OST-247 - Procedure Coding - Chapters 6 - 8
Hamstring muscle neurectomy
27325
Removal of woodlike item deep in the knee area
27372
Primary suture of infrapatellar tendon
27380
Knee arthrodesis
27580
Superficial biopsy of soft tissue of leg
27613
Arthrotomy of ankle with synovectomy
27625
Radical resection of tumor of the calcaneus
27647
I&D of bursa of left wrist
25031-LT
Arthrotomy with exploration of midcarpal joint
25040
Partial excision of ulna for osteomyelitis
25150
Radical resection for tumor of ulna
25170
Drainage of abscess of finger
26010
Radical resection of sarcoma of the soft tissue of the hand-3.5 cm
26118
Finger sesamoidectomy
26185
Correction of claw finger
26499
Open tenotomy of hip flexor of right side
27005-RT
Ischial bursa excision
27060
Injection procedure for hip arthrography
27093
Bilateral pelvis osteotomy
27158
Closed treatment of coccygeal fracture
27200
Removal of indwelling tunneled pleural catheter with cuff
32552
Incision of flexor tendon sheath of wrist
25001
Thoracostomy with rib resection for empyema
32035
Open biopsy of pleura
32098
Thoracotomy for exploration
32100
Thoracotomy for postoperative complications
32120
Pneumonostomy with open drainage of cyst
32200
Parietal pleurectomy
32310
Percutaneous needle biopsy of lung
32405
Temporomandibular joint arthrotomy
21010
Excision of mandible
21025
Incision and drainage of deep abscess of the soft tissue of the thorax
21501
Superficial biopsy of soft tissue of back
21920
Reinsertion of spinal fixation device
22849
I&D in shoulder area for deep abscess
23030
Incision of bone cortex of shoulder
23035
Partial acromionectomy with release of coracoacromial ligament
23130
Single tendon tenotomy of shoulder
23405
Open treatment of chronic sternoclavicular dislocation
23530
I&D of elbow for deep abscess
23930
Arthrotomy of elbow with removal of foreign body
24000
Arthrotomy of elbow with capsular excision for capsular release
24006
Olecranon bursa excision
24105
Removal of humeral and ulnar prosthesis components with debridement and synovectomy
24160
Manipulation of trimalleolar ankle fracture with closed treatment
27818
Fasciotomy of toe
28008
Excision of two interdigital neuromas
28080 and 28080
Metatarsectomy
28140
Phalangectomy of three toes
28150 and 28150 and 28150
Interphalangeal joint excisions of the proximal end of two toes
28160 and 28160
Radical resection of tumor of the phalanx of the toe
28175
Flexor tenolysis, foot, single tendon
28220
Closed treatment of talus fracture
28430
Triple arthrodesis
28715
Application of long arm cast
29065
Application of shoulder to hand cast
29065
Strapping of wrist
29260
Arthroscopy of shoulder with synovial biopsy
29805
Surgical arthroscopy of the shoulder with capsulorrhaphy
29806
Athroscopic partial shoulder synovectomy
29820
Shoulder arthroscopy for complete synovectomy
29821
Extensive debridement of shoulder via arthroscope
29823
Arthroscopic removal of a foreign body in the elbow
29834
Diagnostic arthroscopy of wrist with synovial biopsy
29840
Wrist arthroscopy with synovial biopsy
29840
Arthroscopy of wrist for internal fixation of fracture
29847
Endoscopic release of the transverse carpal ligament of the wrist
29848
Surgical arthroscopy of knee with medial meniscal transplantation
29868
Arthroscopy of knee with synovial biopsy
29870
Lateral release via arthroscopy of knee
29873
Endoscopic plantar fasciotomy
29893
Subtalar joint arthroscopy with removal of foreign body
29904
Subtalar joint arthroscopy with subtalar arthrodesis
29907
Primary rhinoplasty with elevation of nasal tip
30400
Septoplasty with cartilage scoring
30520
Intranasal repair of choanal atresia
30540
Lysis intranasal synechia
30560
Septal dermatoplasty
30620
Repair of nasal septal perforation
30630
Superficial bilateral cautery of mucosa of inferior turbinates
30801
Anterior, simple control of nasal hemorrhage
30901
Ethmoidal artery ligation
30915
Therapeutic fracture of nasal inferior turbinate
30930
Partial horizontal laryngectomy
31370
Epiglottidectomy
31420
Indirect laryngoscopy for diagnosis
31505
Indirect laryngoscopy with foreign body removal
31511
Direct operative laryngoscopy with biopsy
31535
Direct laryngoscopy with stripping of vocal cords
31540
Flexible fiberoptic laryngoscopy with removal of foreign body
31577
Flexible fiber-optic laryngoscopy with removal of lesion
31578
Laryngoplasty for laryngeal web with indwelling keel
31580
Laryngeal reinnervation by neuromuscular pedicle
31590
Thoracoscopy with removal of a clot from the pericardial sac
32658
Repair of a lung hernia via the chest wall
32800
Preoperative and postperative diagnosis: Excessive fluid in pericardial sac Procedure: Initial removal of fluid from pericardial sac After the patient was prepped and draped in the usual fashion, general anesthesia was administered. Using the sternum as an anatomical landmark, a long needle was placed below the sternum. The needle was advanced into the pericardial sac, and 5 cc of fluid were removed and sent to pathology for review. The patient was stable, and the wound was dressed. The patient was sent to the recovery area in satisfactory condition.
