Respiratory System, Chapter 20

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Step-by-step coding

Coding of respiratory system

arranged in Respiratory subsection by anatomic site and then by procedure

Endoscopy coding of respiratory system

listed throughout respiratory subsection according to anatomical site

Fracture repairs of nose, sternum, etc.

listed in musculoskeletal subsection of CPT code book

Throat and mouth procedure coding

not located in Respiratory subsection but in Digestive system subsection

Coding respiratory

Read all notes and code information to ensure that you do not code components of the procedure separately if there is one code that includes all of the components

Rhinoplasty can be performed either _____, through external skin incisions, or closed, through ____ incisions.

open or intranasal

Endoscopic procedures

a scope is placed through an existing body orifice (opening), or a small incision is made into a cavity for scope placement

How to code sinus endoscopies

report unilateral (on one side) procedures except in the case of a diagnostic nasal endoscopy which is unilateral or bilateral

Coding multiple sinus procedures

CPT manual has combined into single code some multiple sinus procedures commonly performed at same operative session

Code to the full extent of the procedure

True

When coding endoscopic procedures that start at one site and follow through to another site.

choose code that most appropriately reflects the furthest extent of the procedure

Code the correct approach for the procedure. The same surgical procedure may be performed using different approaches.

True

Thoracotomy

surgical incision into the chest wall

Thoracoscopy

visual examination of the lungs, pleura, and pleural space with a scope inserted through a small incision between the ribs

Coding multiple endoscopic procedures performed through the same scope during operative session

Each procedure should be reported with modifier-51 (multiple procedures) placed on subsequent procedure(s).

bronchoscopy with biopsy with removal of a foreign body

code bronchoscopy with biopsy
code removal of a foreign body with modifier -51

Intranasal procedures may require that surgical instruments be placed into the nose but do not require an endoscope

True

Coding when an endoscope is used in a nasal/sinus procedure

assign a nasal/sinus endoscopy code

Diagnostic endoscopy coding

always bundled into a surgical endoscopy

If a physician began a diagnostic endoscopic nasal procedure, continuing on to complete a surgical procedure,

code only the surgical procedure

If diagnostic sinus endoscopy is performed on right maxillary sinus and a surgical endoscopic maxillectomy on the left

both procedures are coded with appropriate - LT and -RT modifiers because two different procedures were performed

laryngoscopic procedures

direct or indirect

Indirect laryngoscopy

physician used tongue depressor to hold the tongue down and view the epiglottis with a mirror, patient says "ah" and vocal cords are viewed

Direct laryngoscopy

endoscope is passed into larynx and physician looks directly at larynx

Where endoscopy codes are located in CPT manual index

under endoscopy and then under the anatomic subterm of the site, or by anatomic endoscopy title

otorhinolaryngolotist

ear, nose and throat specialist

1. endoscopic maxillary antrostomy

cpt code 31256

2. direct laryngoscopy for removal of fish bone

...

3. after the airway is sufficiently anestheized, a flexible bronchoscope is inserted through the mouth and advanced to the bronchus, where a transbronchial biopsy of one lobe is obtained

CPT code: 31628

4. Diagnostic thoroscopy of the mediastinal space is accomplished with the use of a flexible endoscope is inserted through a small inicision on the chest (no biopsy was performed)

CPT code: 32601

5. Segmental resection o the right single lung lobe using a flexible endoscope (surgical thoracoscopy)

CPT code: 32663

codes for incision of nasal abscess

divided on whether abscess is on nasal mucosa or septal mucosa

nasal incision external approach

coded from Integumentary subsection

internal nasal approach

coded from Respiratory subsection

supplies

use Medicine section code for supplies, 99070 or HCPCS code as directed by 3rd party payer

When two procedures are completed during the same surgical session, the most complex procedure is sequenced first.

TRUE

Coding biopsy of nose

intranasally - coded from respiratory subsection
externally - coded from integumentary subsecdtion

Nasal polyp excision coding

coding depends on extent of excision: extensive polyp excision usually performed in hospital setting

When polyps are removed from both the left and right sides of the nose

modifier -50(bilateral) assigned

coding excision or destruction of lesions inside nose

codes based on approach -internal (respiratory) or external (integumentary)

exceptions to the rules

if laser was used in destruction of lesion, separate set of codes just for laser destruction; BUT in nose category laser included as one of destruction methods.

