1 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT...

1Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © 2008. Association. CPT only © 2008. Current Procedural Terminology, 2009,Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. American Medical Association. All Rights Reserved.

CHAPTER 9CHAPTER 9

GENERAL SURGERY IGENERAL SURGERY I


Male Genital System Male Genital System Anatomic SubsectionAnatomic Subsection• PenisPenis

• TestisTestis

• EpididymisEpididymis

• Tunica VaginalisTunica Vaginalis

• ScrotumScrotum

• Vas DeferensVas Deferens

• Spermatic CordSpermatic Cord

• Seminal VesiclesSeminal Vesicles

• ProstateProstate Figure: 9.1Figure: 9.1


Subsection FormatSubsection Format

• Format:Format:

– IncisionIncision

– Destruction (method used & if simple or extensive)Destruction (method used & if simple or extensive)

– ExcisionExcision

– IntroductionIntroduction

– RepairRepair

– ManipulationManipulation

– SutureSuture


Biopsy CodesBiopsy Codes

• Located in subheading to which referLocated in subheading to which refer

– Example Biopsy codes in subheadings: Example Biopsy codes in subheadings:

• Epididymis (Excision) Epididymis (Excision)

• Testis (Excision)Testis (Excision)


PenisPenis

• Incision category differs from Incision category differs from Integumentary System codes Integumentary System codes

• Penis Incision codes for deeper Penis Incision codes for deeper structuresstructures

– Example: erectile tissueExample: erectile tissue


Destruction (54050-54065)Destruction (54050-54065)

• Codes divided onCodes divided on

– ExtentExtent: Simple or extensive: Simple or extensive

– MethodMethod ofof destruction: e.g., chemical, destruction: e.g., chemical, cryosurgerycryosurgery

• Extensive destruction can be by Extensive destruction can be by any methodany method


Excision (54100-54164)Excision (54100-54164)

• Commonly used codes biopsy and Commonly used codes biopsy and circumcisioncircumcision

– Appropriate circumcisionAppropriate circumcision code is based on code is based on method and age of patientmethod and age of patient

• Biopsy, penisBiopsy, penis

– Simple biopsy 54100 (separate procedure)Simple biopsy 54100 (separate procedure)

– Complex biopsy 54105Complex biopsy 54105


Peyronie DiseasePeyronie Disease

• Curvature of penisCurvature of penis

• Result of plaque formationResult of plaque formation

• Surgical removal of plaque Surgical removal of plaque (54110-54112)(54110-54112)

• Grafting may be necessary to correct defectGrafting may be necessary to correct defect

– Report with 54111, 54112Report with 54111, 54112

– If harvesting of graft is through a separate If harvesting of graft is through a separate incision, see 20920 & 20926, as appropriateincision, see 20920 & 20926, as appropriate


CircumcisionCircumcision

• Divided based on if device was or was Divided based on if device was or was not utilizednot utilized

• Clamp: 54150Clamp: 54150

• No clamp: 54160 (neonate), 54161 No clamp: 54160 (neonate), 54161 (non-neonate, less than 28 days)(non-neonate, less than 28 days)


Introduction (54200-54250)Introduction (54200-54250)

• Many procedures for corpora cavernosum Many procedures for corpora cavernosum (spongy body of penis)(spongy body of penis)– Injection procedures for Peyronie disease Injection procedures for Peyronie disease

(toughening of the corpora cavernosum) (toughening of the corpora cavernosum) – Treatments for erectile dysfunctionTreatments for erectile dysfunction

• 54240 and 54250 have a global, professional 54240 and 54250 have a global, professional (26), and technical component (tc)(26), and technical component (tc)

• Use of the appropriate modifier is important Use of the appropriate modifier is important when assigningwhen assigning

• If hospital setting, physician uses modifier If hospital setting, physician uses modifier -26 on procedure code-26 on procedure code


Repair (54300-54440)Repair (54300-54440)

• Many plastic repairsMany plastic repairs

• Some repairs are staged (more than Some repairs are staged (more than one stage)—Modifier -58one stage)—Modifier -58

– Stage indicated in code descriptionStage indicated in code description

• Repair of wounds involving skin and Repair of wounds involving skin and subcutaneous tissue of external male subcutaneous tissue of external male genitalia:genitalia:

– See Integumentary Codes 12001-13300See Integumentary Codes 12001-13300


Chordee and HypospadiasChordee and Hypospadias

• ChordeeChordee: Ventral curve (downward) of : Ventral curve (downward) of penispenis

• HypospadiasHypospadias: Congenital abnormality: Congenital abnormality– Urethral meatus (opening) is abnormally Urethral meatus (opening) is abnormally

placedplaced

• Repair codes report repair services for Repair codes report repair services for chordee and hypospadiaschordee and hypospadias


