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4042F

Documentation that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor given intraoperatively (PERI 2)

The provider reports this code for a patient when he does not administer prophylactic antibiotics within four hours prior to a surgical incision or during the surgical procedure.

A patient needs prophylactic antibiotics before, during, and after a procedure to inhibit the growth of bacteria and help against infections. The provider reports this code when he documents that a patient does not receive prophylactic antibiotics within four hours before a surgical incision or during the procedure. Surgical incision refers to a cut into a structure, typically with a surgical knife called a blade or scalpel to initiate a procedure. The provider also documents the visit in the patients healthcare record.

Antibiotic: Substance that inhibits infection.Antimicrobial agent: Substance that repels or destroys microorganisms.Bacteria: Single celled microorganisms, i.e., visible only with a microscope, some of which cause infection.Infection: A disease condition that bacteria, viruses, or other microorganisms cause.Prophylactic, Prophylactic treatment: A treatment that is designed and used to prevent a disease from occurring.

4042F Documentation that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor given intraoperatively (PERI 2)

28465

Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, each

The provider performs open reduction on a patient's displaced tarsal bone fracture and applies internal fixation when necessary, by affixing screws to repair the broken bone. This code does not include work on the talus or calcaneus.

When the patient is appropriately prepped and anesthetized, the provider makes an incision in the foot to reach the fractured tarsal bone, other than the talus or calcaneus. He then manually adjusts the fractured bone for proper placement. He may attach the fragments to each other using screws and pins. Finally, he ensures hemostasis, which is stoppage of bleeding, at the site, and closes the excised area in layers.

Fibula: Bone present in the leg next to the tibia.Internal fixation: Joining the fractured parts of bone using screws and pins.Open reduction: Placing the fractured parts of bone in proper place through an incision large enough to allow direct visualization.Tarsal bones: Bones of the foot situated between the lower end of the tibia and fibula; seven in number; the talus and calcaneus are in the hindfoot and the navicular, cuboid, lateral cuneiform, intermediate cuneiform, and medial cuneiform are in the midfoot.Tibia: Bone present in the lower front area of the leg; also called the shinbone.

You may see the abbreviation ORIF for open reduction, internal fixation.

28465 Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, each

63030

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

This procedure is laminotomy of one lumbar interspace with decompression of the nerve root(s), and includes a partial facetectomy, foraminotomy, and/or the excision of a herniated intervertebral disc. This procedure covers open and endoscopic approaches.

Laminotomy, also known as hemilaminectomy or a partial laminectomy, involves removing the upper and lower portions of adjacent laminae (that is, the laminae on either side of a vertebral interspace), rather than removing the entire lamina(e) of a single vertebra. In this procedure, the surgeon removes upper and lower portions of the laminae surrounding two adjacent vertebral interspaces. If the surgeon performs two hemilaminectomies at adjacent levels, they may choose to remove the entire lamina. Although this may look like a complete laminectomy, the procedure qualifies as two hemilaminectomies as long as the surgeon excises the intervertebral discs as well.

Report an initial laminotomy using 63020 (cervical) or 63030 (lumbar), with +63035 for each additional cervical or lumbar level the provider treats beyond the first.You may append modifier 50 to laminotomy procedures if the provider performs the procedure bilaterally. CPT states you should not append modifier 50 to add-on codes; instead, report the code twice. Check payer preference before reporting.

63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

4044F

Documentation that an order was given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time (PERI 2)

The provider reports this code when he documents the order to administer prophylactic therapy for venous thromboembolism to a patient within 24 hours before a surgical procedure or 24 hours after the surgical procedure.

A patient needs prophylactic therapy before, during, and after a procedure to inhibit the risk of complications. Venous thromboembolism refers to a condition in which a blood clot breaks down within a vein and flows with the blood itself. The flowing blood may reach the lungs and the clot can cause a life threatening pulmonary embolism.Use this code when the provider documents the order to use prophylactic therapy for venous thromboembolism in a patient, within 24 hours before incising a patient to begin a procedure or 24 hours after the surgery ends. The provider also documents the date and time of the order in the patients healthcare record.

Clot: A thick mass of a substance, most commonly blood that is glued together.Embolism: Blood, fat, or gas that blocks an artery.Prophylactic, Prophylactic treatment: A treatment that is designed and used to prevent a disease from occurring.

4044F Documentation that an order was given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time (PERI 2)

27048

Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm

In this procedure, the provider removes a tumor from the soft tissue of the pelvis and hip area situated at the subfascial level. The size of the tumor excision is less than 5 cm.

