Introduction
The surgery section is the largest section of CPT. It contains subsections and is organized by body systems. Each subsection is further subdivided into categories by specific organ or anatomic site. The surgical package includes a variety of services provided by the surgeon. The surgical package includes the surgical procedure performed, local or topical anesthesia, one related encounter, immediate post-operative care and typical post-operative follow up care.
The physician who performs the surgery reports the CPT code. Documentation in the health record must support the code(s) selected. Careful review of the operative report and/or progress note is essential. The guidelines located at the beginning of the surgery section and many of the subsections of the CPT codebook must be carefully reviewed.
Objectives
Upon completion of this module, the student will be able to:
- Define the surgical package and its components
- Describe the organization of the surgical section in CPT
- Given a procedure or operative report, correctly assign CPT surgery codes
- Define National Correct Coding Initiative (NCCI)
Readings & Resources
Required textbook reading: Kuehn, Lynn. Procedural Coding and Reimbursement for Physician Services: Applying Current Procedural Terminology and HCPCS. AHIMA Press. 2012 edition.
Chapter 4
AMA, Current Procedural Terminology (CPT) 2013. Professional Edition.