TestisTestis

• Excision (54500-54535)Excision (54500-54535)– Biopsy, excision, orchiectomyBiopsy, excision, orchiectomy

• BiopsyBiopsy: Incisional or percutaneous: Incisional or percutaneous

• OrchiectomyOrchiectomy codes reported by: codes reported by:– Simple or radicalSimple or radical

– Unilateral or bilateralUnilateral or bilateral

– With or without testicular prosthesis insertionWith or without testicular prosthesis insertion

– Approach usedApproach used(Cont’d…)(Cont’d…)


TestisTestis

(…Cont’d)(…Cont’d)

• Exploration (54550, 54560)Exploration (54550, 54560)• Undescended testis (crytorchidism)Undescended testis (crytorchidism)

– CongenitalCongenital– Testis or testes did not descend into scrotal sacTestis or testes did not descend into scrotal sac– Unilateral or bilateralUnilateral or bilateral– Often associated with herniaOften associated with hernia

• Repair (54600-54680)Repair (54600-54680)– Orchiopexy: Moving and fixation of testis to scrotal sacOrchiopexy: Moving and fixation of testis to scrotal sac

• Abdominal approach: 54650Abdominal approach: 54650• Laparoscopic: 54692Laparoscopic: 54692

• Code selection based on approach (inguinal, scrotal, or Code selection based on approach (inguinal, scrotal, or abdominal)abdominal)

• Check CCI edits for bundled proceduresCheck CCI edits for bundled procedures


EpididymisEpididymis

• Narrow, coiled tubeNarrow, coiled tube

• Connects efferent ducts to vas deferensConnects efferent ducts to vas deferens

• I&D abscess or hematoma: 54700I&D abscess or hematoma: 54700

• Excision category (54800-54861)Excision category (54800-54861)

– BiopsyBiopsy

– Lesion or spermatocele (cyst)Lesion or spermatocele (cyst)

• Repair Category (54900, 54901)Repair Category (54900, 54901)

– Vasectomy reversal (epididymovasostomy)Vasectomy reversal (epididymovasostomy)

– Report operating microscope separately (69990)Report operating microscope separately (69990)


Tunica Vaginalis Tunica Vaginalis (55000-55060)(55000-55060)• Serous sheath of testisSerous sheath of testis

• Site ofSite of hydrocele (fluid collection) (unilateral hydrocele (fluid collection) (unilateral or bilateral)or bilateral)

– Treatment options, such as aspirate, inject, Treatment options, such as aspirate, inject, excise, repairexcise, repair

– Repair: Bottle type repair (55060)Repair: Bottle type repair (55060)

• DrainDrain

• RepositionReposition

• Catheter left in placeCatheter left in place


Scrotum (55100-55180)Scrotum (55100-55180)

• Sac that contains testesSac that contains testes

• Site of lesion, abscess, hematomaSite of lesion, abscess, hematoma– I&DI&D

• Scrotoplasty (oscheoplasty)Scrotoplasty (oscheoplasty)– Traumatic defectTraumatic defect

– Congenital abnormalityCongenital abnormality

– May require graftingMay require grafting• Simple skin flaps included scrotoplastySimple skin flaps included scrotoplasty

• More complex grafts/flaps reported separatelyMore complex grafts/flaps reported separately


Vas Deferens Vas Deferens (55200-55450)(55200-55450)• Tube that conducts sperm from testes to urethraTube that conducts sperm from testes to urethra

• Incision: Vasotomy to collect sperm sample or Incision: Vasotomy to collect sperm sample or identify obstructionidentify obstruction

• Excision: Vasectomy for sterilization procedure is Excision: Vasectomy for sterilization procedure is described as either unilateral or bilateraldescribed as either unilateral or bilateral– Do not use modifier -50Do not use modifier -50

• Introduction: Dye for radiographicIntroduction: Dye for radiographic procedureprocedure

• Repair: Remove obstruction, anastomose ends, Repair: Remove obstruction, anastomose ends, semen sampling includedsemen sampling included– Operating microscope: 69990Operating microscope: 69990


Spermatic Cord Spermatic Cord (55500-55559)(55500-55559)• Hydrocele: 55500 with -50 bilateralHydrocele: 55500 with -50 bilateral

• Variocele: Trapped blood causes vessels to Variocele: Trapped blood causes vessels to swell, for excision:swell, for excision:

– Scrotal approach: 55530Scrotal approach: 55530

– Abdominal approach: 55535Abdominal approach: 55535

– Laparoscopy: 55550Laparoscopy: 55550

– Excision of varicocele and hernia repair: 55540Excision of varicocele and hernia repair: 55540

– Watch: “separate procedure” designation. These only Watch: “separate procedure” designation. These only billed if only service performed or if procedure totally billed if only service performed or if procedure totally unrelated to another procedure performed during the unrelated to another procedure performed during the same sessionsame session


