Procedures

Question 1

Incision

Answer 1

First code in most subheadings. Deals with procedures that require drainage and/or aspiration. May affect the muscle or bone and is coded based on the depth of the incision.

Question 2

Wound Exploration

Answer 2

Used for traumatic wounds such as gunshots and knives. Includes enlarging the wound for exploration, debridement, removal of foreign matter, and repair. The code is found under the General subheading and is coded via anatomical site.

Question 3

Excision

Answer 3

Doctors use this code for muscle and bone biopsies. Codes are based on type, depth, and method of the biopsies.

Question 4

Introduction / Removal

Answer 4

Doctors use this for injections, applications of devices, insertion of wires, pins, or rods, some aspirations, and adjusting / removing foreign matter from the muscles or bones. Codes are based on procedure type.

Question 5

Replantation

Answer 5

Doctors use this for surgically re-attaching a body part completely cut from the patients body. The codes are based on location.

Question 6

Grafts or Implants

Answer 6

Covers the grafting of bone, cartilage, fascia lata (or thick connective tissue), tendon, fat, or dermis. Unless the code includes obtaining graft from the donor site, you’ll code the harvest of the graft separately. The codes for grafts are based both on location and type of tissue.

Question 7

Other Procedures

Answer 7

Under the General subheading, used for monitoring muscles, microvascular grafts/flaps, and electrical and ultrasound stimulation. The codes are based on location.

Question 8

Arthrodesis

Answer 8

Sometimes called fixation. The fusion of two bones together. Can be performed alone or with fracture repair or laminectomy. Codes are based on the approach to the surgical site (whether it’s anterior, anterolateral, posterior, posterolateral, or lateral).

Question 9

Endoscopy / Arthroscopy

Answer 9

Using a lighted scope, camera, and instruments to perform a procedure through small incisions seen through a video monitor. Codes are based on location, type, and the extent of the procedure. Cannot code for both a diagnostic and a surgical arthroscopy at the same time, as the diagnostic arthroscopy is included in the procedure.