March 24, 2022

The Hemic and Lumphatic System subsection splits into three subheadings they are the Spleen, General and Lymph Nodes and Lymphati

Read classmates post and respond with 100 words:

The Hemic and Lumphatic System subsection splits into three subheadings they are the Spleen, General and Lymph Nodes and Lymphatic Channels. The two subheadings I will be discussing are the Spleen and The Lymph Nodes. The Spleen initiates an immune response, filters and removes bacteria from the bloodstream. The codes for the spleen are 38100-38200 and they are divided into categories. Lymph Nodes filter substances that travel through the lymphatic fluid and they contain white blood cells that help fight infection and disease. Lymph Nodes they are divided into different categories of procedures such as incision, excision, resection and introduction. The codes for these are 38300-38999 this includes the Lymph Channels too.

Reference:

Carol J. Buck, Sanders (2022). Step-by-Step Medical Coding, by Carol J. Buck, Saunders

CHAPTER 18

HEMIC, LYMPHATIC, MEDIASTINUM, AND DIAPHRAGM

Slide ‹#›

Hemic and Lymphatic Systems Subsection (Excision, Repair, Introduction)

Divisions

Spleen

General

Lymph Nodes and Lymphatic Channels (Figure 18.1 in text)

Slide ‹#›

This subsection is divided into subheadings of Spleen, General, and Lymph Nodes/Lymphatic Channels.

Further division is based on type of procedure, such as excision, incision, or repair.

Where are the codes for spleen and lymph nodes located in the CPT manual Index? (Under main terms, spleen, lymph nodes, and bone marrow)

Spleen (38100-38200) (1 of 2)

Spleen easily ruptured, causes massive hemorrhage

May require splenectomy

Splenectomy: total or partial

Slide ‹#›

Codes for spleen are further divided into excision, repair, laparoscopy, and introduction.

Why can a person live without a spleen? (The bone marrow, liver, and lymph nodes take over the work of the spleen.)

Spleen (38100-38200) (2 of 2)

Often done as part of more major procedure

Bundled into major procedure

Slide ‹#›

Splenectomy carries the designation “(separate procedure)”; if the splenectomy is an integral part of another procedure, it is bundled into the main procedure code and is not reported separately.

General (38204-38243) (1 of 2)

Codes divided based on

Aspiration

Biopsy

Harvesting

Transplantation/Infusion

Slide ‹#›

What is a bone marrow needle aspiration? What is its code? (When a sample of bone marrow is withdrawn by a needle from the marrow cavity, 38220)

What is involved in a bone marrow biopsy? What is the code for this procedure? (Small pieces of marrow are withdrawn and the lab dissolves these in a solution. Then the substance is analyzed, 38221.)

What is bone marrow harvesting? What is the code for this procedure? (A larger amount of marrow is aspirated from a donor, 38230)

How is bone marrow transplanted? What is the code for this procedure? (Taken from donor and injected into the recipient, 38240-38243)

General (38204-38243) (2 of 2)

Types of cells:

Allogenic: Close relative

Autologous: Patient’s own

Hematopoietic progenitor cells (HPC)

Bone marrow

Peripheral blood apheresis

Umbilical cord blood

Slide ‹#›

Autologous cells are collected from the patient and reinfused later into the same patient.

Why would it be advantageous to collect stem cells from a close relative? (Because there is genetic similarity)

What are the codes for the harvesting and return of blood to the donor? (38205-38206)

Lymph Nodes and Lymphatic Channels (38300-38999) (1 of 3)

Two types of lymphadenectomies:

Limited: Lymph nodes only

Radical: Lymph nodes, submandibular gland, and surrounding tissue

Term “complete” same as radical neck dissection

Slide ‹#›

What is the purpose of the lymphatic system? (To transport fluids, proteins, and fats through the lymphatic channels back to the blood stream)

A limited lymphadenectomy, reported with codes 38562-38564, consists of removal of only the lymph nodes.

A radical lymphadenectomy, reported with codes 38700-38780, involves removal of the lymph nodes, glands, and surrounding tissue.