33010 (In the Index, reference the main term Pericardiocentesis. Code range 33010-33011 is listed. Reference the code range in the main section of the CPT manual.)
Tube pericardiostomy
33015
Complete pericardiectomy
33030
Resection of pericardial tumor
33050
Resection of external cardiac tumor
33130
Preoperative and postoperative diagnosis: Cardiac ischemia Procedure: Thoracotomy for transmyocardial laser revascularization Anesthesia: General The patient was prepped and draped in the usual sterile fashion and placed under general anesthesia. A 12-cm incision was made on the left side of the chest. The incision was made between the ribs and was carried down to expose the heart's surface. An ischemia was visualized on the right side of the heart. The laser was inserted into the cardiac area, and between heartbeats, 15 channels were made and pressure was applied to close the opened areas. Prior to closure of the incision, there was no significant bleeding from the cardiac tissue. The laser was removed, the incision was closed, and dressings were placed on the wound. The patient tolerated the procedure with no complications and was sent to the recovery area in stable condition.
33140 (In the Index, reference the main term Revascularization, then transmyocardial. Review the code range listed in the main section of the CPT manual.)
Direct repair of aneurysm with patch graft by arm incision for ruptured aneurysm of the axillary-brachial artery
35013
Repair of congenital arteriovenous fistula of head and neck
35180
Repair, acquired arteriovenous fistula, thorax and abdomen
35189
Preoperative and postperative diagnosis: Bleeding from pacemaker site Procedure: Relocation of skin pocket for pacemaker With the patient under general anesthesia, the previous skin pocket was opened, and the generator was removed. The skin pocket was explored and bleeding stopped in the area. The generator was then relocated, and the pocket was closed with sutures. A sterile dressing was applied. The patient was in stable condition.
33222 (In the Index, reference the main term Pacemaker, Heart, Revision, then relocate pocket, then chest.)
Procedure: Replacement of pacemaker generator The patient was brought to the operating room and was prepped and draped in the usual fashion. The patient was consciously sedated. The previous subcutaneous right infraclavicular skin pocket was identified, and an incision was made in this area to remove the previously inserted generator. The atrial and ventricular leads were checked. Since the pocket was clean, it was determined that the same pocket could be used for the reinsertion of a new generator. A pulse generator was placed and tested. Noting no complications, the physician sutured the site. The patient was found to be in stable condition and was returned to the recovery room in satisfactory condition.
33228 (Replacement of the pulse generator. The atrial and ventricular leads identify this as a dual chamber.)
Direct repair of blood vessel of the neck
35201
Repair of blood vessel with vein graft, intraabdominal
35251
Modified maze procedure for operative tissue ablation and reconstruction of atria
33254
Preoperative diagnosis: Chest wound Postoperative diagnosis: Foreign body on the surface of the heart Anesthesia: General Procedure: Exploratory cardiotomy This 59-year-old patient sustained an injury to his chest while loading logs onto a truck at work. He was brought to the ER, and imaging showed a chest wound with a possible foreign body on the surface of the heart. He was then taken to the operating room for exploration of the area. An incision was made in the sternum, and the heart was exposed. A foreign body was visualized on the heart and was removed. There were no penetrating cardiac wounds to be sutured. The operative wound was closed, and the patient was sent to the recovery area in stable condition.
33310 (In the Index, reference the main term Cardiotomy. Review the code range listed in the main section of the CPT manual.)
