinct procedures are being performed (30520-50 and 31254-50-51)

If an open procedure, thoracotomy, or another open chest procedure immediately follows a diagnostic thorascopy what codes need to be reported

report both procedures and sequence the open procedure first

When a surgical thoracoscopy is converted to an open procedure what code must you report?

report the code for the open procedure only

Back and Flank codes are

reported for biopsy, tumor excision, and radical resection of tumor procedures performed on the back and flank

thoraplasty

resection of ribs to allow the chest wall to retract, reducing the size of the pleural space

How are turbinates removed?

resection or excision with or without endoscopy, cauterization, debridement, laser, cryotherapy, radiofrequency, or ablation

If an endoscopy is performed to evaluate the sinus cavity prior to sinusotomy, report just _______________

sinusotomy code

2 types of splints

sterotactic and dynamic (not in book)

T/F WHEN ANYTHING IN ADDITIN TO VISUALIZATION IS PERFORMED THE ENDO/ARTHROSCOPY CODES ARE CONSIDERED

surgical

What is arthrodesis

surgical fixation of a joint

Pyramidal Fracture

surgical fracture of the midfacial skeleton at an apex near the superior aspect of the nasal bones

Thoracoplasty

surgical lung collapse therapy

thoracentesis

surgical puncture of the chest wall with a needle to obtain fluid from the pleural cavity

T or F Removal procedure is included in the global service and is not coded separately

t

T or F Do not report a code for diagnostic endoscopy in addition to a surgical endoscopic procedure..

t meaning do not code both a diagnostic and surgical procedure code if performed in one operation

codes for harvesting and inserting tendon grafts from another site, repairing nerves, and treating fracture are reported in addition to ____

tendon repair

When a traumatic injury with an open wound requires surgical debridement but the type of fracture requires manipulation and casting instead of a fixation device, code

the closed fracture treatment in addition to the debridement code

Arytenoidectomy

the excision of arytenoid cartilage, which is located bilateral vocal fold

Direct laryngoscopy

the insertion of a flexible or rigid fiberoptic scope or a rigid laryngoscope to visualize back of the throat while the physician wears headgear that contains a mirror and light source; the mirror reflects light into the patient's mouth, allowing the physician to visualize the throat

Subluxation

the partial displacement of a bone from it joint

what do the surgical collapse therapy and thoracoplasty codes classify

the procedure to therapeutically collapse a pt's lung

Augmentation

the process of enlarging or increasing

Arytenoidopexy

the surgical fixation of arytenoid al cartilage and/or surrounding muscle

Replantation defined

the surgical reattachment of a finger, hand, toe, foot, leg, or an arm that has been completely severed from a body

When surgery is performed on the turbinates, what is important to identify?

the type of turbinate procedure and the technique used

Laryngoscopy

the visualization of the back of the throat, including the larynx and vocal cords

In the event a wedge resection is being performed but a intraoperative pathology consultation determines that a more extensive resection is necessary in the same anatomic location what is coded?

the wedge resection is coded as a diagnostic wedge resection and then code the more extensive resection as well

In the event a wedge resection is being performed and the intraoperative pathology consult determines that a more extensive resection is NOT necessary what do you code?

the wedge resection is coded as a therapeutic wedge resection

why is a thoracentesis performed

to make a diagnostic evaluation or to drain excess fluid from a pt with severe pleural effusion

Dislocation or luxation is a ________

total displacement of bone from its joint

When a laryngoscopy is part of a tracheostomy, only code the ________

tracheostomy

What does a fiberoptic scope do?

transmits light

Harvested bone tissue

transplanted to another site to promote osteogenesis or to provide structural stability

t/f a diagnostic endoscopy is often performed during an open surgical procedure to evaluate the surgical field

true

t/f arthrodesis may be performed independently from other procedures

true

t/f bunion deformities develop differently and repair requires different levels of complexity and different techniqures

true

t/f each lung has multiple segments

true

t/f if a nasal endoscopy , laryngoscopy is performed in addition to a bronchoscopy, you must only report the bronchoscopy

true

t/f some arthrodesis codes are exempt from modifier 51

true

t/f if pt undergoes precut. Vertebroplastry on L1 and L2 you must report 2 radiology codes for each segment

true (3M will give you two codes the book is wrong)

t/f spinal instrumentation procedures are reported in addition to the arthrodesis codes

true (the book wants you to add mod. 51 to the spinal instrumentation code, but this is wrong)

t/f manipulation of spine under anesthesia is performed to treat back pain and other disorders

true, the idea is that the pt is more relaxed under anesthia and better manipulation results

arthroscopic knee surgery is commonly performed and codes are located

under endoscopy/arthroscopy heading of musculoskeletal system

What do endoscopy codes classify?

unilateral procedures

Obturator

used to close a gap

Endoscopic nasal surgical approach

utilizes a fiberoptic endoscope instrument , which is inserted through the nostrils

tracheobronchoscopy

visual exam of interior of trachea and bronchus

define bronchoscopy

visual exam of the interior of the bronchus

thorascopy

visual exam of the pleural cavity and it provides an alternative to open lung or thoracotomy procedures to hrpleural disorders surgically

define tracheoscopy

visual exam of the trachea

Larynx

voice box

When do you report other procedure codes?

when procedures are performed that are not reportable with codes from the grafts or implants codes

trachea aka

windpipe

DOES THE SURGICAL ENDOSCOPY/ARTHROSCOPY ALWAYS INCLUDE DIAGNOSTIC ENDOSCOPY/ARHTROSCOPY

yes


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