Submental and submandibular nodes, chin area and below mandible

Upper jugular nodes, at mandibular angle in front of sternocleidomastoid muscle

Middle jugular nodes, between hyoid bone and cricoid cartilage

Lower jugular nodes, between cricoid cartilage and clavicle

Posterior triangle nodes divided into groups

Upper visceral nodes, by the hyoid bone

Superior mediastinal nodes, between common carotid arteries

38700, 38720—are unilateral codes

Lymph Nodes and Lymphatic Channels (38300-38999) (2 of 3)

Slide ‹#›

“Modified” radical neck: removal of all lymph nodes routinely removed by radical neck dissection, while preserving the internal jugular vein, the spinal accessory nerve, and the sternocleidomastoid muscles (38724)

This is a unilateral procedure

Lymph Nodes and Lymphatic Channels (38300-38999) (3 of 3)

Slide ‹#›

Lymphadenectomies

Often bundled into more major procedure (e.g., prostatectomy)

Do not unbundle and report lymphadenectomy separately

Slide ‹#›

A limited lymphadenectomy may be bundled into a more major procedure; when this occurs, only the major procedure is reported.

What codes reflect whether the procedure was superficial or deep? (Superficial code is 38500 and deep codes are 38510-38525, and internal mammary code is 38530.)

Mediastinum (39000-39499) (1 of 2)

Area between lungs

Figure 18.3

Slide ‹#›

What is the mediastinum? (The area between the lungs)

Where does the Mediastinum and Diaphragm subsection fall in the CPT book? (Directly after the cardiology subsection)

Mediastinum (39000-39499) (2 of 2)

Assigned by approach

Incision codes for foreign body removal or biopsy

Excision codes for removal of cyst or tumor

Endoscopy

Repair

Slide ‹#›

The Mediastinum subheading is divided by procedures and includes incision, excision, and endoscopy categories.

Procedures are reported with use of the codes 39000-39499.

Codes are based on the surgical approach taken to perform the mediastinotomy—either cervical (neck area) or across the thoracic area or sternum.

What primary distinction is made in the excision codes that are listed under the Mediastinum subheading? (The excision codes vary according to whether a tumor or a cyst was excised.)

Diaphragm (39501-39561)

Only category: Repair

Most codes for hernia or laceration repairs

Codes indexed in CPT manual under “Diaphragm”

Slide ‹#›

Where is the diaphragm located? (The diaphragm is the wall of muscle that separates the thoracic and abdominal cavities.)

Only 1 category under Diaphragm subheading, Repair.

Repairs consist of lacerations and hernias.

How are the hernias of the diaphragm divided out? (Type of hernia, age of patient [neonate or other than neonate], and approach [transthoracic or combined thoracoabdominal])

Conclusion CHAPTER 18

HEMIC, LYMPHATIC, MEDIASTINUM, AND DIAPHRAGM

Slide ‹#›

CHAPTER 19

DIGESTIVE SYSTEM

Slide ‹#›

Digestive System

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

Many bundled procedures

Surgical procedures for open and endoscopic:

Mouth and related structures

Pharynx

Adenoids

Tonsils

Esophagus

Stomach

Intestines

Appendix

Colon, rectum, and anus

Liver

Biliary tract

Pancreas

Slide ‹#›

The Digestive System subsection includes codes 40490-49999.

On what basis are the digestive system codes divided? (According to anatomical site beginning with the lips and ending with the abdomen, peritoneum, and omentum)

What are some of the organs that aid the digestive process and are included in this subsection? (Organs such as the pancreas, liver, and gallbladder)

What else is included in this subsection? (Abdomen, peritoneum, omentum, and hernias)

Lips (40490-40799)

Vermilionectomy (40500) is shaving of lip

Vermilion border: Area between lip and mucosal surface of mouth

Large defects (40510-40527)

Repaired with procedures such as transverse wedge excision (40510)

Cheiloplasty is lip repair

Full thickness repair (40650-40654)

Cleft lip repair (40700-40761)

Slide ‹#›

This is the first subheading of the Digestive Subsection.

Name a reason why a vermilionectomy with repair would need to be performed. (A patient with cancer of the lip)

What is a cleft lip? (A congenital defect when the muscle and tissue of the lip didn’t close properly)

Tongue and Floor of Mouth (41000-41599)

Incision and drainage codes based on:

Sublingual (under tongue)

Submandibular (under mandible)

Masticator space (floor of mouth to hyoid bone)

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

Slide ‹#›

Incision and drainages are based on the location of the abscess, cyst, or hematoma.

What other categories fall under the Tongue and Floor of Mouth subheading? (Excision, repair, and other procedures)

Dentoalveolar Structures and Palate/Uvula

Dentoalveolar structures (41800-41899)

Bone (osseous) and soft structures of mouth

Anchors teeth

Palate/Uvula (42000-42299)

Palate (roof of mouth)

Uvula (pendulous structure at back of throat)

Alveolar mucosa. (From Liebgott B: The Anatomical Basis of Dentistry, ed 3, St. Louis, 2011, Mosby.)

