HIT CPT Surgery Respiratory

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CPT Respiratory System

(Buck)

  • 30000-32999 (Surgery)


Format

  • Anatomic Site Arrangement
    • Nose
    • Larynx
  • Further Subdivided by Procedure
    • Incision
    • Excision
    • Introduction
    • Removal of Foreign Body
    • Destruction
    • Endoscopy
    • Other procedures
  • Nose, Sternum Fracture
    • Musculoskeletal
  • Mouth, Throat Procedures
    • Digestive
  • Cosmetic Repair (code correctly)
    • So that the Same Service is NOT Reported More Than Once
      or Unbundled Codes Do NOT Result
  • Notes Important to read
    • Let you know specifically the location, approach, and extent so the correct code is used
  • Respiratory System
    • Nose
    • Nasal Cavity
    • Nasal Conchae
    • Nasopharynx
    • Oropharynx
    • Epiglottis
    • Laryngopharynx
    • Esophagus
    • Larynx
    • Trachea
    • Lung (Right/Left)
    • Primary Bronchus
    • Secondary Bronchi
    • Bronchioles
    • Diaphragm


Endoscopy

TOP

  • Thoracotomy
  • Thoracoscopy
  • Indirect
  • Direct


  • All Subheadings except Nose
    • Why do the codes in the Nose subheading NOT include endoscopy?
      Located in the Accessory Sinus subheading
    • Start in the Nose but go Deeper
  • Scope is Placed in an Orifice for Closer Examination
    • Less Invasive
  • Rule 1: Code Full Extent
    • For Proper Coding and Optimal Reimbursement
    • Example: Procedure begins at mouth and ends at bronchial tube
      • Bronchial tube = Full extent
  • Rule 2: Code Correct Approach
    • Example, for Removal:
      • Interior Lung Lesion via Endoscopy Inserted through Mouth
      • Exterior Lung Lesion via Endoscopy Inserted through Skin
      • Enters the Body through the Nasal Passages and Continues on to the Larynx
  • Larynx
    • Incorrect Approach = Incorrect Code = Incorrect Reimbursement
    • Interior Lung Lesion Removed through the Mouth via Endoscopy
      • Internal Procedure
  • Rule 3: Surgical Always Includes Diagnostic
    • Examples:
      • Diagnostic Bronchial Endoscopy Begins
      • Identifies Foreign Body
      • Removed (Surgical Endoscopy)
  • Laryngoscopy (laryngoscopic)
    • Indirect
      • Tongue Depressor
    • Direct
      • Endoscope Used
  • Surgical Endoscopy example
    • When a Lesion is Removed by Endoscopy
  • If both a diagnostic procedure and a surgical procedure were coded for an endoscopy
    • This is unbundling and considered to be fraud
  • Multiple Procedures
    • Frequent in Respiratory coding
      • Watch for Bundled services
      • Medicare (Reference the CCI edits)
    • Sequence Primary procedure first, No modifier
    • Sequence Secondary procedures next, with Modifier -51
    • Which Procedure is Primary?
      • The procedure that is the Most Resource Intensive
  • Bilateral Procedures
    • Format for Reporting chosen by Payer
      • Example: Nasal lavage
      • 31000 x 2
      • 31000 and 31000-50
      • 31000-50
      • 31000-RT and 31000-LT
      • Medicare requires One (1) Line Item with Modifier -50
      • Maxillary Sinus Lavage Performed Bilaterally?
        With Modifier -50, in units, or with -RT and -LT modifiers
  • Laryngoscopic Procedures
    • Uses terms Indirect and Direct
      • Indirect
        • Tongue Depressor with mirror used to view larynx
      • Direct
        • Endoscopy Passed into Larynx, physician directly views vocal cords


Nose (30000-30999)

  • Used Extensively by Otorhinolaryngologists (ear, nose, and throat specialists ENT)
  • But also used by a wide variety of physicians
  • eg. Control Nosebleeds, Removal of Foreign Objects
  • Rhino-


Nose-Incision (30000, 30020)

  • External Approach
  • Internal Approach
  • Common Office Procedures
    • Nosebleed
    • Nasal Abscess Incision
      • Nasal Mucosa
      • Septal Mucosa
    • Foreign Object Removal
    • Nasal Cyst Removal
    • Nasal Lesion Removal