Turbinates

bones on inside of nose - also called nasal conchae, dived into 3 sections, inferior, middle and superior

coding turbinate bone removal due to chronic congestion or neoplastic growth

document medical necessity for these noncosmetic procedures

Introduction coding (30200-30220)

include injection, displacement therapy and i nsertion

injections in the turbinates

(steroid) therapeutic injections to shrink nasal tissue to improve breathing

displacement therapy (30210)

saline solution flushes the sinuses to remove mucus or pus

insertion of nasal button

technique to repair perforated septum without surgical graftin. A nasal button (silicone or rubber) is sutured in place

coding removal of a foreign body

coding depends on removal in office or extensive removal requiring general anesthesia and more invasive surgical procedure

Nasal repair (30400-30630)

procedures: rhinoplasty, septoplasty, and septodermatoplasty

rhinoplasty

procedure to reshape nose internally, externally, or both, coding based on extent (minor, intermediate, major) whether septum was also repaired and initial or secondary procedure

septoplasty

rearrangement of nasal septum, commonly due to deviated septum. Septoplasty code 30520 is reported when the nasal septum is resected

Do not use a septoplasty code if operative report indicates that only a resection of the inferior turbinate(s) was performed.

The resection of the inferior turbinate(s) is reported with 30140 and is not a procedure performed on the septum

Destruction

can be accomplished by use of ablation

Ablation

removal, usually by cutting

ablation or cauterization is performed to remove excess nasal mucosa or to reduce inflammation

TRU

Destruction codes dived according to extent of procedure

superficxial or intra mural

intramural ablation

ablation of deeper mucosa

superficial ablation

only outer layer of mucosa

other procedures (30901-30920)

control of nasal hemorrhage is found under these codes

control of nasal hemorrhage

coding may be use of anterior or posterior pressure to control hemorrhage. codes divided according to type (anterior/posterior) and extent of control required (level of complexity)

anterior nasal packing

application of pressure using packing to the anterior aspect of the nasal cavity

posterior nasal packing

application of pressure using packing to posterior aspect of nasal cavity

ligation

binding or tying off blood vessels, for nasal hemorrhage could be ethmoid or maxillary artery

therapeutic fracture of nasal turbinate

fracturing of turbinate bone and repostioning of it under local anesthetic often to relive obstructed airflow caused by enlarged inferior turbinates or a previous fracture that has healed out of alignment and resulted in deviation of nose.

1. Biopsy of an intranasal lesion

CPT code 30100

2. Primary rhinoplasty including major septal repair due to deviated nasal septum, acquired

CPT code

3. Anterior control of nasal hemorrhage by means of limited chemical cauterizeation and simple packing.

CPT code

4. Septoplasty with contouring and grafting

CPT code:

5. Removal of crayon from nose of 5-year-old boy, conducted as an office procedure

CPT code: 30300 (nose, removal, foreign body)

accesssory sinuses subsection coding

...

lavage

washing nasal sinuses with saline solution introduced through a canula (hollow tube) to remove infection which can be performed on btoh maxillary and sphenoid sinuses

lavage

use modifier-50(bilateral) when lavage is performed on both the left and right maxillary sinuses.

sinusotomy

procedure in which passage is enlarged or a new passage created from nasal cavity into a sinus (usually due to chronic sinus infection to improve sinus drainage) codes divided according to extent of procedure

1. lavage of maxillary sinus, bilateral

CPT Code

2. Simple left frontal sinusotomy using an external approach

CPT code

3. Unilateral sinusotomy of frontal, ethmoid, and sphenoid

CPT code

4. Right radical maxillary sinusotomy

CPT code

5. Pterygomaxillary fossa surgery, transfacial approach, due to chronic antritis of maxillary sinus

CPT code

Larngotomy

incision that is made over the larynx (thyrotomy) to expose the larynx to view

Diagnostic laryngotomy

...

Laryngocele

air-filled space

cordectomy

removal of vocal cords

throtomy

incision of the larynx through the thyroid cartilage for the purpose of exposing the larynx

tracheostomy

performed usually to establish airflow

radical neck dissection

laryngectomy, removal of larynx, lymph glands and/or other surrounding tissue

intubation

establishment of an airway (introduction) provided on an emergency basis or occurence of an inadequate airway

laryngoplasty for a laryngeal web

usually performed in two stages for repair of conginital webbing between the vocal cords, Stage 1 webbing removed and spacing placed between vocal cords. Stage 2, removal of spacer

1.) diagnostic larynostomy

CPT code

2.) laryngotoplasty, two stages, for repair of congenital laryngeal web, removal of spacer

CPT code

3.) Emergency establishment of positive airway by means of endoctracheal intubation

CPT code:

4.) subtotal supraglottic laryngectomy with removal of adjacent lymph nodes and tissue due to a primary malignant neoplasm of glossoespiglottic folds

CPT code:

5.) Pharyngolaryngectomy with radical neck dissection for a primary malignant neoplasm of the pharyngeal region:

