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CPT Chapter 3-1
Principles of CPT Coding workbook
| Question | Answer |
|---|---|
| What is the nature of the services provided by the physician to any patient considered? | Variable |
| When defining specific services "included" in a given surgical code, what is the 1st service included in addition to the operation? | Local Filtration, metacarpal/metatarsal/digital block or topical anesthesia |
| When defining specific services "included" in a given surgical code, what is the 2nd service included in addition to the operation? | Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical) |
| When defining specific services "included" in a given surgical code, what is the 3rd service included in addition to the operation? | Immediate postoperative care, including dictation operative notes, talking with the family and other physicians. |
| When defining specific services "included" in a given surgical code, what is the 4th service included in addition to the operation? | Writing orders |
| When defining specific services "included" in a given surgical code, what is the 5th service included in addition to the operation? | Evaluating the patient in the post anesthesia recovery area |
| When defining specific services "included" in a given surgical code, what is the 6th service included in addition to the operation? | Postoperative follow-up care |
| The concept of a 'package' of surgical procedures is also called what? | A Global package |
| What can the term global also refer to? | Total Time |
| The procedures and services that are always performed in addition to the primary procedure or service use what kind of code? | Add-on Codes |
| Give 2 examples of specific language used to identify an Add-on code. | 1. Each Additional 2. List separately in addition to... |
| Explain the use of Modifier 51. | Is used for multiple procedures designate by the + sign. This code is not appended to an add-on code because they are exempt from the multiple procedure concept. |
| Explain the use of Modifier 59. | Is used for 'distinct procedural service'. This modifier indicates that the procedure is not considered a component of another procedure, but is a distinct, independent procedure. |
| What anatomy is considered in the integumentary system? | 1. Skin, subcutaneous, and accessory structures. 2. Nails 3. Breast |
| What is debridement? | Is the removal of loose, devitalized, necrotic, and/pr contaminated tissue, foreign bodies, and other debris on the wound, using mechanical or sharp techniques. |
| What is an Excision of Malignant or Benign Lesions? | As indicated in the guidelines preceding these code series, an excision is defined as full thickness (thru the dermis) removal of a lesion including margins. |
| What is an Excision of a Benign Lesion guideline? | Simple repair is included as part of the excision and may not be reported separately. Any Repair by intermediate or complex closure should be reported separately with the appropriate codes. |
| Explain the use of Modifier 58. | Is a staged or related procedure or service by the same physician during the postoperative period. |
| What is a simple repair? | a typical one-layer closure. |
| What is an intermediate repair? | requires layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia, in addition to the skin (epidermal or dermal) closure. |
| What is a complex repair? | include repair of wounds requiring more than layered closure, such as scar revision, debridement (eg, traumatic laceration or avulsions), extensive undermining, stents, or retention sutures. |
| What are a defect, primary, and secondary Tissue Transfer or Rearrangement? | The term defect includes the primary and secondary defects. The primary defect, resulting from the excision, and the secondary defect, resulting from flap design to perform the reconstruction are measured together to determine the code. |
| Autograft | Tissue transplanted from one part of the body to another in the same patient. |
| Allograft (hemograft) | Tissue transplanted from one individual to another of the same species. |
| Xenograft (heterograft) | Tissue transplanted from one species to an unlike species (eg, nonhuman, baboon to human) |
| Skin Replacement | A tissue or graft that permanently replaces lost skin with health skin. |
| Skin substitute | A biomaterial, engineered tissue, or combo of material and cells or tissues that can be substituted for skin autograft or allograft in a clinical procedure. |
| Temp Wound Closure | Not the final resurfacing material but provides closure of the wound surface until the skin surface can be permanently replace. |
| What does the Mohs Micrographic Surgery entail to coding? | Mohs surgery is the only CPT procedure for which the surgeon and the pathologist are the same person. The Mohs surgeon removes the tumor tissue and maps and divides the tumor into pieces. |
| What is a Tissue Block? | an individual tissue piece embedded in a mounting medium for sectioning. |
| What are the 2 types of Breast Biopsies? | percutaneous and open |
| Percutaneous Breast Biopsy | uses a needle for aspiration or removal of tissue. |
| Open Breast Biopsy | Surgical removal of part of a lesion into the skin and exposure of the lesion. |
| Musculoskeletal System Subsection entails procedures involving... | tendons, muscles, fractures and dislocations, spine surgery, bunions, and casting and strapping. |
| For Fracture and Dislocations what is a closed treatment? | This specifically means that the fracture of dislocation site is not surgically opened. |
| For Fracture and Dislocations what is a open treatment? | This means that the fracture is surgically opened and visualized to allow internal fixation, or as noted in the CPT book, an intramedullary fixation of a fracture. |
| For Fracture and Dislocations what is percutaneous skeletal fixation? | A fixation (with pins) is placed across the fracture site, under X-ray imaging. |
| For Fracture and Dislocations what is manipulation? | the attempted reduction or restoration of a fracture or joint dislocation to it normal alignment by applying force. |
| Location of Cervical vertebrae | C1-C7 (neck) |
| Location of Thoracic vertebrae | T1-T12 (upper back) |
| Location of Lumbar vertebrae | L1-L5 (lower back) |
| Location of Sacral vertebrae | S1-S5 (sacrum) |
| Location of Coccygeal vertebrae | coccyx (tailbone) |
| What is Kyphoplasty? | a Percutaneous vertebral augmentation is a new minimally invasive surgical technique for treating fractures of the spine that occur because of osteoporosis, usually in postmenopausal women. |
| What is the technical term used for Bunion? What is the code set? | Hallux Valgas (28290-28299) |
| What is the Respiratory System divided into? | 1. nose 2. accessory sinuses 3. larynx 4. trachea and bronchi 5. lungs and pleura |
| T/F Surgical endoscopy does not always include diagnostic endoscopy when performed by the same physician. | False |
| Indirect Laryngoscopy | Involves the use of a mirror or rigid telescope to view the larynx. |
| Direct Laryngoscopy | Performed with a lighted scope placed into the larynx to allow direct visualization of the larynx. |
| T/F Bronchoscopy is considered an inherently bilateral procedure. | True |
| What is a Thoracocentesis? What codes do you report? | Accumulated fluid or air is removed from the pleural space by puncturing space between the ribs. 32000-32002 |
| What are some keywords to use when looking for Nose procedure codes? | turbinate, mucosa, |
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