CPT - Surgery

Arthroscopy of the right wrist with complete synovectomy

29845-RT arthroscopy, surgical, wrist

The surgeon performed an anterior-to posterior (total) intranasal endoscopic ethmoctomy with sphenoidotomy

31257 Endoscopy, nose, surgical

Patient has a large obstructing mass of the left glottis and subglottis. A direct laryngoscopy with biopsy was performed to reveal squamous cell carcinoma

31535 laryngoscoy, direct, biopsy

D&C performed for a patient with dysfunctional bleeding

58120 dilation and curettage, corpus uteri

Abdominal hysterectomy with salpingo-oophorectomy (uterus weight 270g)

58150 hysterectomy, abdominal, total

Endometrial cryoablation with ultrasonic guidance

58356 ablation, endometrial, with ultrasound guidance

Excision of rectal tumor transanal endoscopic approach

0184T Rcetum, tumor, excision, transanal endoscopic

Fine needle aspiration biopsy of mass in check, under fluoroscopic guidance

10007 biopsy, skin lesion, fine needle

Patient has a Grade III ulcer of the left heel. The physician debrided the 4 cm x 2 cm x 0.5 cm ulcer to the subcutaneous tissue. The #15 blade removed the fibrinous tissue

11005 debridement, skin, infected 11008 removal, mesh abdominal wall

The surgeon performs debridement down to and including the fascia of the abdominal wall due to necrotizing facilitis

11005 debridement, skin, skin, subcutaneous tissue, infected (The index entry for necrotized leads to an incorrect code)

Debridement of below-knee amputation stump. The necrotic wounds were sharply excised down to and including the fascia with a 10-blade scalpel (15 sq cm)

11043 debridement, muscle

Paring of 3 hyperkeratotic lesions from the patient's foot

11056 lesion, skin, paring

In the physician's office, the patient had a punch biopsy of a 1.0 cm skin lesion of the neck

11104 biopsy, skin lesion, punch

A wedge of tissue was biopsied from a mass on the patient's back. The sample was sent to pathology

11106 biopsy, skin lesion, incisional 11103 biopsy, skin lesion, tangential

Full-thickness wedge skin biopsies of suspicious tissue of the arm and hand

11106 biopsy, skin, incisional 11107 add-on code

Diagnosis: mass of chest area. The surgeon made an elliptical incision encompassing the whole mass (6.5 cm x 3 cm x 1.5 cm) dissecting laterally deep to the subcutaneous tissue. Pathology report reveals inflamed epidermal cyst.

11406 Lesion, skin, excision, benign

Pphysician excised a 1.0 cm squamous cell carcinoma from the forehead. The excision required margins of 1.0 cm around the lesion

11642 lesion, skin, excision, malignant

Layered (intermediate) wound repair of a 3-cm laceration of the hand and an intermediate repair of 5.0 cm of arm

12042 repair, wound, intermediate 12032-59 repair, wound, intermediate

Wide excision of a malignant lesion of back (5.0 cm x 3.0 cm) with adjacent skin graft

14001 skin graft and flap, tissue transfer

Physician performs a wide resection of a 3.0 cm malignant skin lesion of the left leg. The defect required an adjacent tissue transfer measuring 15 q cm

14021 skin graft and flap, tissue transfer

The surgeon performed a tubed pedicle flap from the forehead to cover the defect on the nose

15576 pedicle flap, formation

Laser removal of 16 lesions from the back

17111 lesion, skin, destruction, benign

With the use of ultrasound guidance, the surgeon placed a metallic clip to identify the suspicious tissue in the left breast. A percutaneous core needle biopsy was performed

19083-T breast, biopsy, with localization device placement, ultrasound guidance

bilateral total mastectomy with reconstruction using double-pedicle TRAM

19303-50 mastectomy, simple, complete 19369-50 reconstruction, breast, transverse rectus abdominis myocutaneous

Surgical exploration of stab wound of chest with included coagulation of blood vessels and enlargement of the wound

20101 wound, exploration, penetrating, chest

Open treatment with internal fixation of 3 rib fractures

21811 fracture, rib, open

Repair of medial collateral ligament of right elbow using local tissue

24345-RT ligament, elbow, collateral ligament, repair

Open reduction with internal fixation (screws), for a fracture of the left humeral shaft