  • Approach to Nose:
    • External Approach
      • Nasal Abscess, Nasal Biopsy of Skin
      • Integumentary System codes
    • Internal approach
      • Nasal Abscess, Nasal Biopsy, Internal
      • Respiratory System codes
  • Incision for a Nasal Abscess if the medical record does not describe the approach used to treat it?
    You would need to discuss this with the performing physician and find out the correct approach An addendum must be *:made to the documentation to include this information
  • Bundled into Incision codes
    • Drain or Gauze Insertion and Removal
  • Supplies Reported Separately
    • Supplies used by the Physician that are not generally used in the procedure
      • 99070 or a HCPCS code


Nose-Excision (30100-30160)

TOP

  • Biopsy
  • Nasal Polyp Excision
    • Tumor on a Pedicle that Bleeds Easily and May Become Malignant
    • Snare
  • Cyst Excision
  • Lesions
  • Turbinates (Nasal Conchae, Bones on the Inside of Nose)
    1. Inferior
    2. Middle
    3. Superior


  • Removal of Tissue from the Nose
  • Contains Intranasal Biopsy Codes
  • Polyp Excision, by Complexity
  • Simple
    • Involves Polyps that are Easy to Remove
  • Extensive
    • Involves Sessile Polyps (Thick base)
    • More Time Consuming and requires a Greater Skill Level (30115)
  • Includes any method of destruction, even laser
  • Modifier -50 (bilateral) for both sides
  • Reduction of Turbinates (30140)
  • Removal of Tissue from the Nose
  • External Biopsies of the Skin on the Nose
    • Integumentary system
  • Excision of Nasal Polyps in the Physician Office (30110)
  • More Extensive Procedure of Excision of Nasal Polyps Performed in a Hospital setting (30115)
  • One Method of Destruction for Nasal Polyp Excision
    • Laser
  • Nasal Turbinates
    • Excision of Turbinate are considered Unilateral
    • If performed Bilaterally, use modifier -50
    • Sometimes Removed to
      • Aid in Breathing
      • Cosmetic Reasons
      • Neoplastic Growth
    • Would removal of portions of the Turbinates be covered by third-party payers?
      Yes, if it is NOT done for cosmetic reasons
    • It is important to know which Turbinate the procedure is being performed on
      The Deeper the turbinate, the more labor intensive the procedure
    • Resection of the Turbinates (Inferior Turbinates) (30140)


Nose-Introduction (30200-30220)

  • Repair Inside Nose
  • Injections
  • Displacement Therapy
  • Nasal Button


  • Common Procedures
  • Example: Injections to Shrink Nasal Turbinate Tissue
  • Displacement Therapy
    • Saline Flush (performed through nose to remove mucus)
  • Insertion of Nasal Button (30220)
    • Insertion, Nasal Septal Prosthesis
  • Steroid Injection in the Turbinates (bones on the inside of the nose)
    To shrink the nasal tissue to improve breathing
  • Common use for Displacement Therapy in the sinuses
    To flush mucus or pus from the sinuses
  • How is a hole in the septum repaired?
    Insert a Nasal Button
  • What do the procedures that use introduction codes from the Nose subheading have in common?
    They’re all used to repair the inside of the nose
    Nose-Removal of a Foreign Body (30300-30320)
  • Divided by whether Removal at Office or Hospital (requires general anesthesia)
  • Office Procedure for the Removal of a Foreign Body from the Nose (30300)
  • Why are separate codes used for the removal of foreign objects with or without the use of invasive surgical procedures?
    The more invasive surgical procedure brings different reimbursement than an office procedure


Nose-Repair (30400-30630)

TOP

  • Plastic Procedures
  • Rhinoplasty
  • Septoplasty
  • Septal Dermatoplasty


  • Many Plastic Surgery Procedures, such as:
    • Rhinoplasty
      • Reshaping Nose, Internal and/or External
    • Stated as “Revision” or “Primary”
    • Rhinoplasty for Nasal Deformity Secondary to Congenital Cleft Lip/Palate
    • Septoplasty
      • Deviated Septum
      • Rearrangement of Nasal Septum
      • Included in a Rhinoplasty
  • Why is it especially important to document the Medical Necessity for a procedure such as rhinoplasty?
    Most third-party payers will not pay for procedures done for cosmetic reasons
  • Rhinoplasty codes Divided?
    They are based on
    • Extent of the Repair
      • Minor
      • Intermediate
      • Major
    • If the Nasal Septum was Treated, and
      • Septoplasty
    • If it was the Initial or Secondary procedure
  • Nasal Reconstruction
    • Codes for Obtaining Grafts for Nasal Reconstruction surgery
      • Musculoskeletal subsection
    • Codes for Other Procedures on the Nose
      • Integumentary subsection
      • External Approach
  • CAUTION
    • Do NOT use Septoplasty code if Resection of Inferior Turbinate