Seminal Vesicles Seminal Vesicles (55600-55680)(55600-55680)

• Pair of bands, posterior to bladderPair of bands, posterior to bladder

• Provide majority of semen fluidProvide majority of semen fluid

• Incision: VesiculotomyIncision: Vesiculotomy– Simple 55600, complicated 55605Simple 55600, complicated 55605

• Excision: VesiculectomyExcision: Vesiculectomy– For removal of tumor, calculus, or other For removal of tumor, calculus, or other

obstructionobstruction

– 55650, any approach55650, any approach

– Add -50 for bilateralAdd -50 for bilateral


Prostate (55700-55899)Prostate (55700-55899)

• BPH, BPH, Benign Prostatic HyperplasiaBenign Prostatic Hyperplasia– Enlargement of the prostateEnlargement of the prostate

• Treatment options:Treatment options:

– Urethral stent (52282) keeps urethra open at level Urethral stent (52282) keeps urethra open at level of prostateof prostate

– TUMT (53850) microwave heatTUMT (53850) microwave heat

– TUNA (53852) radiofrequencyTUNA (53852) radiofrequency

• Each code description lists approach and Each code description lists approach and bundled procedures, if appropriatebundled procedures, if appropriate


BPH or Neoplasm Surgical BPH or Neoplasm Surgical OptionsOptions• TURP (52601, 52630) gold-standardTURP (52601, 52630) gold-standard

– Through urethra, electrical loop removes Through urethra, electrical loop removes obstructionobstruction

• TUIP (52450)TUIP (52450)

– Incisions relieve pressure, no tissue Incisions relieve pressure, no tissue removedremoved


ProstatectomyProstatectomy

• Two types of codes:Two types of codes:

– Coagulation (52647)Coagulation (52647)

– Vaporization (52648)Vaporization (52648)

• Vaporization may be with or without Vaporization may be with or without resectionresection

(Cont’d…)(Cont’d…)




• Coagulation, laser (52647)Coagulation, laser (52647)• Contact or Non-contactContact or Non-contact• Contact: Laser comes in contact with prostate Contact: Laser comes in contact with prostate

tissuetissue• Non-Contact: Laser does not come in contact Non-Contact: Laser does not come in contact

with prostate tissuewith prostate tissue• TULIP (non-contact) no direct view by surgeonTULIP (non-contact) no direct view by surgeon• VLAP (non-contact) direct view by surgeonVLAP (non-contact) direct view by surgeon• ILCP (contact) no direct view by surgeonILCP (contact) no direct view by surgeon(Cont’d…)(Cont’d…)




Laser vaporization (52648)Laser vaporization (52648)– TUVP or TVP (contact) electrical current vaporizes TUVP or TVP (contact) electrical current vaporizes

tissue by means of a ball that is rolled over tissuetissue by means of a ball that is rolled over tissue

• Laser vaporization with/without resection Laser vaporization with/without resection (52648)(52648)– HoLEP or THLR (contact) laser resects tissue with HoLEP or THLR (contact) laser resects tissue with

holmium laser fiberholmium laser fiber





• 55801-55845 open surgical procedures55801-55845 open surgical procedures

• First based on approachFirst based on approach– Perineal: Space between rectum and scrotumPerineal: Space between rectum and scrotum

– Suprapubic: Above the pubic boneSuprapubic: Above the pubic bone

– Retropubic: Posterior to the pubic boneRetropubic: Posterior to the pubic bone

• Second based on extentSecond based on extent– Subtotal or radicalSubtotal or radical





• LRP (55866)LRP (55866)

• Laparoscopic = minimally invasiveLaparoscopic = minimally invasive

• RAP (no CPT code)RAP (no CPT code)

– Use withUse with 55866 with -2255866 with -22

– www.davinciprostatectomy.com/video.htmlwww.davinciprostatectomy.com/video.html


Incision (55700-55725)Incision (55700-55725)

• Prostate BiopsyProstate Biopsy– Needle or punch, 55700Needle or punch, 55700

– Needle, transperineal, stereotactic, 55706Needle, transperineal, stereotactic, 55706

– Incisional, 55705Incisional, 55705

• When fine needle biopsy/aspiration performed When fine needle biopsy/aspiration performed refer to 10021 & 10022refer to 10021 & 10022

• Prostatotomy (55720 simple, 55725 complicated)Prostatotomy (55720 simple, 55725 complicated)– Drain abscessDrain abscess

– Either via perineum or through rectumEither via perineum or through rectum

– Complicated = documented complexity, such as Complicated = documented complexity, such as excess bleedingexcess bleeding


Brachytherapy (55860-Brachytherapy (55860-55865)55865)• MethodsMethods

– High dose, temporaryHigh dose, temporarymethodmethod

– Low dose, permanentLow dose, permanentimplants (seeds)implants (seeds)

