Chapter 17 — Further Reading

Tier 1 — Verified canonical sources

The CPT Surgery guidelines, current edition. This is the source of the surgical package, stated in about a page, and it is the most consequential page in CPT that coders do not read. Everything in §17.1 is a paraphrase of it.

The CPT subsection guidelines for the Integumentary and Musculoskeletal systems. Each carries rules this chapter summarizes — the lesion measurement rule, the repair classifications and the adding rule, the Mohs requirements, and the fracture treatment definitions all appear here, in the source, with qualifications a summary cannot carry.

The parenthetical notes throughout both sections. Chapter 13 §13.5 said the instructions are hiding in the parentheticals. The surgery sections are where that is most true, and the "(separate procedure)" designation in particular is three italic words that decide whether a code may be on the claim.

CPT Assistant. Subscription. The lesion measurement rule and the repair adding rule are among its most frequently revisited topics, precisely because they are so consistently misapplied.

Medicare Physician Fee Schedule relative value file, CMS. Free. This is where the global period indicator lives, in a column, for every code. Chapter 14 named four questions answered by four columns in this file; §17.2 uses the first of them, and it is the one you will open most often.

Medicare Claims Processing Manual (Publication 100-04), Chapter 12 — CMS's global surgery instructions, including its treatment of the global package, the preoperative day, and the global period modifiers. CMS's global surgery guidance is more operationally specific than CPT's and is free.

The CMS Global Surgery Booklet, Medicare Learning Network. Short, free, and written for a general audience. If §17.1 and §17.2 went too fast, read this next.

National Correct Coding Initiative Policy Manual, CMS, particularly the chapters covering the integumentary and musculoskeletal systems. This is the document that governs whether Account 31-2245's line 3 was permissible, and it addresses arthroscopic debridement specifically.

NCCI Procedure-to-Procedure edit files, CMS. Free, updated quarterly. You can look up the 29827/29822 pairing yourself, see the edit and its modifier indicator, and know before you bill.

OIG Work Plan and reports on Mohs micrographic surgery, wound care and debridement, and global surgery billing. All three have been recurring items, and the reports describe the specific patterns reviewers look for.

Payer surgical reimbursement policies, particularly on fracture care, casting supplies, and arthroscopic bundling. §17.8's 📞 On the Phone turns on whether a payer bundles the casting supply, which varies.

Tier 2 — Attributed, specifics unverified

Specialty society coding resources — orthopedics, dermatology, plastic surgery, general surgery. For this chapter more than any other, specialty material is better than general material, because it works from real operative notes in the specialty you are coding. Orthopedic coding guidance on fracture care and arthroscopy is particularly good.

AAPC and AHIMA surgical coding material, including material on reading operative reports. The "read the body, not the heading" discipline is widely taught and worth hearing from a second voice.

Published guidance on the lesion excision measurement rule. It is a favorite topic of coding educators for a reason, and the explanations frequently include diagrams this book cannot reproduce.

Wound care and debridement coding guidance, an area with substantial specialized literature and substantial audit attention. Depth-versus-exposure is the recurring theme.

Commentary on modifier 59 utilization in surgical specialties, including comparative rate analyses. Case Study 1's frequency report is the technique these analyses use.

Compliance literature on billing macros and automated modifier application. Case Study 1's root cause, in the general literature.

Tier 3 — Illustrative and constructed

The operative note excerpts in §17.3 and §17.10, and all four notes in the exercises.

The measurement scenario in §17.4's 🧮 Run the Numbers — the four numbers and the three wrong ones.

The repair scenarios in §17.5, including the four-laceration 🔍 Check Your Understanding.

Account 31-2245 in its entirety and Case Study 1 — Ridgeview Orthopedic Surgery, the 42 claims, the \$612.40, the \$25,720.80, and the eleven defensible claims. All constructed. The pattern is one of the most frequently documented findings in surgical coding.

Case Study 2 in its entirety — the two practices, the fracture, the ninety days, and the patient's six hours on the telephone. Constructed; the collision is ordinary.

Account 10-4471's 20610 analysis in §17.2 and §17.7.

Three things worth doing

Read the CPT Surgery guidelines straight through. About a page. It is the source of every rule in §17.1 and most coders working in surgical practices have never read it.

Open the NCCI edit file and look up one code pairing you bill. See the edit, see the modifier indicator, and notice that you could have known before the claim went out. Account 31-2245 is eighteen months of not doing this.

Then run the frequency report from Case Study 1 against your own organization: for each code pairing where a distinctness modifier is used, what percentage of the time is it used? Anything above 90% is a finding. It is one query, it needs no charts, and it is the second technique in this book you can run in an afternoon — Chapter 15 §15.9's time summation was the first.