Nose-Destruction (30801, 30802)

  • Ablation
    • Intramural
    • Superficial


  • Ablation (Removing by Cutting)
  • Removal of Excess Nasal Mucosa or to Reduce Turbinate Inflammation
  • Based on Intramural or Superficial Extent of Destruction
    • Intramural
      • Deeper Mucosa
    • Superficial
      • Outer Layer of Mucosa
  • Difference between Cauterization and Ablation?
    Ablation is removal by cutting
    Cauterization is removal by burning
  • How are Destruction codes Divided
    The Depth of the Destruction
  • What is the Difference between Intramural and Superficial Ablation or Cauterization?
    Intramural is in the Deeper Mucosa of the Nose


Nose-Other Procedures (30901-30999)

TOP

  • Therapeutic Fracture
    • Nasal Turbinate


  • Nasal Hemorrhage (30901-30906)
    • Based on:
      • Site of Hemorrhage
        • Anterior
        • Posterior
      • Control
        • Simple
        • Complex
    • If Posterior hemorrhage
      • Was it the Initial or a Subsequent procedure
  • Correct coding of Nasal Hemorrhage
    • Anterior or Posterior Hemorrhage
    • Simple or Complex
    • Initial or Subsequent
  • Control of Nasal Hemorrhage
    • Packing
    • Ligation
      • Anterior Ethmoidal Artery
      • Posterior Ethmoidal Artery
      • Internal Maxillary Artery
    • Cauterization
  • Anterior packing (Anterior nasal packing)
    • Placed through Nose
    • Through the Nasal Cavity
    • When Surgery is Performed Solely to Improve the Patient Appearance
      • No Signs/Symptoms
      • Cosmetic
      • Non-Covered Under the Medicare program (DX V50.1)
  • Posterior Packing (Posterior Nasal Packing)
    • Placed at Very Back of Throat
    • Through the Nasal Cavity to the Back of the Nasal Cavity before Entering the Pharynx
    • Balloon may be Inserted to Further Control Bleeding
    • Hemorrhage may Require the Insertion of
      • Stents
      • Tampons
      • Nasal Catheters
      • Posterior Packing
    • Simple Packing with Gauze or Anterior Packing Suggests a Simple Procedure
  • Nasopharyngoscopy with Endoscope (92511)
    • Bundled into any Respiratory Procedure Performed at the Same Session
  • How are codes in the Other Procedures category of the Nose subheading divided?
    • Controlling Nasal Hemorrhages
    • Ligation of Arteries
    • Fracture of Turbinates


Accessory Sinuses (31000-31299)

TOP

Accessory Sinuses-Incision

  • Sinusotomy
  • Paranasal Sinuses
    • Frontal Sinus
    • Ethmoid Sinus
    • Sphenoid Sinus
    • Maxillary Sinus (Antrum)
  • Antrum (Maxillary sinus)


  • Lavage (washing) of Sinuses
    • Remove Infection
  • Cannula (hollow tube) Placed into Sinus, Saline Solution Flushed through
  • Modifier -50 (bilateral) for Both Sides
  • Sinusectomy
    • All Sinus Contents including Mucous Membranes are Removed
  • Sinusotomy
    • Enlargement of the Passage
      or Creation of a New Passage from the Nasal Cavity into the Sinus
  • Antrostomy
    • Making an Opening into the Sinus
  • Antrotomy
    • Cutting into the Sinus
    • Cutting through the Antrum Wall to make an Opening in the Sinus


Larynx

TOP

Larynx-Excision (31300-31420)

