Surgery Guidelines

Question 1

What do surgery codes describe?

Answer 1

Procedures done in offices, hospitals, or outpatient settings

This includes various services associated with the surgery.

Question 2

What services are included in many surgery codes?

Answer 2

• History and physical exam before surgery
• Local anesthesia
• Immediate post-op care
• Post-op recovery and routine follow-up care

These services are part of the surgical package.

Question 3

What does the term ‘surgical package’ refer to?

Answer 3

Multiple services bundled into one code

Examples include local anesthesia and pre-op visits.

Question 4

What follow-up care is included for diagnostic procedures?

Answer 4

Only issues from the diagnostic procedure

If other issues are found, they may require a separate code.

Question 5

What follow-up care is included for therapeutic procedures?

Answer 5

Usual care like checking for healing, but complications may need separate reporting

Therapeutic procedures are typically surgical.

Question 6

How can extra supplies used during surgery be billed?

Answer 6

Separately using codes 99070 or a supply code

This includes items like sterile trays or drugs.

Question 7

What should be done if more than one procedure is performed?

Answer 7

Use modifiers to show this

Refer to CPT Appendix A for details.

Question 8

What does it mean if a code is marked as a ‘separate procedure’?

Answer 8

It’s usually part of a bigger procedure and shouldn’t be billed alone unless done separately

This indicates specific billing guidelines.

Question 9

What should be done if a procedure isn’t listed in the CPT book?

Answer 9

Use an ‘Unlisted Procedure’ code and write a Special Report with details

This includes codes like 15999 and 20999.

Question 10

What details should be included in a Special Report for unlisted procedures?

Answer 10

• What was done
• Why it was needed
• Time and effort involved
• Equipment used

These details justify the use of an unlisted code.

Question 11

What does ‘surgical destruction’ refer to?

Answer 11

Methods like cauterization or chemical destruction to remove a problem

These codes are used when no specific code covers the procedure.

Question 12

What codes exist for removing implants or foreign bodies?

Answer 12

Specific codes exist for these procedures

Examples include codes for broken screws or swallowed objects.

Question 13

How can imaging guidance be reported during surgery?

Answer 13

Reported separately if not bundled into the procedure code

This includes X-rays or ultrasound used to guide the surgery.