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CODE.MODE

SURGERY 

Surgery Codes 

Surgery Codes are one of the six sections of the CPT Category I codes and range from 10004-69990. 

RANGE

10004-69990

SUBSECTIONS

  • General

  • Integumentary System

  • Musculoskeletal System

  • Respiratory System

  • Cardiovascular System

  • Hemic & Lymphatic Systems

  • Mediastinum & Diaphragm 

  • Digestive System

  • Urinary System

  • Male Genital System

  • Reproductive System Procedures

  • Intersex Surgery

  • Female Genital System

  • Maternity Care & Delivery

  • Endocrine System

  • Nervous System

  • Eye & Ocular Adnexa

  • Auditory System

  • Operating Microscope

MODIFIERS

  • CPT Category I Modifiers
  • Anesthesia Modifiers 

Guidelines

CPT Surgical Package Definition

  • E/M service(s) --including history & physical-- subsequent to the decision for surgery on the day before and/or day of surgery

  • Local infiltration, metacarpal/metatarsal / digital block or topical anesthesia

  • Immediate postoperative care, including dictating operative notes, talking with the family or other physicians or other qualified health care professionals

  • Writing orders

  • Evaluating the patient in the postanesthsia recovery 

  • Typical postoperative follow-up care

Services

Some surgery services are listed as parts of other sections:

  • E/M Services (99201-99499)

    • ​Services provided in the office, home, or hospital; consultation, 

  • Medicine (99000-99091)

    • "Special Services and Reporting"  

Separate Procedures

Codes designated as "separate procedure" are NOT reported in addition to the code for the total procedure or service of which it is considered an integral component. 

Codes designated as "separate procedure" MAY be  reported by itself or in addition to another procedure / service by adding Modifer -59 to the "separate procedure" code IF they are carried out independently or considered unrelated or distinct. (Examples include a different session or encounter, a different procedure or surgery, different site/organ system, separate incision/excision, separate lesion, separate injury, or area of injury in extensive injuries.) 

Follow-Up Care for Diagnostic Surgical Procedures

Follow-up care for diagnostic procedures, such as endoscopy, ONLY include the care related to the recovery of the diagnostic procedure itself. 

This doe NOT include care for the condition for which the procedure was performed nor for other concomitant conditions. These must be listed separately. 

Follow-Up Care for Therapeutic Surgical Procedures

Follow-up care for therapeutic procedures, ONLY includes the care which is usually part of the surgical service. 

This doe NOT include complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services These must be reported separately. 

Unlisted Procedure / Service

Unlisted codes are reported for services that are not included in the CPT book. If reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service, identifying it as a "Special Report." 

When defining the specific services included in a given CPT surgical code, the following are "included" (when furnished by a physician or other qualified health care professional) in addition to the operation:

Special Report

Some services that are new, rarely provided, variable, or unusual require a special report. These reports must include pertinent  information, including a description of the following:

  • nature, extent, & need for procedure

  • time, effort, & equipment necessary

Supplied Materials

Supplies and materials exceeding those usually included may be listed separately.  

Reporting More Than One Procedure / Service 

If more then one procedure / service is performed on the same date, same session, or during a post-operative period (subject to the "surgical package" concept), several CPT modifiers may apply, and, if so, must be used.

Imaging Guidance 

Guidelines for image documentation for Radiology (Including nuclear Medicine and Diagnostic Ultrasound) will apply when imaging or imaging supervision and interpretation is included in a surgical procedure. 

Surgical Destruction 

Surgical destruction is part of a surgical procedure . Unless the techniques substantially alters the standard management of the problem / condition, , different methods of destruction are not ordinarily listed separately. 

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