• PlacementPlacement

– Transperineal (55875)Transperineal (55875)

– Open exposure (55862)Open exposure (55862)

• Radioelements reported with Radioelements reported with __________-77778-77778

Brachytherapy for prostate cancerBrachytherapy for prostate cancer

From Wein AJ, editor: From Wein AJ, editor: Campbell-Walsh Campbell-Walsh UrologyUrology, ed 9, Philadelphia, 2007, Saunders, ed 9, Philadelphia, 2007, Saunders

7777677776


Reproductive System Reproductive System Procedure (55920)Procedure (55920)

• Reports placement of catheters/needles Reports placement of catheters/needles into pelvic organs/genitalia for into pelvic organs/genitalia for subsequent interstitial radioelement subsequent interstitial radioelement applicationapplication


Intersex Surgery (55970, Intersex Surgery (55970, 55980)55980)

• There only 2 codes within subsectionThere only 2 codes within subsection

• Male to female Male to female

• Female to maleFemale to male

• Complicated procedures completed over Complicated procedures completed over extended period of timeextended period of time

• Performed by multiple physicians with Performed by multiple physicians with extensive specialized trainingextensive specialized training


Urinary SystemUrinary System

• Anatomic divisionsAnatomic divisions

– KidneyKidney

– UreterUreter

– BladderBladder

– UrethraUrethra

• Procedures on prostate in either Urinary or Procedures on prostate in either Urinary or Male Genital SystemMale Genital System



Urinary SystemUrinary System


• Further divided by procedureFurther divided by procedure




Kidney (50010-50592)Kidney (50010-50592)

• Endoscopy codes for procedures done Endoscopy codes for procedures done throughthrough

– Previously establishedPreviously established stomastoma


• Most cystoscopy procedures have zero Most cystoscopy procedures have zero global daysglobal days

• A cystoscopy is a visual examination of A cystoscopy is a visual examination of urinary bladder by means of cystoscopeurinary bladder by means of cystoscope



• Caution:Caution:– Kidney located in retroperitoneal areaKidney located in retroperitoneal area– Each has codes for proceduresEach has codes for procedures

• Renal explorationRenal exploration– Kidney diagnostic procedure (50010), no further procedures Kidney diagnostic procedure (50010), no further procedures

performedperformed– Retroperitoneal area diagnostic procedure (49010)Retroperitoneal area diagnostic procedure (49010)

• Renal abscessRenal abscess– Kidney abscess (50020)Kidney abscess (50020)

– If radiological supervision & interpretation were performed If radiological supervision & interpretation were performed see 75989see 75989

– Retroperitoneal abscess (49060)Retroperitoneal abscess (49060)


ProceduresProcedures

• Nephrostomy (50040): Insertion of catheter Nephrostomy (50040): Insertion of catheter into kidney with one end in kidney and one into kidney with one end in kidney and one end outside bodyend outside body

• Nephrotomy (50045): Exploration of inside of Nephrotomy (50045): Exploration of inside of kidneykidney

– No definitive procedureNo definitive procedure

– Verify all CCI code edits to prevent unbundlingVerify all CCI code edits to prevent unbundling

• Nephrolithotomy (50060-50075): Removal of Nephrolithotomy (50060-50075): Removal of calculuscalculus



ProceduresProcedures


• ESWL: Use of shock waves to fragment ESWL: Use of shock waves to fragment calculuscalculus

• Percutaneous lithotripsy: Insertion of probe Percutaneous lithotripsy: Insertion of probe to pulverize calculusto pulverize calculus– Basket attached to probe and pulverized calculus Basket attached to probe and pulverized calculus

removedremoved

• Percutaneous nephrostolithotomy (PCNL) or Percutaneous nephrostolithotomy (PCNL) or pyelostolithomypyelostolithomy– Removal of kidney calculusRemoval of kidney calculus


Excision (50220-50290)Excision (50220-50290)

• Nephrectomy: Partial or total (radical) excision of kidney Nephrectomy: Partial or total (radical) excision of kidney (50220-50240)(50220-50240)– Radical: Removal of fascia, fatty tissue, regional lymph node, Radical: Removal of fascia, fatty tissue, regional lymph node,

adrenal glandadrenal gland

• Nephrectomy medical record documentation should Nephrectomy medical record documentation should indicate if procedure was partial or total, laparoscopic, or indicate if procedure was partial or total, laparoscopic, or open, and if any structures were removedopen, and if any structures were removed

• Code 50225 describes a complicated nephrectomy Code 50225 describes a complicated nephrectomy because of previous surgery on same kidneybecause of previous surgery on same kidney

• AblationAblation– Cryosurgery, 50250Cryosurgery, 50250

– Laparoscope, 50542Laparoscope, 50542

– Percutaneous, 50593Percutaneous, 50593


Renal Transplant (50300-Renal Transplant (50300-50880)50880)• Backbench workBackbench work

