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03/08/25, 3:57 pm - Wife...: <Media omitted>
03/08/25, 3:57 pm - M Ganeshan: Another on file
03/08/25, 3:58 pm - M Ganeshan: Please send me
03/08/25, 3:58 pm - Wife...: vaginal delivery -first baby (episotomy inculsive )
1.same physician performed Antepartum/postpartum/delivery - 59400
2.physician see only vaginal delivery- 59409
both vaginal /postpartum - 59410
3.antepartum only -4-6 - 59425
7 or visit - 59426
physiscian see antepartum visit 1 - 3 - e/m code report
postpartum care - 59430
if A physician saw only patient anteparum 2 visit only performed - e/m
once baby delivered physician taken care of delivery as well postpartum care performed -
59410
james physician performed antepartum care /Postpartum/delivery - 59400
Ceaseran section (FIRST BABY)
low transverse or transerve section /classic section
1.same physician performed Antepartum/postpartum/delivery -59510,+59525
2. physician see only ceaseran delivery- 59514,+59525
both ceaseran /postpartum -59515,+59525
3.when cearseran performed additionally uterus removed(HYSTERECTOMY ) either
subtotal(NERALY 80 PER ) or total -report both codes (+59525) (dont report hysterectomy
code)
delivery after pervious ceasren delivery (2nd baby )
2nd baby vanginal delivery
1.same physician performed Antepartum/postpartum/ vaginal delivery after pervious ceasren
delivery - 59610
2.physician see only vaginal delivery- 59612
both vaginal /postpartum -59614
2nd cesearan delivery
1. same physician performed Antepartum/postpartum/ceaseran delivery after pervious
ceasren delivery -59618( unsucessful vaginal delivery )
2..physician see only ceaseran delivery- 59620
both ceaseran /postpartum -59622
ABORTION
Spontaneous abortion - medical tretament doing complete abortion - report E/M
surgically doing incomplete abortion -59812
missed abortion -surigically complete abortion - first trimester(0-13 weeks 6 days )/2nd
trimester (14 weeks to 27weeks.6days )
septic abortion - sugically completed
induced abortion - D&C or D&E(without doing otomy or injection )
Aminotic injection (reduce pain & healing purpose ) 1 or more - 59850
D&C OR D&E -59851
Unsccessful or failed converted into hysterotomy -59852
medicatioin treament -vaginal suppostiries 1 or more (postglandin) - 59855
D&C OR D&E -59856
Unsccessful or failed converted into hysterotomy-59857
colposcopy - examine vagina & cervix
cudloscopy -examine pelivic cavity
ligation (made band or clip using in falliopian tube )
1.ligation method doing any period (58600 )
2.postpartum (once baby delivered within 6 weeks pt stay in hospital )-58605
3.any other major abominal surgery & cersearn doing at the time report both code - cesearn
code along +58611 & abdominal major surgery CPT along with +58611(ligation )
4.report RT,LT
vaginal FB with general anesthia - 5 series
vaginal FB without anesthesia or local annesthia - E/M
Male reproductive organ
circumcision
using clamp with or without regional dorsal penile or ring block -(52 modifier )
other than clamp excision -28 days less than or more than
after surgery completed get complication
post circumcision
repair incomplete circumcision
patient got ED (ERECTILE DYSFUNCTION )(perform implant device in penis )
Inseration / removal /use 52 modifier /remove & replace in same session 54410
/remove & replace in same session aditionally debridement (infection )54411
repair
orichectomy -(remova of testies ) - REPAIR /SCOPY
simple or partial
tumour -ingunial apporach
report 50,RT,LT
Orchipexy (surgical fixtation of testies)
apporach(INGUNIAL /SCORTAL/ABDOMINAL) /report 50,RT,LT
ingunial hernia procedure aditionally perform orchiopexy - report both 4 series
along 54640
Anesthesia
- physical status modifier - P1 TO P6
-00326,00561,00834,00836 Do not report +99100
- add on code shoul not report primary cpt
- add on code should not report modifier
- anesthesia (0 series ) + physical status modifier + patient condition
(+99100,99116,99135,99140)
- CPT modifeir (47 - surgeon performed anesthesia CPT code along 47 dont
report 0 series ) ex - 20610 -47
- 23 modifier only report along with 0 series- 00326-23
- MAC (QS ,G8,G9)
- hernia repair - checking age
- checking anatomical site /checking type of procedure -(carefully
checking below bracket description )
-10 % affect burn - frist 9 % 01952 ,01953
TERMINOLOGY
Ectomy-surgical removal
pexy-fixation
plasty-repair/restore/replace
otomy-incision
ostomy-aritfical opening
