CH. 7 Review Flashcards
Removal of all or part of a lesion for pathologic examination.
BIOPSY
Removal by cutting all or part.
EXCISION
The means by which the provider gains access to the body to complete a service or procedure.
APPROACH
Procedures that, when performed with another procedure at the same anatomical site at the same time, are bundled into the other procedure and not coded separately.
SEPARATE PROCEDURES
Procedures that are completed without incision and are considered noninvasive in nature.
CLOSED PROCEDURES
Creation of an opening by surgically cutting into the skin or other tissue.
INCISION
Suffix meaning “to reshape or replace by surgical means”
-PLASTY
A prescribed period of time surrounding the surgical procedure; also known as the postoperative or post-op period.
GLOBAL SURGICAL PACKAGE
The Surgery section of CPT is divided into _________ subsections based on _________.
SIX
ORGAN SYSTEMS OR
BODY AREAS
When a provider documents a service or procedure for which there is no specific HCPCS Level I code, the following (if a code exists) should be used first to report the service or procedure:
A CATEGORY III CODE
Which of the following modifiers would be appropriate to use if each surgeon performed integral parts of the same procedure?
62
CPT coding for breast procedures is categorized in which section of the CPT manual?
INTEGUMENTARY
The process of using a scope inserted through a natural opening or stoma to examine the inside of an organ or system (e.g., respiratory or gastrointestinal) is referred to as:
ENDOSCOPY
CASE STUDY - Process 1: Procedural Coding (CPT)
Preoperative diagnosis: Possible torn medial meniscus
Postoperative diagnosis: Bucket-handle tear of medial meniscus
Operation: Surgical arthroscopy
The patient was brought to the operating room and placed on the operating table in the supine position. The left lower extremity was prepped in usual sterile fashion. The knee was inflated with normal saline; a 2-centimeter incision was made anteriolaterally. The arthroscope was inserted.
One additional 1-centimeter incision was made anteriomedially. The medial compartment was first visualized; very minimal erosion of the medial femoral condyle and medial plateau was found. A bucket-handle medial meniscus tear was noted. Basket forceps were used, and this area was repaired. Meniscal shaving was completed as well. The remainder of the medial compartment was grossly normal.
The scope was then moved to the intracondylar notch region. The anterior cruciate ligament was found to be intact.
The knee was then flexed to approximately 60 degrees, and the lateral compartment was visualized. The lateral femoral condyle, lateral meniscus, and lateral tibial plateau were patent. As were the popliteus idis and tendon. No loose bodies noted.
The scope was then moved into the suprapatellar pouch with the knee extended. The patellofemoral joint was inspected, with no erosion of the patellar surface noted.
At this point, the instruments were withdrawn and the wounds closed with 4-0 nylon sutures and compression dressing. Pneumatic pressure cuff was released, with good return of capillary refill to the toes. The patient was moved to the recovery room in good condition.
Based on the documentation, what is (are) the correct code(s) for this case?
29881
QUESTION 2: Based on the documentation, what is the correct ICD-10-CM code for this case?
S83.212A
CASE STUDY - Process 3: Adding Modifiers
Preoperative diagnosis: Possible torn medial meniscus
Postoperative diagnosis: Bucket-handle tear of medial meniscus
Operation: Diagnostic arthroscopy
The patient was brought to the operating room and placed on the operating table in the supine position. The left lower extremity was prepped in usual sterile fashion. The knee was inflated with normal saline; a 2-centimeter incision was made anteriolaterally. The arthroscope was inserted.
One additional 1-centimeter incision was made anteriomedially. The medial compartment was first visualized; very minimal erosion of the medial femoral condyle and medial plateau was found. A bucket-handle medial meniscus tear was noted. Basket forceps were used, and this area was repaired. Meniscal shaving was completed as well. The remainder of the medial compartment was grossly normal.
The scope was then moved to the intracondylar notch region. The anterior cruciate ligament was found to be intact.
The knee was then flexed to approximately 60 degrees, and the lateral compartment was visualized. The lateral femoral condyle, lateral meniscus, and lateral tibial plateau were patent. As were the popliteus idis and tendon. No loose bodies noted.
The scope was then moved into the suprapatellar pouch with the knee extended. The patellofemoral joint was inspected, with no erosion of the patellar surface noted.
At this point, the instruments were withdrawn and the wounds closed with 4-0 nylon sutures and compression dressing. Pneumatic pressure cuff was released, with good return of capillary refill to the toes. The patient was moved to the recovery room in good condition.
Which modifier should be appended to the CPT code for this case?
LT