Figure 19.6

Slide ‹#›

Dentoalveolar procedures consist of drainage of abscesses or cysts and excisions of lesions.

Palate/Uvula subheading contains codes for incisions, excisions, and repairs.

Grafts are reported separately.

Salivary Gland and Ducts (42300-42699)

Three salivary glands

Parotid

Submandibular

Sublingual

Codes divided initially by gland

Slide ‹#›

Codes are divided based on the gland the procedure is performed on or the number of glands involved.

Imaging guidance is reported separately.

Pharynx, Adenoids, and Tonsils (42700-42999)

Incision codes 42700-42725 initially divided on approach

Intraoral

External

Figure 19.9, A & B

Tonsillectomy and adenoidectomy

42820-42836

Based on gland removed and age of patient

Slide ‹#›

Which category are the biopsies found in? (Excision, Destruction)

Incision category is for peritonsillar abscesses.

Esophagus (43020-43499)

Approaches—Incision, Excision

Cervical

Thoracic

Abdominal

Endoscopy

Code esophageal dilation

Know the device or method used

How each device works

Whether dilation was endoscopic or nonendoscopic

Diagnostic endoscopy always included in surgical endoscopy

Slide ‹#›

The key for billing removal of foreign bodies of the esophagus is the approach.

What approach does code 43100 use? (Cervical)

Esophagoscopy (43180-43233)

Limited to esophagus only

Scope may be advanced into stomach but is short of pylorus

If scope transverses pyloric channel, becomes an EGD (43235-43259, 43210)

If scope passes beyond second portion of duodenum, report Endoscopy, Small Intestine codes 44360-44408

Multiple procedures, same day, same provider, add modifier -51

Biopsy on two different sites add modifier -59

Slide ‹#›

Stomach (43500-43999)

Gastric bypass performed for morbid obesity

Many different types, such as RNY

May be performed via laparoscope

Bariatric surgery (43770-43775)

Gastric restrictive device (such as band)

Figure 19.12

Slide ‹#›

Some procedures are performed open, when the stomach is in full view to the physician, and others are done laparoscopically. Be certain to identify the approach used.

The gastric banding is adjustable because the band is a hollow tube that can be inflated and deflated with the administration of fluid.

Intestines (Except Rectum) (44005-44799)

Separate procedures common

Colostomies always bundled with major procedure

Unless code states otherwise

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

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

Slide ‹#›

Be sure to watch for the codes listed as separate procedures.

Endoscopy, Small Intestine (44360-44408)

Diagnostic bundled into surgical endoscopic

Code to furthest extent of procedure

Through stomal report 44380-44408

Slide ‹#›

Endoscopic codes can be found throughout the Digestive System subsection by anatomical site.

Is diagnostic endoscopy coded separately when surgical endoscopy is performed? (No, surgical endoscopy always includes diagnostic endoscopy.)

Once anatomic site has been determined, what other factor guides code selection? (The surgical procedure)

Endoscopy Terminology (1 of 2)

Notes define specific terminology

Code descriptions are specific regarding:

Technique and depth of scope

Esophagoscopy: Esophagus only

Esophagogastroscopy: Esophagus to past diaphragm

Esophagogastroduodenoscopy: Esophagus to beyond pyloric channel

Read notes preceding 45300-45398

Slide ‹#›

The notes define the specific terminology that should be used.

In particular, read the notes preceding codes 45300-45398.

Endoscopy Terminology (2 of 2)

Sigmoidoscopy: Entire rectum, sigmoid colon, and may include part of the descending colon (up to 26 inches or 26-60 cm is visualized)

Proctosigmoidoscopy: Rectum and sigmoid colon (6.25 cm is visualized)

Colonoscopy: Entire colon, rectum to cecum, and may include terminal ileum (more than 60 cm visualized or 23.6 inches)

Slide ‹#›

Understanding the terminology is crucial to coding the procedure appropriately.

What is the route through which the endoscope is inserted during a sigmoidoscopy? (The endoscope is passed through the entire rectum, sigmoid colon, and possibly part of the descending colon.)

Which parts of the anatomy are involved in a colonoscopy? (The entire colon, rectum to cecum, with possible inclusion of the terminal ileum)

Colon Procedures and Screening

For colonoscopy procedures determine how it was performed:

Through a colostomy

Through a colotomy

Through the rectum

For Colorectal Cancer Screening see HCPCS Level II codes:

G0104

G0105

G0106

G0120

G0121

G0122

Slide ‹#›

Laparoscopy and Endoscopy

Some subheadings have both laparoscopy (from outside) and endoscopy (from inside) procedures

Example: Subheading Esophagus

Endoscopy views inside

Laparoscopy inserted through umbilicus, views from outside

Laparoscopic bariatric surgery codes (43770-43774)

Use of gastric band and/or subcutaneous port components

Slide ‹#›

Some headings include both laparoscopy (outside) and endoscopy (inside) procedures.