When the patient is appropriately prepped and anesthetized, the provider makes an incision in the skin of the pelvis and hip area over the tumor to be removed. He dissects down through the subcutaneous tissue to the subfascial or intramuscular level and locates the tumor to be targeted. He then dissects the tumor from its base, circling the incision around the tumor. He ensures that the tumor tissue is completely removed. He then obtains hemostasis at the surgical site and closes the wound by suturing the soft tissue in layers. He may also leave a drain in place.

Use 27045 when the provider excises a tumor from the soft tissue of the pelvis and hip area situated at the subfascial tissue level with an excision size 5 cm or greater.

27048 Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm

96372

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

A therapeutic, prophylactic, or diagnostic substance (a fluid, a drug, etc.) is injected via intramuscular or subcutaneous route into the patient's body. The procedure is performed by the physician himself or by his assistant or nurse under direct supervision of the physician. Injection of a vaccine or toxoid is not included in this code.

First, the area for administration of the injection on the skin is cleansed and disinfected with alcohol or spirit solution. The specific volume of substance to be injected is drawn from the vial into the syringe. The physician himself or an assistant under direct physician supervision administers the substance (except vaccine / toxoid) into patient's body through an intramuscular or subcutaneous route. Injection of a substance includes drugs, other fluids, etc.

Intramuscular (IM): An intramuscular (IM) medication is given / injected by needle into the muscle.Subcutaneous: With a subcutaneous injection, a needle is inserted just under the skin. A drugcan then be delivered into the subcutaneous tissues.

96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

87797

Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism

The lab analyst performs a test for an infectious agent, not otherwise specified in another code, in the specimen using direct nucleic acid probe technique. Use this code if you know the laboratory technique is direct probe technique but do not find a code for the specific infectious agent.

The lab analyst performs all technical steps to assess the presence of specific nucleic acid sequences that indicate the presence of an infectious agent not otherwise specified, NOS, in a primary specimen from the patient, such as blood. The lab analyst prepares the specimen and mixes it with a nucleic acid probe, which is a fabricated single strand sequence of DNA or RNA that joins with the complementary sequence in the specimen through a process called hybridization. The nucleic acid probe includes a label, such as a radioactive or chemical tag, that allows the lab analyst to visualize the hybridization product, if present.Although not limited to testing for a specific condition, providers may order this test if they are looking for a rare cause of an infection, perhaps if testing for all the usual organisms has been reported as negative. For example, Shewanella putrefaciens is a bacteria that can cause pneumonia, on rare occasions. Use 87797 if the clinician orders Shewanella putrefaciens detection by nucleic acid direct probe technique.

Hybridization: Forming a double stranded DNA or RNA molecule by combining two complementary single strands; in the case of tests to detect infectious agents, one strand is from the probe and one is from the specimen.Infection: A disease condition that bacteria, viruses, or other microorganisms cause.Nucleic acid: DNA or RNA; sequence of specific biological chemicals, called nucleotides, which carry genetic information.

If you are testing for more than one NOS organism, you may have to use a modifier to indicate that although this is the same code, you are performing multiple tests.If you know the lab technique but that code family doesnt list the specific infectious agent, you'll have to report the general code, like this one, for that technique. Use these codes for organisms that are not otherwise specified. Some payers may pay separately for collecting the specimen using a code such as 36415 for venipuncture.

87797 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism

90696

Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use

The provider administers a combination vaccine for diphtheria, tetanus toxoids, acellular pertussis and polio virus intramuscularly to children between four to six years of age.

The provider presents the parent, guardian, or patient with the options for immunization. He reviews the risks and benefits along with the potential side effects. When the patient is appropriately prepped, the provider administers the vaccine intramuscularly in the deltoid muscle of the upper arm.Children ages four through six who received DTaP and/or DTaP HepB IPV as the first three doses and DTaP as the fourth dose can receive DTaP IPV as the fifth dose of DTaP or as the fourth dose of IPV. Children younger than four years of age should not receive DTaP IPV.

