CPC

Operative notes describe the approach (how the surgeon reached the site) and the action (what was done). Both drive code choice: the same removal may have separate codes for open, laparoscopic, and endoscopic approaches.

Term	Defi nition
Biopsy	Removaloftissueforpathology Incisionalremovespartofalesion;excisionalremovesthewhole .
	lesion .
Excision·Destruction	Excisioncutstissueout(fullthickness specimenavailable);destructionablatesit(laser cryosurgery , , ,
	electrosurgery chemical)andleavesnospecimen , .
Shaving	Sharp removal of an epidermal or dermal lesion by transverse incision or slicing , without a full -
	thicknessexcision .
Debridement	Removalofdevitalizedorcontaminatedtissue;codedbydepth(skin subcutaneoustissue muscle , ,
	andfascia bone)andsurfacearea , .
Incisionanddrainage(I&D)	Openinganabscess cyst orhematomatoreleaseitscontents , , .
Aspiration	Withdrawingfluidorcellswithaneedleandsuction .
Resection·Ablation	Removal of all or part of an organ · destruction of tissue by energy (radiofrequency , cryo , laser) .
Anastomosis	Surgicalconnectionoftwotubularstructures(bowel vessels ducts) , , .
Ligation·Fulguration Reduction	Tying off a vessel or duct · destruction of tissue with electric current . Restoringafractureordislocationtonormalalignment:closed(manipulationwithoutincision)oropen (surgicalexposure) .

Commonproceduralterms(Continued)

Term	Defi nition
Fixation	Internal(plates screws rods pinsplacedinside)orexternal(aframeoutsidethebodyattachedby , , ,
	pinsthroughtheskin) .
Graft·Flap	Graft:tissuemovedwithoutitsownbloodsupply(autograftfromthepatient allograftfromadonor , ,
	xenograftfromanotherspecies) Flap:tissuemovedwithitsbloodsupplyattached . .
Curettage·Dilation·Lavage	Scraping with a curette · widening a passage · washing out a cavity .

A surgical endoscopy always includes the diagnostic endoscopy, and a surgical laparoscopy includes the diagnostic laparoscopy. When the diagnostic look leads to a biopsy, removal, or repair in the same session, code only the surgical scope procedure.

Directional terms assume anatomical position: standing upright, facing forward, arms at the sides with palms forward. They appear in operative notes and in code descriptors (proximal humerus, distal radius, superficial vs deep).

TermPair	Meaning
Anterior(ventral)·Posterior(dorsal)	Towardthefront·towardtheback
Superior(cranial)·Inferior(caudal)	Towardthehead·towardthefeet
Medial·Lateral	Towardthemidline·awayfromthemidline
Proximal·Distal	Closertothetrunkorpointofattachment·fartherfromit(usedforthelimbs)
Superficial·Deep	Towardthebodysurface·awayfromthesurface
Ipsilateral·Contralateral	Sameside·oppositeside

Position	Description
Supine	Lyingontheback faceup ,
Prone	Lyingontheabdomen facedown ,
Lateraldecubitus	Lyingononeside(rightorleftlateraldecubitusnamesthesidedown)
Lithotomy Trendelenburg Fowler's	Supinewithhipsandkneesflexedandlegsinstirrups(gynecologic urologic andrectalproced1ures) , , Supinewiththeheadlowerthanthefeet(reverseTrendelenburg:headhigher) Sitting or semi -sitting head of the bed raised (semi -Fowler's about 30 to 45 degrees) ,

The skin has two layers, the epidermis (the outer, avascular layer; its surface is the stratum corneum) and the dermis (connective tissue containing blood vessels, nerves, hair follicles, and sebaceous and sweat glands). Beneath them lies the subcutaneous tissue (hypodermis), mostly fat, which rests on fascia and muscle. Depth of involvement defines skin lesion, debridement, repair, and burn codes.

Burndepth

Depth	LayersInvolved
Firstdegree(superficial)	Epidermisonly;red painful noblisters , ,
Seconddegree(partialthickness)	Epidermisandpartofthedermis;blisters
Thirddegree(fullthickness)	Throughthedermisintosubcutaneoustissueordeeper

Burn extent is estimated with the rule of nines: head and neck 9%, each upper limb 9%, each lower limb 18%, anterior trunk 18%, posterior trunk 18%, genitalia 1%. ICD-10-CM codes burns by site and degree (T20–T25) and by total body surface area (T31).

The skeleton divides into the axial skeleton (skull, vertebral column, ribs, sternum) and the appendicular skeleton (shoulder and pelvic girdles and the limbs). A long bone has a shaft (diaphysis), ends (epiphyses), the flared region between them (metaphysis), an outer membrane (periosteum), and a central medullary cavity.

Type	Description
Closed·Open	Skin intact · bone communicates with an open wound (compound) . ICD-10-CM default when not
	documented:closed .
Displaced·Nondisplaced	Fragments out of alignment · fragments aligned . ICD-10-CM default when not documented:
	displaced .
Comminuted	Bonebrokenintothreeormorefragments
Greenstick	Incompletefracture onesidebentandtheotherbroken;seeninchildren ,
Transverse·Oblique·Spiral	Straightacrosstheshaft·angled·twistingaroundtheshaft
Pathological	Fractureofboneweakenedbydisease(osteoporosis neoplasm)withlittleornotrauma;coded ,
	from Chapter 13 (M80 M84 .4–M84 .5) not as an injury , ,
Stress	Fatigue fracture from repetitive force (M84 .3-)

Joints are classified as immovable (synarthroses), slightly movable (amphiarthroses), or freely movable synovial joints (diarthroses). A synovial joint has articular cartilage, a synovial membrane and capsule, and supporting ligaments (bone to bone); tendons attach muscle to bone, and bursae cushion moving parts. The knee has medial and lateral menisci and cruciate (ACL, PCL) and collateral (MCL, LCL) ligaments; the shoulder's rotator cuff consists of the supraspinatus, infraspinatus, teres minor, and subscapularis.

CPT fracture treatment terms are not the same as ICD-10-CM fracture types. Closed treatment means the fracture site is not surgically opened, open treatment means it is exposed (or fixed with an intramedullary device through a remote incision), and percutaneous skeletal fixation means pins placed across the fracture under imaging. An open (compound) fracture can receive closed treatment.