Surgery

Add-On Codes:    The CPT manual contains certain codes that are to be submitted in addition to other codes. They are indicated in the CPT book with a + to indicate add on code. a list of add on codes can be found in your CPT book appendix E.

Comprehensive code: A procedure or service of the highest complexity is known as a comprehensive code. It will have the highest relative value

Component Code: When other procedures or services must be performed to accomplish a procedure or service represented by the comprehensive code, a component code is assigned.  Designation of Sex: Some procedure codes have a sex designation within the code narrative.

Global Surgical package: Items that are included in the CPT Code for the defined surgical service are considered the global surgical package. It includes Preoperative days (most payers exclude the consultation or visit in which the decision for performing the surgery was made. There are 2 classifications Major and minor. Major procedures usually have a global period of 90 days. Minors have 10 days

Surgical procedure:  any component procedures included in the comprehensive procedure (such as the incision or closure of an open procedure) postoperative days.

Medical/Surgical Practice Standards: Because many physician activities are integral to a procedure or service, it is impractical and unnecessary to list, as part of the code narrative, every event common to all procedures of a similar nature. Many of these common or generic activities simply reflect the normal principles of medical/surgical care, and it is assumed they are part of acceptable medical/surgical practice. While they could be performed separately, they should not be considered as such when a code narrative is defined. Accordingly, all services integral to accomplishing a procedure or service will be considered bundled into that procedure and, therefore, will be considered a component or part of the comprehensive code. They should not be coded separately.

Examples of generic services that are integral to the standar medical/surgical services would include:  cleansing, shaving, and prepping skin, drapping and positioning the patient, insertion of intravenous access for medication; sedative administered by the physician performing the procedure, local, topical or regional anesthetic administered by the physician performing the procedure

Surgical approach, including identification of anatomical landmarks; incision; evaluation of the surgical field; simple debridement of traumatized tissues; lysis of simple adhesions; isolation of neurovascular, muscular, bony or other structures limiting access to surgical field; surgical cultures; wound irrigation; insertion and removal of drains, suction devises, dressing and pumps into the same site

surgical closure:  application, management or removal of postoperative dressings including analgesic devices (transcutaneous electrical nerve stimulation (TENS) units, institution of patient-controlled analgesia (PCA)

Preoperative, intraoperative and postoperative documentation including photographs, drawings, dictation and transcription Surgical supplies, unless excepted by existing payer policy

Methodology: The term "Methodology" refers to the technique used to accomplish a service or procedure. Correct code selection often depends upon the methodology of the procedure.  Most extensive procedures: The CPT manual contains codes with narratives that describe services or procedures that are basically the same or performed on the same site but are qualified by an increased level of complexity. When this occurs, the less extensive procedure is bundled into the more complex procedure.

Example

Simple and complex CPT codes are billed. The simple procedure is bundled into the complex procedure when performed on the same site

Limited and Complete CPT Codes are billed. The limited procedure is bundled into the complete procedure when performed on the same site

Simple and Complicated CPT codes are billed. the simple procedure is bundled into the complicated procedure when performed on the same site

Superficial and deep CPT codes are billed. the superficial procedure is bundled into the deep procedure when performed on the same site.

Intermediate and comprehensive cpt cods are billed. The intermediate procedure is bundled into the comprehensive procedure on the same site

Incomplete and complete CPT codes are billed. The incomplete procedure is bundled into the complete procedure when performed on the same site.

External and internal CPT codes are billed. The external is bundled into the internal when performed on the same site.

Mutually Exclusive procedures: Certain procedures cannot reasonably be performed in the same session. The codes for these procedures cannot be billed together because they are "mutually exclusive" of each other. This decision is based on either the CPT definition or the medical impossibility or improbability that the services can be performed during the same session. These mutually exclusive codes are known as code pairs. These codes are not necessarily indented codes.

Professional Component: The physician's work and associated overhead for performing a procedure or service is known as the professional component.

Sequential Procedures: An initial procedure or surgical approach may be followed by a second, usually more invasive, approach during the same patient encounter. The second procedure is usually performed because the first was unsuccessful in accomplishing the medically necessary service. Separate CPT codes may describe each approach. These procedures are considered "sequential approaches), usually the more invasive.

Significant Procedures: In 1987 Medicare required that all "significant procedures" be coded using the HCPCS/CPT coding system. A significant procedure includes incisions, excisions, repairs, manipulations, amputations, endoscopies, destructions, suture, and introductions.

Technical Component: The technical component is also known as the facility component.

Unbundling: The term "unbundling" refers to the billing of multiple procedure codes for a service or procedure that actually can be identified by one comprehensive code. There are 2 types of unbundling

Unintentional unbundling results from a genuine misunderstanding of coding and billing guidelines.  Intentional unbundling occurs when a person manipulates code assignment(s) to maximize payment. Intentional unbundling constitutes fraud, which is a criminal offense.