– RetrievalRetrieval of organ of organ• Deceased (50300)Deceased (50300)

• Living (50320, open; 50547, laparoscopy)Living (50320, open; 50547, laparoscopy)

– PreparationPreparation of organ of organ• Deceased (50323)Deceased (50323)

• Living (50325)Living (50325)

– TransplantationTransplantation• Without nephrectomy, 50360Without nephrectomy, 50360

• With nephrectomy, 50365With nephrectomy, 50365

• Add -50 for bilateral procedureAdd -50 for bilateral procedure



• AspirationsAspirations

• Catheters and injections for radiographyCatheters and injections for radiography

• Insertion of guide wiresInsertion of guide wires

• Tube changesTube changes

• Usually reported with radiology componentUsually reported with radiology component


Repair (50400-50540)Repair (50400-50540)

• PyeloplastyPyeloplasty

– Repair of ureteropelvic junction (UPJ)Repair of ureteropelvic junction (UPJ)

– Simple 50400Simple 50400

– Complicated 50405Complicated 50405

• Closure of fistula (abnormal opening)Closure of fistula (abnormal opening)

– 50520-5052650520-50526


Laparoscopy (50541-50549)Laparoscopy (50541-50549)

• Ablation of renalAblation of renal

– Cyst (50541)Cyst (50541)

– Lesion (50542)Lesion (50542)

– Cryoablation (50250)Cryoablation (50250)

– Percutaneous (0135T)Percutaneous (0135T)


Endoscopy (50551-50580)Endoscopy (50551-50580)

• Renal endoscopy codes divided byRenal endoscopy codes divided by– Established connection between kidney Established connection between kidney

and body exterior (50551-50562)and body exterior (50551-50562)

– Nephrotomy or pyelotomy (50570-50580)Nephrotomy or pyelotomy (50570-50580)

• Further divided based on purposeFurther divided based on purpose– BiopsyBiopsy

– Removal of foreign body/calculusRemoval of foreign body/calculus


UreterUreter

• Divided based on type of procedureDivided based on type of procedure



• Laparoscopy codes describe surgical Laparoscopy codes describe surgical proceduresprocedures

• Codes may be bilateral or unilateralCodes may be bilateral or unilateral



• Report open proceduresReport open procedures

– Explore or drain (50600)Explore or drain (50600)

– Insert indwelling stent (50605)Insert indwelling stent (50605)

– Remove calculus (50610-50630)Remove calculus (50610-50630)

• Based on location of upper third, middle third, Based on location of upper third, middle third, or lower thirdor lower third


Excision and Introduction Excision and Introduction (50650-50690)(50650-50690)

• ExcisionExcision

– Ureterectomy (50650, 50660)Ureterectomy (50650, 50660)

• Bladder cuff excision or total excisionBladder cuff excision or total excision

• IntroductionIntroduction

– Reports injections,Reports injections, manometric (measures manometric (measures pressure) studies, change of stents/tubespressure) studies, change of stents/tubes


Laparoscopy and Endoscopy Laparoscopy and Endoscopy (50945-50980)(50945-50980)

• Laparoscopic placement of urethral Laparoscopic placement of urethral stent (50947, 50948)stent (50947, 50948)

• Endoscopy codes (50951-50980) for Endoscopy codes (50951-50980) for procedure through established stomaprocedure through established stoma


BladderBladder

• Many bundled codesMany bundled codes

– Example: Urethral dilation is included with Example: Urethral dilation is included with insertion of cystoscopeinsertion of cystoscope

• Read all descriptions carefully for site, Read all descriptions carefully for site, technique and reason for proceduretechnique and reason for procedure


Incision and ExcisionIncision and Excision

• Incision (51020-51080)Incision (51020-51080)– Suprapubic catheter placement, 51102Suprapubic catheter placement, 51102

– Cystotomy (51020-51045) for lesion Cystotomy (51020-51045) for lesion destruction, insertion of radioactive destruction, insertion of radioactive material, fulguration (use of electrical material, fulguration (use of electrical current)current)

• Excision (51500-51597)Excision (51500-51597)– Cystotomies & cystectomies (51520-51596)Cystotomies & cystectomies (51520-51596)

• Codes divided based on extent of procedureCodes divided based on extent of procedure



• Injection procedures (51600-51610) for Injection procedures (51600-51610) for urethrocystographyurethrocystography

– Radiographic S&I reported separatelyRadiographic S&I reported separately

• Instillation of anticarcinogenic agent Instillation of anticarcinogenic agent via a catheter for bladder cancervia a catheter for bladder cancer

– Retention time includedRetention time included


Urodynamics (51725-51798)Urodynamics (51725-51798)

• Procedures relate to motion and flow of urine Procedures relate to motion and flow of urine (motor & sensory function)(motor & sensory function)

