2007 PMCC Musculoskeletal System Chapter 10

1. 2007 PMCCMusculoskeletal System Chapter 10

2. Chapter Outline Introduce students to Anatomical terminology Surgical terminology Coding issues related to the musculoskeletal system

3. Basics of Anatomy Musculoskeletal system is a system of fibrous connective tissue that provides Movement, form, strength, protection Made up of Bones, muscles, cartilage, joints Human skeleton divided into two parts Axial, appendicular Muscles Serve to provide movements called contractions to body parts Locomotion, grasping and variety of functions would not be possible without muscles Three types of muscles—skeletal, cardiac, smooth

4. Documentation Global concept of fracture care differs slightly from other surgical codes First cast application is included with fracture care Setting and care of closed fractures and/or dislocations with casts/straps Not traditional surgeries since no anesthesia is administered, no creation of surgical wounds Closed treatment of fractures Falls under global procedure guidelines for CMS and commercial payers

5. Diagnosis Coding Appropriate codes for fracture or dislocation of a bone/joint Based on identifying several key criteria Type of treatment Site of defect Nature of the fracture Type of fracture and how it was sustained Critical for ICD-9-CM code selection Chapter 16 (Symptoms, Signs, and Ill-Defined Conditions) Not inclusive of all conditions considered integral to a disease process A condition that may not be associated routinely with the disease should be assigned additional codes

6. CPT Procedure Coding When reporting CPT code with descriptor that includes “separate procedure” Coder must determine if procedure was an integral part of the major procedure If performed alone, the code may be reported If performed at same time as an integral part of major procedure, “separate procedure” considered incidental and cannot be reported Coding Concepts Musculoskeletal chapter divided into procedural sections that are common to many anatomical regions Example: Codes for fractures and/or dislocation are found under 14 subsections

7. Fractures and/or Dislocations Types of Fractures/Dislocations Dislocation—displacement or derangement of bones that come together to form a joint is most often encountered when treating dislocations Open Fracture or Dislocation—one that communicates with or breaks through a wound in the skin (synonymous with a compound fracture or dislocation) Closed Fracture or Dislocation—has no communication with the skin or the outside environment. Also known as simple fracture or dislocation

8. Fractures and/or Dislocations Coding the Fracture/Dislocation Procedures Type of fracture does not have any coding correlation with type of treatment provided Codes for treatment of fractures and joint injuries are categorized by type of Manipulation (reduction) and Stabilization (fixation or immobilization) Codes can apply to either Open or closed fractures or joint injuries

9. Fractures and/or Dislocations Coding the Fracture/Dislocation Procedures Closed treatment Refers to a fracture/dislocation that is treated without making an incision into the fracture site; three different methods of fracture care Closed treatment without manipulation Closed treatment with manipulation Closed treatment with or without the application of traction

10. Fractures and/or Dislocations Coding Re-reductions of a Fracture/Dislocation When patient has already had cast or strapping material applied and returns for repeat radiograph that shows bone to be misaligned Orthopedic surgeon may choose among several treatment options Realign and cast the fracture Take patient to operating room for ORIF

11. Fractures and/or Dislocations Coding Re-reductions of a Fracture/Dislocation continued Coders Tip Modifier 76 should be attached to CPT code when used a second time for a procedure Modifier 77 may be used if repeated by another physician Modifier 78 would be required when procedure occurs within postoperative period

12. Fractures and/or Dislocations Coding Malunions, Nonunions Procedure codes are located in subsection “Repair, Revision and/or Reconstruction” Important to accurately code surgery for malunions or nonunions with CPT code specific to these problems ICD-9-CM code should reflect medical necessity of these procedures (eg, 733.81 or 733.82) Determining when fracture becomes malunion/nonunion is at Provider’s discretion

13. CPT Procedure Coding Coding Arthrodesis Arthrodesis is surgical fixation of a joint May be performed and reported alone May be performed along with another definitive procedure such as Laminectomy, osteotomy, fracture care, vertebral corpectomy If arthrodesis performed with definitive procedure, both procedures may be reported along with modifier 51

14. CPT Procedure Coding Coding Amputation Common indications for amputation include Circulatory impingement resulting from peripheral vascular disorders Traumatic and thermal injuries Malignant tumors Uncontrolled or widespread infection of an extremity Congenital disorders Do not code an amputation When it may be considered an avulsion Variety of amputation techniques Coded first based on location, then coded based on technique

15. CPT Procedure Coding Incisions (20000-20005) Primarily relates to procedures such as Incision and drainage of both deep and superficial infections Incisions are made into soft tissues to Drain and clean out abscesses Remove foreign bodies Codes 20000-20005 Describe incisions of soft tissue abscesses

16. CPT Procedure Coding Wound Exploration (20100-20103) Separate procedure codes that report Exploration, debridement, enlargement of wound, extension of dissection from penetrating gunshot or stab wounds Involves subcutaneous tissue, muscle fascia, muscle, ligation or coagulation of “minor” muscular or subcutaneous blood vessels Exception to reporting these codes is Circumstances involving major structures or major blood vessels Use specific codes describing those procedures Do not use wound exploration trauma codes