24515-LT fracture, humerus, shaft, open treatment

The surgeon performed open reduction with internal fixation of medial condylar fracture of the humerus

24579 fracture, humerus, condyle, open treatment

Open reduction with internal fixation OORIF) of intertochanteric fractured femur using Gamma nail

27245 fracture, femur, intertrochanteric intramedullary implant

Removal of splinter embedded deep in the left skin

27372-LT removal, foreign body, knee joint

The orthopedic surgeon reduces a fracture of the left proximal fibula. After closed treatment and skeletal traction, the physician applies a short leg cast

27781-LT fracture, fibula, closed treatment (initial cast application included with treatment code)

Closed treatment of distal fibular fracture without manipulation; the patient was int he postoperative period for an arthroscopy of the shoulder performed 2 wks ago; the same physician performed both surgeries

27786-79 Fracture, fibula, closed treatment

Repair of hammertoe, second digit of right foot

28285-T6 hammertoe repair, correction

Arthroscopy of the left elbow with removal of loose body

29834-LT arthroscopy, surgical, elbow

Patient treated in the emergency department for severe epistasis (first visit for this condition); physician performs posterior packing, bilateral

30905 Epistaxis (see hemorrhage, nasal) Hemorrhage, control, nasal, initial (note: although this is a bilateral procedure, the NCCI edits did not prompt for -50)

Direct larngoscopy with injection of botulinum toxin for treatment of laryngeal dystoria

31570 Larynx, endoscopy, direct

The patient has a history of persistent hoarseness. The surgeon perfomrs a flexible laryngoscopy to evaluate the larynx

31575 laryngoscopy, flexibe, diagnostic

Flexible bronchoscopy with bronchial brushings and cell washings

31623 bronchoscopy, brushings (code for cell washings (31622) is a separate procedure)

bronchoscopy with transbronchial biopsy of lung

31628 bronchoscopy biopsy

Bronchoscopy for removal of tumor using argon plasma coagulation

31641 bronchoscopy, removal, tumor

Bronchoscopy with EBUS-guided transbronchia sampling of 2 mediastinal lymph nodes

31652 bronchoscopy, with endobronchia ustrasound (EBUS)

Percutaneous drainage of pleural cavity via indwelling catheter, with imaging

32557 puncture, pleural cavity, drainage

Insertion of permanent cardiac pacemaker with right atrial and ventricular transvenous electrodes; at a university hospital. The surgeon performed procedure but not the peroperative or postoperative care

33208-54 Pacemaker, heart, insertion (modifier for surgical care only)

The patient has been diagnosed with severe aortic stenosis. Through a percutaneous incision in the leg (transfemoral), the surgeon performs a transcatheter aortic valve replacement (TAVR)

33361 transcatheter aortic valve replacement, femoral artery approach

A coronary artery bypass graft (CABG) procedure was performed. The surgeon bypassed 3 coronary artery sites by grafting the left internal mammary artery (LIMA) and one site was treated by grafting the greater saphenous venous graft to the obtuse marginal from the aorta

33517 Coronary Artery Bypass Graft (CABG), arterial-venous bypass 33535 coronary artery bypass graft (CABG), arterial bypass

Open revision of AV fistula with thrombectomy, patient receiving hemodialysis

36833 arteriovenous fistula, revision, with thrombectomy

Ppercutaneous thrombectomy of forearm AV graft that was inserted for dialysis treatment

36904 thrombectomy, percutaneous, dialysis circuit

A patient is seen for surgical treatment of an occlusion of the femoral artery, left. Percutaneously, under guidance, the surgeon inserts a catheter to perform an atherectomy (lower extremity revascularization)

37225-LT revascularization, artery, femoral/popliteal

Procedure: Excision of pseudoaneurysm of temporal artery. Operative note states that the artery was divided and aneurysm removed. Artery was ligated with fine Vicryl suture

37609 artery, temporal, ligation

Mediastinoscopy with biopsy of mediastinal adenoma

39401 Mediastinoscopy, biopsy, mediastinal mass

Laparoscopic repair of recurrent incisional hernia

49656 hernia, repair, incisional, laparoscopic

Palatoplasty for cleft palate, soft

42200 palatoplasty

ERCP with removal of biliary stent

43275 bile duct, endoscopy, removal, foreign body

Laparoscopic gastric bypass and Roux-en-Y gastroenterostomy performed for obesity