Hemorrhoidectomy and Fistulectomy Codes (46200-46320)

Divided by

Anatomy

Subcutaneous: no muscle involvement

Submuscular: sphincter muscle

Complex fistulectomy involves excision/incision of multiple fistulas

Slide ‹#›

What is a hemorrhoid? (It is inflammation of the area around the anus)

Hemorrhoids may occur inside or outside of the body.

There are different degrees of severity.

Who should determine the degree of severity? (Physician)

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

Laparoscopy

Diagnostic (49320)

Surgical (49321-49323)

Repair category contains hernia repair codes

Slide ‹#›

The Abdomen, Peritoneum, and Omentum subheading includes a repair category that contains hernia repair codes.

Hernia Codes Divided On

Type

Example: inguinal, femoral

Initial or subsequent repair

Age of patient

Clinical presentation:

Strangulated: Blood supply cut off

Incarcerated: Cannot be returned to cavity (not reducible)

Implantation of mesh or prosthesis is reported separately

Slide ‹#›

Hernia repairs using an abdominal approach are reported with the use of codes 49491-49611.

Hernia repairs performed through laparoscopy are reported by means of codes 49650-49659.

Name some types of hernias. (Inguinal, umbilical, incisional, epigastric, lumbar)

Conclusion CHAPTER 19

DIGESTIVE SYSTEM

Slide ‹#›

CHAPTER 20

URINARY AND MALE GENITAL SYSTEMS

Slide ‹#›

Urinary System (1 of 2)

Anatomic divisions

Kidney

Ureters

Bladder

Urethra

Procedures on prostate in either Urinary or Male Genital System

Figure 20.1

Slide ‹#›

Procedures involving the urinary system are reported using codes 50010-53899.

What are the four subheadings for the urinary system codes? (The codes are arranged anatomically by four subheadings: kidney, ureters, bladder, and urethra.)

Urinary System (2 of 2)

Further divided by procedure

Incision

Excision

Slide ‹#›

On what basis are the category codes organized? (Arranged by procedure—incision, excision, introduction, and repair.)

Kidney (50010-50593)

Endoscopy codes for procedures done through

Previously established stoma

Incision

Most cystoscopy procedures have zero global days

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

Figure 20.6

Slide ‹#›

The Kidney subheading includes codes 50010-50593.

Endoscopy codes are assigned according to approach—either a previously established stoma is used as an entry point (which is created by placing a catheter through the skin and into the kidney), or an incision is used.

When coding endoscopy procedures, the coder must identify the entry method in order to assign the right code.

Incision (50010-50135)

Caution:

Kidney located in retroperitoneal area

Each has codes for procedures

Renal exploration

Kidney diagnostic procedure (50010), no further procedures performed

Retroperitoneal area diagnostic procedure (49010)

Renal abscess

Kidney abscess (50020)

If radiological supervision and interpretation were performed see 75989

Retroperitoneal abscess (49060)

Slide ‹#›

What is the reason for renal exploration? (When the cause of the patient’s condition is unknown)

If something is found on the exploratory procedure and a corrective procedure ensues, do not bill for the exploratory procedure.

Exploratory = Diagnostic.

Procedures (1 of 2)

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

Nephrotomy (50045): Exploration of inside of kidney

No definitive procedure

Verify all CCI code edits to prevent unbundling

Nephrolithotomy (50060-50075): Removal of calculus

Slide ‹#›

It is important to know the difference in these terms and understand that the surgeon may start out performing a nephrotomy to explore the kidney and find a reason for the patient’s urinary obstruction, and the procedure then becomes a nephrolithotomy when a calculus is found.

Procedures (2 of 2)

ESWL: Use of shock waves to fragment calculus

Percutaneous lithotripsy: Insertion of probe to pulverize calculus

Basket attached to probe and pulverized calculus removed

Percutaneous nephrostolithotomy (PCNL) or pyelostolithotomy

Removal of kidney calculus

Figure 20.3

Slide ‹#›

How is ESWL performed? (The patient is placed on a water-filled cushion on his or her back, and while the patient is under general anesthesia, shock waves are targeted to the stones, which are pulverized with repeated shocks.

What is the benefit of this? (It breaks up large stones and makes them easier to pass.)