• Used to diagnose urine flow obstructionsUsed to diagnose urine flow obstructions

• Bundled: All usual, necessary instruments, Bundled: All usual, necessary instruments, equipment, supplies, equipment, supplies, and technical assistanceand technical assistance

• Always code urodynamic code in addition to Always code urodynamic code in addition to all other cysto codes if both are performedall other cysto codes if both are performed

• Modifier -51 is reported for multiple Modifier -51 is reported for multiple proceduresprocedures


Repair and LaparoscopyRepair and Laparoscopy

• Repair (51800-51980)Repair (51800-51980)

– CystoplastyCystoplasty

– CystourethroplastyCystourethroplasty

– Vesicourethropexy/uretropexy (urinary Vesicourethropexy/uretropexy (urinary incontinence)incontinence)

• Laparoscopy (51990-51999)Laparoscopy (51990-51999)

– Stress incontinence proceduresStress incontinence procedures


EndoscopyEndoscopy—Cystoscopy, —Cystoscopy, Urethroscopy, CystourethroscopyUrethroscopy, Cystourethroscopy

• 52000-5201052000-52010

• Many combination codesMany combination codes

• Notes before 52000 indicate that included are:Notes before 52000 indicate that included are:– MeatotomyMeatotomy

– Urethral calibrationUrethral calibration

– Urethral dilationUrethral dilation

– UrethroscopyUrethroscopy

– CystoscopyCystoscopy

– Ureteral catheterization, etc.Ureteral catheterization, etc.


Endoscopy—Cystoscopy, Endoscopy—Cystoscopy, Urethroscopy, CystourethroscopyUrethroscopy, Cystourethroscopy

• 52000 is assigned for IVP, if appropriate52000 is assigned for IVP, if appropriate

• 52005 is assigned for retrograde pyelogram52005 is assigned for retrograde pyelogram

• When coding cystourethroscopies with When coding cystourethroscopies with dilation ask following questions:dilation ask following questions:

1.1. Is patient male or female?Is patient male or female?

2.2. Is this an initial or subsequent procedure?Is this an initial or subsequent procedure?

3.3. Was general or spinal anesthesia used?Was general or spinal anesthesia used?


Transurethral Surgery Transurethral Surgery (52204-52355)(52204-52355)• Urethra/bladder, 52204-52318Urethra/bladder, 52204-52318

– TURBT (52234-52240)TURBT (52234-52240)

• Excision or fulguration of bladder tumorExcision or fulguration of bladder tumor

• Ureter/pelvis, 52320-52355Ureter/pelvis, 52320-52355

– Includes insertion and removal of Includes insertion and removal of temporary stentstemporary stents


Vesical Neck and Prostate Vesical Neck and Prostate (52400-52700)(52400-52700)• Contains codes for transurethral Contains codes for transurethral

resection of the prostateresection of the prostate (TURP)(TURP)

– ExampleExample: 52601 complete transurethral : 52601 complete transurethral electrosurgical resection of the prostateelectrosurgical resection of the prostate

• Other approaches are reported with Other approaches are reported with 55801-5584555801-55845

– ExampleExample: 55801 reports a removal of the : 55801 reports a removal of the prostate gland (prostatectomy) through an prostate gland (prostatectomy) through an incision in the perineumincision in the perineum


UrethraUrethra

• Excision (53200-53275)Excision (53200-53275)– 53210 female53210 female

– 53215 male53215 male

• Repair (53400-53520)Repair (53400-53520)– Urethroplasty may be one or two stageUrethroplasty may be one or two stage

– Some codes divided based on male/femaleSome codes divided based on male/female

• Manipulation (53600-53665)Manipulation (53600-53665)– Stretches of narrowed passageStretches of narrowed passage


Digestive SystemDigestive System

• Divided by anatomic site from mouth to abdomen, peritoneum, Divided by anatomic site from mouth to abdomen, peritoneum, and omentum + organs that aid digestive processand omentum + organs that aid digestive process

• Many bundled proceduresMany bundled procedures• Surgical procedures for open & endoscopic approaches:Surgical procedures for open & endoscopic approaches:

– Mouth & related structuresMouth & related structures– PharynxPharynx– AdenoidsAdenoids– TonsilsTonsils– EsophagusEsophagus– StomachStomach– IntestinesIntestines– AppendixAppendix– Rectum and anusRectum and anus– LiverLiver– Biliary tractBiliary tract– PancreasPancreas


Lips (40490-40799)Lips (40490-40799)

• Vermilionectomy (40500) is shaving of lipVermilionectomy (40500) is shaving of lip

– Vermilion border: Area between lip and mucosal Vermilion border: Area between lip and mucosal surface of mouthsurface of mouth

– Large defects (40510-40527)Large defects (40510-40527)