17. CPT Procedure Coding Excisions (20150-20251) Bone biopsy used to distinguish between Malignant tumors and benign bone disease Performed by making incision into skin for inserting a needle to retrieve sample of bone for examination In adults Sample usually taken from pelvic bone, typically from the posterior superior iliac spine Codes 20240 and 20245 Excisional or incisional bone biopsy Often used when a wider or deeper portion of skin is needed

18. CPT Procedure Coding Introduction and Removal (20500-20694) Code range 20500-20615 Includes various injections bases on anatomical site Some codes may be used to report aspiration procedure Code 20526 Therapeutic injection into carpal tunnel Codes 20600-20610—used for arthrocentesis and/or injection of a joint, bursa, ganglion cyst Imaging guidance performed in conjunction with these, see 76942, 77002, 77021 Codes 20650-20694 Refer to application or removal of various fixation and traction devices used in conjunction with surgeries involving bone

19. CPT Procedure Coding Replantation (20802-20838) Involves Cleansing of amputation site (traumatic) Debridement of devitalized tissue Shortening of bone (if necessary) Internal fixation or arthrodesis Repair of tendons, arteries, veins and nerves Skin closure including tendon, skin flaps, grafts Codes 20802-20838 Replantation of specific body part Includes necessary attachments of all underlying structures associated with a complete amputation

20. CPT Procedure Coding Grafts or Implants (20900-20938) Bone graft Autologous bone—harvested from patient’s pelvic bone and provides calcium scaffolding for growth of new bone Allograft bone—provides calcium scaffolding and does not have any bone-growing cells or bone-growing proteins Codes for obtaining autogenous bone grafts, cartilage, tendon, fascia lata grafts or other tissues through separate incisions Used only when graft is not already listed as part of the basic procedure However, when CPT description includes terms “with autograft, “with bone graft” or “with or without bone graft” Appropriate to report additional bone graft if it was harvested through a separate skin or fascial incision

21. CPT Procedure Coding Other Musculoskeletal Procedures (20950-20999) Code 20950—method of detecting muscle compartment syndrome or muscle ischemia Interstitial pressure-monitoring device is inserted into muscle compartment by using a needle, wick catheter, or other means Codes 20955-20962 Vascularized bone grafts Used where there are large defects, usually in long bones, where standard iliac bone graft or other types of nonvascularized bone grafts are not likely to heal Codes 20974-20975 Electrical stimulation to aid bone healing, noninvasive or invasive

22. CPT Procedure Coding Head (21010-21499) CPT code 21060—surgical removal or part or total meniscus of the TMJ Repair, Revision, and/or Reconstruction (21120-21296) Codes 21141-21160 Reconstruction of midface, Lefort I, II, or III procedures Complex, requiring multiple incisions, bone grafts and introduction of internal hardware to hold defects in place

23. CPT Procedure Coding Neck (Soft Tissues) and Thorax (21501-21899) Code 21685—enlarging of the retrolingual/hypopharyngeal airway to help correct sleep-disordered breathing Commonly described as hyoid myotomy and suspension Procedure opens the oropharyngeal airway and performed on the laryngeal skeleton Back and Flank (21920-21935) The four codes in this subsection report Biopsy of soft tissue, tumor excision, radical resection of a tumor

24. CPT Procedure Coding Spine (Vertebral Column) (22100-22899) Spinal column divided into five regions Cervical, thoracic, lumbar, sacral, coccygeal Access to spinal surgery can be accomplished through variety of approaches Two most common are posterior and anterior Vertebral Body, Emobilization or Injection (22520-22525) Codes 22520-22522—represent percutaneous vertebroplasty procedures

25. CPT Procedure Coding Arthrodesis Bone grafts (20930-20938) performed in conjunction with an arthrodesis May be reported in addition to codes for fusion Modifier 51 exempt Arthrodesis—accomplished through use of cortical bone graft packed in and around the spine Promotes production of new bone cells secondary to addition of graft material Instrumentation (22840-22848, 22851) performed in conjunction with arthrodesis Reported in addition to the code for the fusion Modifier 51 exempt

26. CPT Procedure Coding Lateral Extracavitary Approach Technique (22532-22534) Codes 22532-22533 Vertebral body resection and fusion procedures at single thoracic and lumbar level Code 22534 Add-on code for each additional level after the first This approach requires Resectioning of the ribs, pleura, and peritoneum Dissecting spinal/paraspinal tissues to access the vertebral bodies/discs

27. CPT Procedure Coding Exploration (22830) Used when surgeon explores previous spinal fusion Not considered integral to an arthrodesis Modifier 51 appended to additional procedure Spinal Instrumentation (22840-22855) Used to treat Abnormal curvature of the spine, stabilize spine after spine surgery, treatment of fracture and/or dislocation