Valvuloplasty, aortic valve; open, with cardiopulmonary bypass
33390
Incision of subvalvular tissue for discrete subvalvular aortic stenosis
33415
Aortoplasty completed for supravalvular stenosis
33417
Replacement, mitral valve, with cardiopulmonary bypass
33430
Tricuspid valve valvectomy with cardiopulmonary bypass
33460
Valvotomy, pulmonary valve, closed heart; via pulmonary artery
33471
Replacement, pulmonary valve
33475
Infundibular stenosis corrected by right ventricular resection (commissurotomy)
33476
Repair of anomalous coronary artery from pulmonary artery origin; by graft, without cardiopulmonary bypass
33503
Preoperative and postoperative diagnosis: Thrombus and atherosclerosis of iliac artery Procedure: Iliac thromboendarterectomy The patient was prepped and draped in the usual sterile fashion and placed under general anesthesia. An abdominal incision was made, and dissection past the large and small bowel occurred to expose the iliac artery. Clamps were placed to isolate the iliac area. A longitudinal incision was made in the artery, and the thrombus and plaque were removed. Then the area was sutured. The diameter of the artery was significantly improved after the procedure. Blood loss was minimal, and the wounds were closed and dressed. No complications were noted. The patient was sent to recovery.
35351 (In the Index, reference the main term Thromboendarterectomy, then iliac artery. Review the code range listed in the main section of the CPT manual.)
Preoperative diagnosis: Possible hemorrhage Postoperative diagnosis: Abdominal hemorrhage of previous operative area This patient underwent abdominal surgery 36 hours ago. An exploration of the abdominal incision site is planned. After being placed under general anesthesia, the original abdominal incision site was reopened. A small bleeding site was noted, and electrocautery was used. The wound was closed. The patient tolerated the procedure and was sent to the recovery area.
35840 (In the Index, reference the main term Exploration, then blood vessel, then abdomen.)
Neonatal Intensive Care Unit Note This 4-day-old neonate is suspected to be anemic. A blood sample was ordered by the attending, who completed the collection due to the size of the neonate. Procedure: Venipuncture for collection of venous blood, nonroutine, upper-extremity vein
36406 (In the Index, reference the main term Venipuncture, then infant, then percutaneous. Review the code range listed in the main section of the CPT manual. Because the case does not specify the vein used, select Other.)
Preoperative diagnosis: Malignant carcinoma of breast Postoperative diagnosis: Same This 39-year-old female presents today for insertion of catheter for central venous access for chemotherapy. The patient was placed in the supine position and sterile prep occurred. Lidocaine was injected into the right clavicular area. A needle was inserted into the right subclavain vein, and a J-wire was then passed into place. A tunnel was created from the area over the clavicle to the venotomy site, and a dilator was placed over the wire and then dilated. The catheter was then placed into the subclavian vein and secured. The area was flushed, and incisions were sutured. There was minimal blood loss, and the patient was stable and sent to the recovery area.
36558 (In the Index, reference the main term Insertion, then catheter, then venous. Review the range listed in the main section of the CPT manual.)
Preoperative diagnosis: Leukemia, in remission Postoperative diagnosis: Same Procedure: Tunneled venous access port removal Reason for procedure: This 8-year-old male completed chemotherapy. The patient was prepped and draped in the normal sterile fashion. His right side was anesthetized, and an incision was made above the port area. The port was a tunneled device with a subcutaneous port that was peripherally inserted. The incision was taken down to the device, which was freed. The retention sutures were identified and cut. After confirmation that the device was free, it was removed. Hemostasis was obtained, and the wound was closed in layers using 3-0 nylon. A sterile dressing was applied to the area. Patient vitals were taken, and the patient was noted to be stable. He was sent to the recovery room in stable condition.
36590 (In this case, the use of the venous access device is the starting point for finding this code. In the Index, reference the main term Removal, then the subterm infusion pump, then intravenous.)
The "AV" in the term "AV node" means _____ node.
atrioventricular
When the impulse reaches the junction of the atria and the ventricles, the _____ node directs the impulse to the ventricles, causing them to contract.
atrioventricular
The heart is divided into ____ chambers.
four
Blood enters the right atrium through the superior vena cava from the upper part of the body and through the _____ _____ _____from the lower part of the body.
inferior vena cava
The middle layer of the heart is the _____.
myocardium
Fluid is drained from the pericardial space by a long needle. The needle is exchanged for an indwelling catheter. This procedure is called tube _____.
pericardiostomy
The heart is enclosed in the _____, a double-walled sac.
pericardium
The _____ node is found where the superior vena cava and the right atrium meet.
sinoatrial