• Repaired with procedures such as transverse wedge Repaired with procedures such as transverse wedge excision (40510)excision (40510)

• Chelioplasty is lip repairChelioplasty is lip repair

– Full thickness repair (40650-40654)Full thickness repair (40650-40654)

– Cleft lip repair (40700-40761)Cleft lip repair (40700-40761)


Tongue and Floor of Mouth Tongue and Floor of Mouth (41000-41599)(41000-41599)

• Incision and drainage codes based on:Incision and drainage codes based on:

– Sublingual (under tongue)Sublingual (under tongue)

– Submandibular (under mandible)Submandibular (under mandible)

– Masticator space (floor of mouth to Masticator space (floor of mouth to hyoid bone)hyoid bone)

• Extraoral (outside mouth) I&D of Extraoral (outside mouth) I&D of abscess, cyst, hematoma on floor of abscess, cyst, hematoma on floor of mouthmouth


Dentoalveolar Structures Dentoalveolar Structures and Palate/Uvulaand Palate/Uvula• Dentoalveolar structures (41800-41899)Dentoalveolar structures (41800-41899)

– Bone (osseous) and soft structures of Bone (osseous) and soft structures of mouthmouth

– Anchors teethAnchors teeth

• Palate/Uvula (42000-42299)Palate/Uvula (42000-42299)

– Palate (roof of mouth)Palate (roof of mouth)

– Uvula (pendulous structure at back of Uvula (pendulous structure at back of throat)throat)


Salivary Gland and Ducts Salivary Gland and Ducts (42300-42699)(42300-42699)

• Three salivary glandsThree salivary glands

– ParotidParotid

– SubmandibularSubmandibular

– SublingualSublingual

• Codes divided initially by glandCodes divided initially by gland


Pharynx, Adenoids, and Pharynx, Adenoids, and Tonsils (42700-42999)Tonsils (42700-42999)• Incision codes 42700-42725 initially Incision codes 42700-42725 initially

divided on approachdivided on approach

– IntraoralIntraoral

– ExternalExternal

• Tonsillectomy and adenoidectomyTonsillectomy and adenoidectomy

– 42820-4283642820-42836

– Based on gland removed and age of Based on gland removed and age of patientpatient


Esophagus (43020-43499)Esophagus (43020-43499)

• Approaches—Incision, ExcisionApproaches—Incision, Excision– CervicalCervical

– ThoracicThoracic

– AbdominalAbdominal

– EndoscopyEndoscopy

• Code esophageal dilationCode esophageal dilation

1.1. Know the device or method usedKnow the device or method used

2.2. How each device worksHow each device works

3.3. Whether dilation was endoscopic or non-endoscopicWhether dilation was endoscopic or non-endoscopic

• Diagnostic endoscopy always included in surgical Diagnostic endoscopy always included in surgical endoscopyendoscopy


Esophagoscopy (43200-43228)Esophagoscopy (43200-43228)

• Limited to esophagus onlyLimited to esophagus only

• Scope may be advanced into stomach Scope may be advanced into stomach but is short of pylorusbut is short of pylorus

• If scope transverses pyloric channel, If scope transverses pyloric channel, becomes an EGD (43234-43259)becomes an EGD (43234-43259)

• If scope passes beyond second portion If scope passes beyond second portion of duodenum, becomes an ERCP of duodenum, becomes an ERCP procedure (43260-43272)procedure (43260-43272)


Stomach (43500-43999)Stomach (43500-43999)

• Gastric bypass performed for morbid Gastric bypass performed for morbid obesityobesity

– Many different types, such as RNYMany different types, such as RNY

– May be performed via a laparoscopeMay be performed via a laparoscope

• Bariatric surgery (43770-43774)Bariatric surgery (43770-43774)

– Gastric restrictive device (such as band)Gastric restrictive device (such as band)


Intestines (Except Rectum) Intestines (Except Rectum) (44005-44799)(44005-44799)

• Separate procedures commonSeparate procedures common

• ColostomiesColostomies always bundled with major always bundled with major procedureprocedure– Unless code states otherwiseUnless code states otherwise

• Small intestine extends for 20 feet from Small intestine extends for 20 feet from pyloric sphincter to first part of large pyloric sphincter to first part of large intestineintestine

• Large intestine extends from end of ilium to Large intestine extends from end of ilium to anus, 4 parts (cecum, colon, sigmoid colon, anus, 4 parts (cecum, colon, sigmoid colon, and rectum)and rectum)


Endoscopy, Small Intestine Endoscopy, Small Intestine and Stomal (44360-44397)and Stomal (44360-44397)

• Diagnostic bundled into surgical Diagnostic bundled into surgical endoscopicendoscopic