external cause -only report SDX -dont report PDX - FX,laceration ,contusion
,abrasion,sprain/strain ,Burn care (S,T series )
malignant - primary - metaststic /secondary - meastatsis
Endocrine system
1.Thyroid Lobectomy procedure - 2 lobes (RT& LT )- Parital /subtotal /total (single lobe )
report RT,LT modfier
2.thyroidectomy - total or complete (60240 ) - parital or subtotal (apporach -60271)
patient having malignancy performed thyroidectomy - limited or radical neck
dissection
pervious performed portion of reomove thyroid now pt came balance thyroid
tissues -60260
3.parathyroid gland - exploration /reexploration/transthoraic apporach
4.thymectomy - apporach -with or without radical mediastinal dissection
5>adernal gland - ectomy - Excicsion or scopy
insert scopy but unsuccessful converted to open apporach - open reoprt cpt
Nervous System
Subdural Tap -infant - initial /subsquent
venticular puncture (diagnostic (drian csf fluid or reduce pressure )- with or without injestion
of medicaine
cisternal or laternal puncture (c1-c2)- with or without injestion of medicaine
twist drill burr holes
1.venticular puncture venticular puncture
2.evaaction sudrual hematoma evaaction sudrual hematoma
,extrdural
hematoma - twistdrill /burr hole /carinectomy or otomy
transcather placement - CNS(intracranial /spinal cord )- Non CNS (head or neck - extracranial
/branchiocephlic branch )
stent + angioplasty - report stent (angioplasty inculsive )
ballon dilation - initial vessel - additional vessels (same vascular family or diffierernt vascular
family )
blood clot - ectomy or lysis (medication throught dissolve the blood clot )
Lesion - carnial region
Sterotaic radiosurgery (laser treatment ) - how many lesion / simple or complex
repair - carinotomy / repair / carnioplasty / reduction (megaly condition )
CSF shunt - where te create opening -which area they can re - route
subarchnoid / sudrual(create opening ) - atrial /jugular/
peritoneal/pelural/auricular
venticulo - atrial /jugular/ peritoneal/pelural/auricular
Spinal cord - cyst - aspiration - report gudiance code
- biopsy (collecting samples ) - using needle - report
gudiance code
lumbar punctute - diagnostic or therpeutic (csf fluid leakage )- with fluroscopic or ct gudiance
(inculsive ) dont report (77002, 77012)
- US or MRI gudiance using perform LP - report both
code
Injection & Infusion - subarchnoid /epidural (cervical thoraic ,lumbar,sacrum)
injection
Myelography via lumbar injecction - one region (cervical /thoraic
/lumbosacral)
2 or more region
laminectomy - cxalculate veterbral segment
laminotomy - calculate the interspace - report RT,LT,50 modifier
reexploration (63040) - calculate the interspace - report RT,LT,50
modifier
nerve injection - types of nerve /continou infusion by catherter
transfominal epidural injection - check level of region (C1-C7 ,T1-T12,L1-L5) - type of region -
fluroscopic or CT inculsive
- report RT,LT,50 modifier - dont report
modifeir in add on code 50 modifier - report twice
chemodenervation - checking muscles 1-4 either 5 or more (extermity) / trunk muscles 1-5
either 6 or more muscles
EYE procedure
1 - Removal of EYE - evisccration (scelra left other internal orbit removed )-Enucelation (eye
ball removed ) - Externation (eyeball with eyelid entire removed )
-with or without implant
2.Implant - modification /again secondary inseration / reinseration /removal
3. kertaplasty - anterior lamellaer (perseve posteiro stroma ) /penetrating (entire cornea
replace ) /endolethelial ( inner layer cornea )
4 . goniotomy / trabeculoplasty - galucoma (intraoccular eye pressure )
5. Intraocular lens procedure
Extracapsular -complex (using device )-66982 or without using
device 66984
intracapsular - 66983
- lens prostehesis + seconday implant -both code report
(66982,66984,66983 + 66985)
Strabisum Surgery (weakness of muscle )
- horizontal muscles (lateral or medial )
- vertical (superior or inferior )
- how many muscles taken
- superior oblique muscle
strabisum + any adjustustable suture / posterior fixation /scarring /expolartion - both code
chalzion - excision - same or diffierent eyelid - single or muplitle - under general anesthesia
(67808)
Cerumen impaction (ear wax ) - irriagation/lavage (69209) or insutrument using(69210)
- unsuccessful - E/M (IP/OP)
- report RT,LT,50
Myringotomy - with or without general anesthesia
Tympanostomy (inseration ventailation tube ) - local or topical (69433 )
-
general anesthesia (69436 )
Tympanoplasty - with or without mastoidectomy /mastiotomy