Excision (50200-50290)

Nephrectomy: Partial or total (radical) excision of kidney (50220-50240)

Radical: Removal of fascia, fatty tissue, regional lymph node, adrenal gland

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

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

Ablation

Cryosurgery, 50250

Laparoscope, 50542

Percutaneous, 50593

Slide ‹#›

What is a nephrectomy? (Removal of a kidney)

Nephrectomy codes are based on the complexity and extent of the procedure.

What does ablation mean? (The cutting away or erosion of tissue)

Renal Transplant (50300-50380)

Backbench work

Retrieval of organ

Deceased (50300)

Living (50320, open; 50547, laparoscopy)

Preparation of organ

Deceased (50323)

Living (50325)

Transplantation

Without nephrectomy, 50360

With nephrectomy, 50365

Add modifier -50 for bilateral procedure

Slide ‹#›

Allotransplantation is a transplant between two people who are not related.

Autotransplantation is a transfer of tissue from one part of a person’s body to another part of his or her body.

Introduction (50382-50435)

Aspirations

Catheters and injections for radiography

Insertion of guidewires

Tube changes

Usually reported with radiology component

Slide ‹#›

What additional component is usually reported with procedures in the Introduction category? (These are usually reported with a Radiology component.)

These category codes include extensive notes, which should be read by coders before they code in this area.

Repair (50400-50540)

Pyeloplasty

Repair of ureteropelvic junction (UPJ)

Simple 50400

Complicated 50405

Closure of fistula (abnormal opening)

50520-50526

Slide ‹#›

What does the UPJ connect? (It connects the renal pelvis to the ureter.)

Usually congenital defect but it can be acquired.

Closure of a fistula depends on the approach. It will either be abdominal or thoracic.

Laparoscopy (50541-50549)

Ablation of renal

Cyst (50541)

Lesion (50542)

Cryoablation (50250)

Percutaneous (50593)

Slide ‹#›

What are the codes in this category based on? (The extent of the procedure)

Endoscopy (50551-50580)

Renal endoscopy codes divided by

Established connection between kidney and body exterior (50551-50562)

Nephrotomy or pyelotomy (50570-50580)

Further divided based on purpose

Biopsy

Removal of foreign body/calculus

Slide ‹#›

Renal Endoscopic procedures are less invasive than open procedures and often can be performed on an outpatient basis.

Ureter

Divided based on type of procedure

Incision

Excision

Laparoscopy codes describe surgical procedures

Codes may be bilateral or unilateral

Slide ‹#›

The Ureter subheading includes codes 50600-50980.

On what basis are the Ureter subheading codes divided? (Codes are divided according to type of procedure—incision, excision, introduction, repair, laparoscopy, or endoscopy.)

The endoscopy codes in this subheading (50951-50980) are used to report procedures that involve an established stoma.

Incision/Biopsy (50600-50630)

Report open procedures

Explore or drain (50600)

Insert indwelling stent (50605)

Remove calculus (50610-50630)

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

Slide ‹#›

What is the medical term for the removal of a calculus from the ureter? (Ureterolithotomy)

Laparoscopic approach billed with 50945.

Open approach billed with 51060.

Excision and Introduction (50650-50690)

Excision

Ureterectomy (50650, 50660)

Bladder cuff excision or total excision

Introduction

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

Slide ‹#›

Bladder cuff is the tissue that connects the ureter to the bladder.

Excision of the bladder cuff is only coded if it is the only procedure performed. If it is performed in conjunction with another procedure, it is bundled in and not separately reportable.

Manometric studies are tests to measure kidney and ureter flow and pressure.

Laparoscopy and Endoscopy (50945-50980)

Laparoscopic placement of ureteral stent (50947, 50948)

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

Slide ‹#›

Why is a urethral stent placed? (Because of a UVJ obstruction)

The Endoscopy Category can be intimidating due to the medical terminology used in this category.

Great knowledge of medical terminology will increase your coding accuracy.

Bladder

Many bundled codes

Example: Urethral dilation is included with insertion of cystoscope

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

Figure 20.8

Slide ‹#›

The Bladder subheading (51020-51597) includes many usual services, for example, incision and excision, but it also contains urodynamic category.

When coding from this subheading, it will help to know the anatomy of the bladder.

Incision and Excision

Incision (51020-51080)

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

Suprapubic catheter placement, 51102

Excision (51500-51597)

Cystotomies and cystectomies (51520-51596)

Cod

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The Hemic and Lumphatic System subsection splits into three subheadings they are the Spleen, General and Lymph Nodes and Lymphati

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