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CPT Surgery V General Guidelines

This chapter provides CPT guidelines for male genital system, female genital system, intersex surgery, maternity care and delivery. Includes code assignment and procedures for various conditions.

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CPT Surgery V General Guidelines

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  1. Chapter 15 CPT Surgery V

  2. General Guidelines • CPT guidelines that apply to subsections are located at beginning of Surgery section • Unique code guidelines for each system are located in notes below headings or codes • Notes located beneath headings and/or subheadings apply to all codes in heading or subheading, respectively

  3. Male Genital System • Prostate • Seminal vesicles • Penis • Testicles (testes) • Epididymis • Tunica vaginalis • Vas deferens • Scrotum • Spermatic cord (continued)

  4. Male Genital System Delmar/Cengage Learning

  5. Male Testicle Delmar/Cengage Learning

  6. Vasectomy Procedure Delmar/Cengage Learning

  7. Code Assignment • Determine: • Approach • e.g., incision, destruction, excision, introduction • Reason for surgery

  8. Varicocele • Review operative report to locate type of approach • Laparoscopic • Abdominal (continued)

  9. Varicocele Varicocele affecting left testicle Delmar/Cengage Learning

  10. Benign Prostatic Hypertrophy (BPH) Treatment • TURP • Subtotal open prostatectomy • Subtotal prepubic prostatectomy • Subtotal retropubic prostatectomy

  11. TURP Performed to treat benign prostatic hypertrophy Delmar/Cengage Learning

  12. Prostate Biopsy • Review operative report to locate type of biopsy performed • Needle • Punch • Incisional

  13. Intersex Surgery • Performed as series of staged procedures to transform normal adult genitalia of one sex to that of the other sex • Two codes • Male to female • Female to male

  14. Female Genital System • Vulva • Perineum • Introitus • Vagina • Cervix uteri • Uterus • Oviduct (fallopian tube) • Ovary (continued)

  15. Female Genital System Delmar/Cengage Learning

  16. Vulvectomy Procedures • Simple • Removal of skin and superficial subcutaneous tissue • Radical • Removal of skin and deep subcutaneous tissue (continued)

  17. Vulvectomy Procedures • Partial • Removal of less than 80 percent of vulvar area • Complete • Removal of greater than 80 percent of vulvar area

  18. Hysteroscopy • Direct visualization of cervical canal and uterine cavity to examine endometrium to carry out surgical procedures • Dilation and curettage (D&C) • Removal of foreign body • Cervical polyp • Biopsy • Polypectomy

  19. Laparoscopy (Hysteroscopy) Delmar/Cengage Learning

  20. Dilation Expansion of cervical opening Delmar/Cengage Learning

  21. Curettage Removal of material from endometrial lining of uterus Delmar/Cengage Learning

  22. Vaginal Hysterectomy (A) For vaginal hysterectomy, just uterus and cervix are removed; (B) For vaginal hysterectomy with bilateral salpingo-oophorectomy, cervix, uterus, fallopian tubes, and ovaries are removed Delmar/Cengage Learning

  23. Tubal Ligation Delmar/Cengage Learning

  24. Conization • Removal of cone-shaped piece of tissue • Loop electrodissection conization • Thin wire loop used to perform deep dissection of cervix • Loop electrosurgical excision procedure (LEEP) electrodissection conization • Superficial dissection of cervix

  25. Maternity Care and Delivery (Obstetrics) • Antepartum • Delivery • Postpartum

  26. Pregnancy • Divided into trimesters • First • Fetal organ development • Second • Well visits • Third • Baby maturity • Delivery at 38 to 40 weeks

  27. Coding Pregnancy • Three stages of pregnancy care include services provided as part of total obstetrical care • Antepartum • Delivery of baby • Postpartum

  28. Total Obstetrical Care • Does not include the following: • Diagnostic procedures • e.g., ultrasound, amniocentesis, special screening tests • Physician office visits for conditions unrelated to pregnancy • Codes for these services reported separately from E/M and Medicine sections of CPT

  29. Maternity Care and Delivery • Additional procedures performed on same day as maternity care and delivery service reported separately, except: • Fetal monitoring during labor • Episiotomy • Delivery of placenta

  30. Antepartum Care • Includes the following • Initial and subsequent history • Physical examinations • Documentation of weight, blood pressure, and fetal heart tones • Routine chemical urinalysis (continued)

  31. Antepartum Care • Includes the following • Monthly visits up to 28 weeks gestation • Biweekly visits up to 36 weeks gestation • Weekly visits until delivery • Included with total obstetrical care • Not reported separately

  32. Delivery Services • Begins with admission to hospital and ends with delivery of placenta (continued)

  33. Delivery Services • Includes the following • Admission to hospital • Admission history and physical exam • Management of uncomplicated labor • Vaginal delivery • Induction of labor • Artificial rupture of membranes (AROM)

  34. Stages of Labor Delmar/Cengage Learning

  35. Delivery Services • Report the following services separately with code from E/M or Surgery section of CPT • Management of surgical problems • Admission for observation prior to delivery • Medical complications that complicate management of labor and delivery • Tubal ligation performed after delivery

  36. Endocrine System • Includes 13 glands • Two adrenal • Two gonads (female ovaries and male testes) • One pancreas (islets of Langerhans) • Four parathyroid • One pituitary (two lobes) • One thymus • Two thyroid

  37. Endocrine Glands Delmar/Cengage Learning

  38. Nervous System • Central nervous system • Peripheral nervous system • Codes for procedures performed on pituitary and pineal glands located in nervous system subsection

  39. Divisions of the Nervous System

  40. Nervous System Structures Delmar/Cengage Learning

  41. Nervous System • Central nervous system • Brain and spinal cord • Peripheral nervous system • 12 pairs of cranial nerves extending from brain • 31 pairs of spinal nerves extending from spinal cord (continued)

  42. Nervous System • Arranged anatomically • Skull, meninges, and brain • Spine and spinal cord • Extracranial nerves, peripheral nerves, and autonomic nervous system

  43. Skull, Meninges, and Brain • Injection, drainage, or aspiration • Twist drill, burr hole(s), or trephine • Craniectomy or craniotomy (continued)

  44. Skull, Meninges, and Brain • Surgery of skull base • Approach procedures • Definitive procedures • Repair and/or reconstruction of surgical defects of skull base • Endovascular therapy (continued)

  45. Skull, Meninges, and Brain • Surgery of aneurysm, arteriovenous malformation, or vascular disease • Stereotaxis • Neuroendoscopy • Repair • Cerebrospinal fluid (CSF) shunt (continued)

  46. Skull, Meninges, and Brain Delmar/Cengage Learning

  47. Skull Base Surgery • Review operative report to identify the following • Size of lesion or tumor • Anatomy of patient • Whether initial procedure to treat condition or reoperation • Codes arranged anatomically • Anterior, middle, and posterior cranial fossae

  48. Cerebrospinal Shunt Allows drainage of CSF from brain into peritoneal cavity Delmar/Cengage Learning

  49. Spine and Spinal Cord • Anatomic site • Epidural • Facet joint nerves • Diagnostic or therapeutic procedure (continued)

  50. Spine and Spinal Cord • Type of substance injected • Contrast media • Neurolytic substance • Whether injections are continuous

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