Acellular pertussis: Immensely infectious respiratory disease.Antibody: Proteins produced in blood activated as part of the immune response to neutralize specific invaders such as bacteria or viruses, also called immunoglobulin.Antigen: Foreign bodies, such as bacteria, that enter the human body or substances that form within the body that cause an immune response and possibly infection.Antitoxin: An antibody to counterbalance the toxin secreted by the antigen.Atrophy: Reduction in amount of tissue.Combination vaccine:A vaccine with components that protect against multiple illnesses; they reduce the number of injections required and help promote timely vaccinations and complete immunizations.Deltoid: Fan shaped muscle in the shoulder region.Diphtheria: Upper respiratory tract infection that Corynebacterium diphtheria causes.DTaP IPV:A combination vaccine to protect against diphtheria, tetanus, pertussis, and polio.Immunization: Use of a modified form of an infectious agent to protect against an infectious disease.Inactivated:Derived from a killed virus.Infectious: Able to cause infection.Intramuscular:Within a muscle.Polio: An acute infectious viral disease that causes fever, motor paralysis, and atrophy of skeletal muscles with permanent defect and impairment.Tetanus: Bacterial disease that causes rigidity and involuntary contraction of voluntary muscle; lockjaw.Toxoids: Inactive bacterial infection that stimulates the immune system to produce specific antitoxin antibodies that destroy the toxins released by bacteria.Vaccine: An altered form of a virus given to an individual for long term protection against the disease caused by the virus.

When coding for immunizations, report separate codes for vaccine administration, the actual vaccine, and an office visit, based on the documentation. Include sufficient documentation from your provider explaining the product administered, administration route, and purpose.Some insurance companies require modifier 25 to be appended to the associated evaluation and management (E/M) code.Medicare and private insurance companies might have different guidelines for reporting any vaccines, or for reporting certain vaccines during the same visit, such as flu and pneumonia vaccines. Check with the individual payers for their specific guidelines. Be sure to have the policy in writing to protect your practice in the event the payer questions your modifier use which is not consistent with CPT guidelines.Select the appropriate DT or DTaP code from the available options, such as 90696-90702.

90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use

38211

Transplant preparation of hematopoietic progenitor cells; tumor cell depletion

The provider prepares the hematopoietic progenitor cells (HPCs) using a combination of enrichment and depletion techniques to remove the most tumor cells possible to minimize the chances of reintroduction of tumor cells into the recipient.

After the provider harvests, preserves, and thaws the hematopoietic progenitor cells (HPCs), he prepares the solution for transplant into a patient from whom the provider harvested the cells. The provider reduces the number of tumor cells left in the HPC solution using multiple methods such as elutriation, agglutination, and CD34-positive cell enrichment technique in which the provider uses CD34, a positive antigen, to separate the tumor cells from the rest of the cells. For this service, he combines these techniques, usually applying the C34-cell enrichment technique first and then following with a depletion technique such as elutriation for additional removal of tumor cells.

Agglutination: Abnormal clumping of particles of any substances, most commonly in case of abnormal clumping of blood cells due to contact between incompatible blood groups.CD34-positive cell enrichment: Process by which the provider isolates CD34 cells from all the other cells, including the targeted cells the provider wants to remove in the hematopoietic progenitor solution; the provider is then able to remove the unwanted cells, including such cells as T cells or tumor cells.Elutriation: A process of separating particles of a solution on the basis of particle size.Hematopoietic progenitor cells (HPCs): Specialized blood-forming cells found in bone marrow that can develop itself into different types of blood cells.Tumor cell: An abnormal cell with a capacity to multiply in an uncontrolled manner.

Report this service only once per day.

38211 Transplant preparation of hematopoietic progenitor cells; tumor cell depletion

27059

Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greater

You'll use this code for extensive surgical removal of a soft tissue tumor and surrounding tissues of the pelvis and hip area, measuring 5cm or more.

With the patient under anesthesia, the physician makes an incision and raises subcutaneous flaps. He exposes the muscles around the tumor and cuts into the fascia. Radical excision of the target area is performed, removing the tumor en bloc as well as necessary surrounding structures, including fascia and skin. Lymphatics and blood vessels are ligated as needed. The area is inspected, and frozen sections are taken from tissue around the area. The specimen is taken to pathology. Based on the pathology, the physician may perform additional excision at the area. Once margins are clear, the physician irrigates the wound, places a drain if needed, and closes the wound in layers.

Radical Resection of soft tissue tumor: Surgical removal of the tumor as well as wide margins of healthy tissue

Compare with 27049. Check the documentation carefully for the size and the skin layer depth to which the surgery took place before choosing the code.When selecting a code for this type of procedure, the defining measurement is the size of the excision, not the size of the lesion. For instance, the surgeon might have to excise 7 cm to remove a 4.5 cm tumor. If the doctor documents only the size of the lesion and not the resection size, you could end up with a lower code.Measure before pathology: The surgeon should measure and document the resection size during surgery. Excised tissue shrinks dramatically during processing, so you'll under-size the excision if you base the measurement on the pathology report.

27059 Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greater