CPT code

tracheostomy

planned or performed as emergency procedure

planned tracheostomy

for prolonged ventilation support, beyond the level of support that can be provided by endotracheal intubation or when a patient cannot tolerate an endotracheal tube.

emrgency transtracheal tracheostomy

transverse (across) incision used in a transtracheal approach between cricoid cartilage and the sternal notch

cricothyroid membrane tracheostomy

vertical incision

Introduction category (31715-31730)

catheterization, instillation, injection, and aspiration of the trachea and the placement of tubes into trachea

bronchographic procedures

may include instillation of contrast material into larynx to improve viewing, the contrast material is suspended in a gas (which contains radiant energy) that the patient inhales

bronchographic procedure codes

radiology section codes are reported in conjunction with inject of contrast material

unilateral bronchography with contrast material injection

code 31899 for service of injection the contrast material into the trachea
71040 for supervision and interpetation of unilateral bronchography
not bundled, report each component of service separately

trachea and bronchi excision/repair

include plastic repairs such as tracheoplasty and bronchioplasty,

tracheoplasty

surgical repair of damaged trachea (may involve reconstruction of trachea using grafts or splints formed from cartilage taken from other area of the body or use of prosthesis

bronchoplasty

repair of the bronchus which may involve grafting repair or stents, a chest tube for draining which is bundled into code. The GRAFTING procedure is not bundled and would be coded separately (31770)

1) Emergency tracheostomy, cricothyroid approach

CPT code:

2) Excision of a tumor of the trachea, cervical

CPT code:

3) transtracheal injection for bronchography (code only the injection procedure)

CPT Code

4) Planned tracheostomy in 47 year old patient with acute respiratory failure

CPT code

5) catheterization with bronchial brush biopsy for bronchiolitis, acute.

CPT code

Thoracotomy

surgical incision into chest wall and opening the area to view by surgeon

Thoracotomy coding

codes divided according to reason for procedure (biopsy, control of bleeding, cyst removal, foreign body removal, or cardiac massage)
Chest tube insertion bundled into thoracotomy codes

Pleurectomy

removal of parietal pleura by opening chest, using rib spreader.
Not coded if bundled into major procedure

pneumonectomy with pleurectomy

pleurectomy bundled with pneumonectomy code

Percutaneous needle lung or mediastinum biopsy

often under radiologic guidance for correct placement of needle. biopsy code (32405)

pneumonocentesis

withdrawal of fluid from the lung by means of aspirating needle (

pneumonothorax

air or gas in pleural cavity, occurs when lung is traumatically ruptured or emphysematous bulla ruptures

thoracic cavity

intrathoracic

collapsed lung

air pressure increases in thoracic cavity, pressure on lung can result in lung collapase, surgeon withdraws air to allow the lung to reinflate

removal of lung coding

based on how much of lung removed, segmentectomy for one segment, lobectomy for one lobe, bilobectomy for two lobes, total pneumonectomy for entire lung as well as extent of procedure and approach

segmentectomy

removal of one lung segment

lobectomy

removal of one lobe

bilobectomy

removal of two lobes

total pneumonectomy

entire lung

removal/repair of part of bronchus during lobectomy or segmentectomy

code service with add-on code 32501

thoracenteis

withdraw fluid from pleural space that has accumulated (from congestive heart failure, pneumonia, TB or carcinoma)

chest tube insertion

may be inserted using thoracentesis as an indwelling method of draining the accumulated fluid in the pleural space

pleural effusion

accumulated fluid in the pleural space

multichamber water-seal suction tube

tube used to withdraw fluid pneumothorax, hemothorax, pleural effusion (conditions due to trauma, secondary disease process, or occurs sponatenously)

thoracoplasty

portion of interal skeletal support removed to treat a condition in which pus chronically collects in the chest cavity, requires extensive resection of membrane lining chest cavity

chronic thoracic empyema

chronic collection of pus in chest cavity

coding thoracoplasty

code 32905 thoracoplasty refers to all stages, subsequent stages for removal of packing and are bundled into the surgical code

pneumonolysis

procedure to separate the inside of the chest cavity from the lung to permit the lung to collapse, originally a treatment for tuberculosis, now used in pleural disease evaluation, debridemen of chronic emphysema and more

pneumothorax injection

therapeutic procedure inserting a needle into pleural cavity and injecting air, increasing pressure and lung partially collapses. A Tuberculosis treatment. Chest tube inserted for further injections of air and is bundled into procedure.

1) thoracotomy for exploration

CPT code

2) percutaneous needle lung biopsy

CPT code

3) lobectomy and bronchoplasty performed at same surgical session

CPT code:

4) resection of an apical malignant lung neoplasm

CPT code

5) pneumonostomy with open drainage of absess (pulmonary necrosis

CPT code

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