  • Laryngotmy
  • Radical Neck Dissection
  • Laryngo-


  • Laryngotomy
    • Open Surgical Procedure to Expose Larynx
    • For Removal Procedure (e.g., Tumor)
  • Sometimes Confused with Trachea/Bronchi codes for Tracheostomy
    • Used to Establish Airflow
  • Difference between a Laryngotomy and a Tracheostomy?
    Laryngotomy is an Incision made over the Larynx for the Removal of a Tumor, Laryngocele, or Vocal cord
    Tracheostomies are Usually Performed to Establish Airflow
  • Laryngoscopy
    • Visual examination of the Larynx
    • Flexible Lighted Tube passed through Mouth or Nose into Larynx


Larynx-Introduction (31500, 31502)

  • Intubation


  • Endotracheal Intubation (31500)
    • Establishment of Airway
    • Involves a Tube Placed through the Nose or Mouth,
      through the Pharynx and Larynx, and into the Trachea
      to Establish an Airway
  • Numerous CCI edits
  • Trach Tube Change


Larynx-Repair (31580-31590)

  • Laryngeal Web


  • Several Plastic Procedures and Fracture Repairs
  • Laryngoplasty Procedures Based on Purpose
    • Plastic Repair of Larynx
  • Laryngeal Web
    • When the Vocal Cords are Connected by Webbed Tissue


Trachea/Bronchi

TOP

Trachea/Bronchi -Incision (31600-31614)

  • Tracheostomy
    • Emergency Transtracheal Tracheostomy
    • Emergency Cricothyroid Tracheostomy
  • Trachea, Carinal


  • Tracheostomy (most codes)
    • To Aid in Breathing
    • Planned (ventilation support)
    • Emergency
  • Divided by Type (Approach):
    • Transtracheal Approach (31603)
      • Horizontal Incision Across the Trachea
    • Cricothyroid Approach (31605)
      • Vertical Incision Across the Trachea
  • What is the Purpose of this procedure? (Exposure of the trachea for emergent tracheostomy)
  • What is the Incision code for a Transtracheal approach? (31603)
  • Fistula, Tracheoesophageal
    • Speech Prosthesis (Voice button)


  • Trachea/Bronchi -Endoscopy (31615-31656)
    • Bronchoscope Inserted into Nose or Mouth
    • Rigid Endoscopy performed under General Anesthesia
    • Flexible Endoscopy performed under Local or Conscious Sedation
    • Know if the scope was Rigid or Flexible
    • If the scope is Surgical, know what Procedure was performed
    • Diagnostic Scopes are Bundled into Surgical Scopes if Performed in the Same Area


Trachea/Bronchi -Introduction (31715-31730)

  • Injection
  • Catheterization
  • Aspiration
  • Transtracheal Introduction
  • Some include Inhaled Gas as Contrast Material
  • Transglottic Catheterization
    • Puncture of the Glottis with a Needle to Insert a Catheter for Passage
  • Why are Instillation and Injection used?
    To Insert Contrast
  • What is the Purpose of Contrast Materials?
    To Improve Viewing During a Procedure


Trachea/Bronchi -Excision/Repair (31750-31830)

  • Tracheoplasty
  • Bronchoplasty


  • Plastic Repairs of Trachea and Bronchi
  • Excision of Stenosis/Tumors
  • Suturing Tracheal Wounds
  • Scar Revision
  • Tracheoplasty
    • Surgical Repair of a Damaged Trachea
    • Approach
      • Cervical
      • Thoracic
    • Extent
    • Type of Repair
  • Bronchoplasty
    • Repair of the Bronchus


Lungs and Pleura

TOP

Lungs and Pleura-Incision (32035-32225)

  • Thoracotomy
  • Pleura (covering of the Lungs and Thoracic Cavity)


  • Biopsy Codes in Incision and Excision categories
    • Excisional Biopsy with Percutaneous Needle
    • Incisional Biopsy with Chest Open
  • Includes Pneumocentesis and Lung Removal
    • Segmentectomy: 1 segment
    • Lobectomy: 1 lobe
    • Bilobectomy: 2 lobes
    • Total Pneumonectomy: 1 lung
  • Thoracotomy
    • Surgical Opening of Chest to Expose to View
    • Surgical Incision into the Thoracic Cavity
    • Biopsy
    • Cyst
    • Foreign Body Removal
    • Cardiac Massage
    • Divided
      • Procedure that was Performed and if it was Limited or a Major Procedure
  • It is important to know the exact location of the procedure and portion of the division of the lung
    • Remember if the physician performed a segmentectomy and the code 32440 was sent to the third-party payer, this would be deemed fraud as the description for code 32440 is for the removal of a full lung, or a total pneumonectomy, and only a segment of that lung had actually been removed