• Code to furthest extent of procedureCode to furthest extent of procedure


Endoscopy TerminologyEndoscopy Terminology

• Notes define specific terminologyNotes define specific terminology

• Code descriptions are specific regarding:Code descriptions are specific regarding:– Technique and depth of scopeTechnique and depth of scope

• Esophagoscopy: Esophagus onlyEsophagoscopy: Esophagus only

• Esophagogastroscopy: Esophagus to past diaphragmEsophagogastroscopy: Esophagus to past diaphragm

• Esophagogastroduodenoscopy: Esophagus to beyond Esophagogastroduodenoscopy: Esophagus to beyond pyloric channelpyloric channel

• Read notes preceding 45300-45392Read notes preceding 45300-45392



Endoscopy TerminologyEndoscopy Terminology


• SigmoidoscopySigmoidoscopy:: Entire rectum, sigmoid Entire rectum, sigmoid colon, and may include part of the colon, and may include part of the descending colon descending colon

• ProctosigmoidoscopyProctosigmoidoscopy: Rectum and : Rectum and sigmoid colon sigmoid colon

• ColonoscopyColonoscopy: Entire colon, rectum to : Entire colon, rectum to cecum, and may include terminal ileumcecum, and may include terminal ileum


Colon Procedures & ScreeningColon Procedures & Screening

• For colonoscopy procedures determine how it was For colonoscopy procedures determine how it was performed:performed:

1.1. Through a colostomyThrough a colostomy

2.2. Through a colotomyThrough a colotomy

3.3. Through the rectumThrough the rectum

• For Colorectal Cancer Screening see HCPCS Level II For Colorectal Cancer Screening see HCPCS Level II codes:codes:

– G0107G0107– G0104G0104– G0105G0105– G0106G0106– G0120G0120– G0122G0122


Laparoscopy Laparoscopy and Endoscopyand Endoscopy• Some subheadings have both laparoscopy Some subheadings have both laparoscopy

(from outside) and endoscopy(from outside) and endoscopy (from inside) (from inside) proceduresprocedures– Example: Subheading EsophagusExample: Subheading Esophagus

• Endoscopy views insideEndoscopy views inside

• Laparoscopy inserted through umbilicus, Laparoscopy inserted through umbilicus, views from outsideviews from outside

• Laparoscopic bariatric surgery codes Laparoscopic bariatric surgery codes (43770-43774)(43770-43774)

• Use of gastric band and/or subcutaneous port Use of gastric band and/or subcutaneous port componentscomponents


Abdomen, Peritoneum, and Abdomen, Peritoneum, and Omentum Subheading (49000-49999)Omentum Subheading (49000-49999)

• LaparoscopyLaparoscopy

– Diagnostic (49320)Diagnostic (49320)

– Surgical (49321-49323)Surgical (49321-49323)

• Repair category contains hernia Repair category contains hernia repair codesrepair codes


Hemorrhoidectomy and Hemorrhoidectomy and Fistulectomy Codes (46221-Fistulectomy Codes (46221-46320)46320)• Divided byDivided by

– ComplexityComplexity

• Simple: no plastic procedure involvedSimple: no plastic procedure involved

• Complex: includes plastic procedure and fissurectomyComplex: includes plastic procedure and fissurectomy

– AnatomyAnatomy

• Subcutaneous: no muscle involvementSubcutaneous: no muscle involvement

• Submuscular: splinter muscleSubmuscular: splinter muscle

– Complex fistulectomy involves excision/incision Complex fistulectomy involves excision/incision of multiple fistulasof multiple fistulas


Hernia Codes Divided onHernia Codes Divided on

1.1. TypeType– Example: inguinal, femoralExample: inguinal, femoral

2.2. Initial or subsequent repairInitial or subsequent repair

3.3. Age of patientAge of patient

4.4. Clinical presentation:Clinical presentation:– Strangulated: Blood supply cut offStrangulated: Blood supply cut off

– Incarcerated: Cannot be returned to cavity Incarcerated: Cannot be returned to cavity (not reducible)(not reducible)• Implantation of mesh or prosthesis is reported Implantation of mesh or prosthesis is reported

separatelyseparately


MediastinumMediastinum

• Area between Area between lungslungs

Figure: 9.23Figure: 9.23


Mediastinum (39000-39499)Mediastinum (39000-39499)

• Assigned by approachAssigned by approach

• IncisionIncision codes for foreign body codes for foreign body removal or biopsyremoval or biopsy

• ExcisionExcision codes for removal of cyst or codes for removal of cyst or tumortumor

• Endoscopy with or without biopsy Endoscopy with or without biopsy (39400)(39400)


Diaphragm (39501-39561)Diaphragm (39501-39561)

• Only category: RepairOnly category: Repair

– Most codes for hernia or laceration repairsMost codes for hernia or laceration repairs


Conclusion Conclusion

CHAPTER 9CHAPTER 9

GENERAL SURGERY IGENERAL SURGERY I

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