43644 Laparoscopy, gastric restrictive procedures

Laparoscopy pyloroplasty

43659 unlisted laparoscopy procedure, stomach. There is not entry for laparoscopic pyeloplasty. The open procedure is 43800

percutaneous replacement of gastrostomy tube requiring debridement of granulation tissue in order to insert the new tube

43763 gastrostomy tube, replacement, percutaneous, requireing revision of gastrostomy tract

Laparoscopic rectopexy for patient with prolapse

4500 Proctopexy, laparoscopic

Proctosigmoidoscopy with remova of 2 polyps with the use of hot biopsy forceps

45315 proctosigmoidoscopy, removal of polyp

The surgeon performs a colonoscopy that extends to the first portion of the ascending colon before being stopped due to equipment failure

45378-53 Colonoscopy, flexible diagnostic

Under fluoroscopy, the physician percutaneously places an eternal biliary catheter into the bile duct for drainage

47533 bile duct, drainage, catheter, placement

Laparoscopic resection of cystic duct

47579 Unlisted laparoscopy procedure, biliary tract

Laparoscopic aspiration of ovarian cyst

49322 laparoscopy, aspiration

Laparoscopy with aspiration of ovarian cyst

49322 laparoscopy, aspiration, cyst

Recurrent incarcerated inguinal hernia repair with implantation of mesh (56-year-old patient)

49521 hernia, repair, inguinal, incarcerated

Inital repair of strangulated ventral hernia requiring mesh (49-year-old patient)

49568 implantation, mesh

Cystourethroscopy with fulguration of bladder tumor (3.0 cm)

52235 cystourethroscopy, with fulguration, tumor

Cystourethroscopy with ureteroscopy with lithotripsy and insertion of double J ureteral stent

52356 cystourethroscopy, with ureteroscopy

Biopsy of 2 lesions, 1 from labia minora and another from the vaginal oriffice, which requires suture closure

56605 biopsy, vulva (external genitailia) 57105 biopsy, vagina

Vulvectomy, partial removal of skin and superficial subcutaneous tissues

56620 vulvectomy, simple, partial (use definitions at beginning of section)

Hysteroscopy with polypectomy and D&C

58558 hysteroscopy, surgical with biopsy

Diagnosis: Chronic menometrorrhagia, uterine leiomyomata, and left Bartholin's gland cyst Procedure: Operative hysteroscopy with resection of submuccous myomas and left Bartholin's gland cystectomy

58561 hysteroscopy, removal, leiomyomata 56740 Bartholin's Gland, excision

laparoscopy with removal of tubes and ovaries; the operative report indicates that the procedure was extremely difficult to perform and took 2 hrs longer to complete than usual

58661-22 Laparoscopy, removal, fallopian tube

Patient desires elective sterilization. Surgeon performs laparoscopic coagulation of the fallopian tubes

58670 fallopian tube destruction, endoscopic

Total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, dissection of pelvic lymph nodes with removal of a portion of the para-aortic lymph nodes, and dubulking of ovarian tumors

58954 Salpingo-oophorectomy, resection ovarian malignancy

Patient with severe back pain requires a single interlaminar epidural steroid injection, L5-S1 interspace with imaging

62323 epidural, injection

parathyroidectomy

60500 parathyroid gland, excision

Laparoscopic hemithyroidectomy

60650 laparoscopy, adrenal gland, excision. Note: there is misleading index entry for this example. Adrenalectomy, aparoscopic, leads to 50545, which is incorrect

Laparoscopic hemithyroidectomy

60659 unlisted laparoscopy procedure, endocrine system (Laparoscopic procedures, on the endocrine glands are limited. This is a good example for students to leaving the index and explore the codes in the chapter)

Craniotomy for evacuation of supratentorial subdural hematoma

6132 craniotomy, surgery or hematoma, brain, evacuation via crainotomy

Open lumbar laminectomy for decompression of the spinal cord, L3-L4

63005 laminectomy, for decompression, lumbar

Glycerol rhizotomy of trigeminal nerve

64600 trigeminal nerve, destruction

Sciatic neuropasty, leg

64712 neoplasty, pherpheral nerve, sciatic

Suture repair of posterior tibial nerve

64840 suture, nerve

Bilateral tympanostomy with insertion of ventilating tube, performed under general anesthesia

69436-50 tympanostomy, general anesthesia