Lungs and Pleura-Excision, Resection (32310-32405)

  • Pleurectomy
  • Percutaneous Needle Lung Biopsy
  • Mediastinum Biopsy


  • Includes Pneumocentesis and Lung Removal
    • Segmentectomy: 1 segment
    • Lobectomy: 1 lobe
    • Bilobectomy: 2 lobes
    • Total Pneumonectomy: 1 lung
  • Biopsy codes in Excision and Incision categories
    • Excisional Biopsy
      • Performed with Percutaneous Needle
    • Incisional biopsy
      • Performed with Chest Open
      • More Labor Intensive
  • Pleurectomy
    • Removal of the Pleura (Sac Surrounding the Lung)


Lungs and Pleura-Removal (32421, 32422)

  • Pneumonocentesis
    • Pneumothorax (Air in pleural cavity)
    • Thoracic Cavity (Intrathoracic) (Air Pressure Increase)
  • Lobectomy
  • Thoracentesis
    • Chest Tube
    • Pleural Space (Pleural effusion)


  • Pneumocentesis
    • Withdrawing Fluid from the Lung with an Aspirating Needle
  • Thoracentesis
    • Surgical Puncture of the Thoracic Cavity, usually Needle, Remove fluids
    • Needle or Catheter Inserted into Pleural Space
      for Aspiration (withdrawal) of Fluid or Air for Analysis
    • To Drain Pleural Effusions, or to Re-expand a Collapsed Lung
    • To Remove Excess Fluid from the Pleural Space
      that Caused Decreased Expansion of the Lungs
    • Needle is Inserted between the Ribs and Fluid is Withdrawn
    • Allow for Enlargement of Heart
    • Chest Tube may be Inserted to Drain Fluid and is Reported in Addition to Aspiration
      • Both Aspiration and Tube Insertion coded
  • Two (2) Separate Parts of One (1) Procedure
    • Conditions Might Require Treatment with a Chest Tube, and Causes
      • Pneumothorax (air, gas)
      • Hemothorax (blood)
      • Pleural Effusion (fluid, caused by trauma)
      • Secondary to Another Disease Process
        (sometimes this just happens spontaneously)


  • Lungs and Pleura-Introduction and Removal (32550, 32551)
    • Insertion of Tunneled Indwelling Pleural Catheter (32550)
    • Tube Thoracostomy (32551)
      • Surgical Incision into Chest Wall and Insertion of Tube
      • Includes Moderate Sedation
      • Trocar
    • Lungs and Pleura-Removal (32552)
  • Lungs and Pleura-Destruction (32560-32562)
    • Chemical Pleurodesis or Effusion
      • For Recurrent Persistent Pneumothorax or Multiloculated Effusion
  • Lungs and Pleura-Thoracoscopy (32601-32674)
    • Video-Assisted Thoracic Surgery (VATS)
    • Diagnostic and Surgical Lung Procedures
    • Surgical Thoracoscopy always includes Diagnostic Thoracoscopy


Jack Rogers developed chest pain and difficulty breathing. He has also been coughing up thick, blood-tinged sputum. A chest radiograph shows an ill-defined mass. A diagnostic bronchoscopy of one lung is performed and a specimen of the endobronchial mass is taken. The pathology report comes back positive for primary cancer of upper lobe. One week later, a lobectomy is performed.
31625, 32480-58


The 65-year-old patient underwent bronchoscopy and biopsy for a left lower lobe lung mass. The biopsy was sent to pathology immediately and revealed adenocarcinoma of the left lower lobe. The patient then underwent a left lower lobectomy and thoracic lymphadenopathy. Select the CPT code for the first-listed procedure in this case.
32480


Lungs and Pleura-Surgical Collapse Therapy: Thoracoplasty

TOP

  • Pus Chronically Collects in Chest Cavity
    • Chronic Thoracic Empyema
  • Pneumonolysis
    • Separate inside of Chest Cavity from Lung
  • Pneumothorax Injection
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