28. CPT Procedure Coding Spinal Instrumentation (22840-22855) continued Segmental—fixation is provided at two ends of a bony construct and there is minimum of one additional bony attachment placed in between Nonsegmental—fixation at both ends of a construct without any additional attachments between them Codes 22842-22844 Posterior segmental instrumentation Code 22840 Nonsegmental fixation of posterior spine

29. CPT Procedure Coding Abdomen (22900-22999) Code in this subsection reports Excision of a subfascial abdominal wall tumor Also other code for other procedures to the abdomen Coders should always check the Category III codes prior to assigning an unlisted procedure code Documentation should accompany claim when reporting either an unspecified or category III code

30. CPT Procedure Coding Humerus (Upper Arm) and Elbow (23930-24999) Tip—Sequestrectomy is removal of a piece of necrotized tissue (bone) that has separated from the healthy bone. Sequestrectomy codes are classified by site Example: code 24134, humerus and 24138, olecranon process Hands and Fingers (26010-26989) Four muscle groups found in hand Each housed in separate compartment No-man’s land (Zone 2) Area between the distal crease of the palm and the proximal end of the middle phalanx

31. CPT Procedure Coding Hands and Fingers (26010-26989) continued Coders must differentiate among codes that mention Work on single tendon versus work on multiple tendons through same incision Code 27685—single tendon lengthened or shortened in leg or ankle Code 27686—each tendon or group of multiple tendons lengthened/shortened in leg or ankle Many procedures Bundled into the repair codes Should not be identified separately

32. CPT Procedure Coding Toe-to-Hand Transfer (26551-26556) Offers patient possibility of recovering Mechanical and sensory function Toe-to-hand transfer with microvascular anastomosis, great toe “wrap around” Significantly different from standard great toe-to-hand transfer Pelvis and Hip Joint (26990-27299) Joint prosthesis is identified as Total hip arthroplasty if both articular surfaces of acetabulum and femur replaced Imaging of hip joint and its complications relies on Information obtained from routine radiography and to a lesser extent arthrography, nuclear medicine, sonography

33. CPT Procedure Coding Femur (Thigh Region) and Knee Joint (27301-27599) Head of femur Fits into acetabulum of the innominate bone and allows rotational movement in hip joint Greater tronchanter and less tronchanter Sites for muscle attachment Patella Fits into groove at distal anterior surface of the bone Diaphyseal fractures Result from significant force transmitted by direct blow or from indirect force transmitted at the knee

34. CPT Procedure Coding Foot and Toes (28001-28899) Bunions—caused by swelling and inflammation on first digit at the joint where distal metatarsal joins proximal phalanx Hallux valgus—refers to altered angle of great toe leaning in toward other toes and at times over- or underlapping with them Hammertoe—flexion deformity of the PIP joint that is fixed creating claw-like appearance Code for hammertoe correction is 28285 Codes for hallux valgus correction are 28290-28299

35. CPT Procedure Coding Bunionectomy Codes and Their Eponyms Keller, McBride or Mayo Type, 28292—removes medial eminence of distal metatarsal bone and resection from base of proximal phalanx Keller-Mayo with Implant, 28293—removes medial eminence of distal metatarsal bone and resection from base of proximal phalanx with insertion of double stem implant in proximal phalanx Joplin Procedure, 28294—rearranges the tendons of toe to correct a bunion deformity followed by removal of medial eminence of distal metatarsal bone Mitchell, Chevron, Austin or Concentric Type Procedure, 28296—involved double osteotomy in first distal metatarsal Lapidus-Type Procedure, 28297—fuses metatarsal bone to cuneiform bone to affect distal repair of bunion and correction of hallux valgus Aiken Procedure, 28298—removes a wedge from bottom of proximal phalanx and usually medial eminence of distal metatarsal bone; toe immobilized with percutaneous placement of Kirschner wire

36. CPT Procedure Coding Application of Casts and Strapping (29000-29750) Application and removal of first cast or strapping device Part of the global surgical care for musculoskeletal procedures Subsequent replacement of casts and/or traction devices may require reporting additional CPT code See CPT codes 29000-29799 When cast or strapping is replacement from first cast within or after follow-up period Code for cast application is reported E/M services rendered in conjunction with reapplication are not reported separately

37. CPT Procedure Coding Application of Casts and Strapping (29000-29750) continued If significant and identifiable service rendered in addition to casting Appropriate to report E/M service with modifier 25 When removal of cast is from physician other than the physician who applied the cast Removal of cast can be reported with cast removal codes 29700-29715

38. CPT Procedure Coding Endoscopy/Arthroscopy (29800-29999) Surgical arthroscopies always include diagnostic arthroscopies of same joint If no CPT code available for therapeutic arthroscopy performed, it is not appropriate to code for open procedure When diagnostic scope procedure followed by open procedure Appropriate to code both and append modifiers 59 and 51

39. CPT Procedure Coding Nervous System Codes Related to Musculoskeletal System Codes in the 60000 series include Those related to the musculoskeletal system Excision codes for herniated disks and corpectomy and laminectomy codes Excision of Herniated Disc (63020-63044, 63055-63066) Herniation of the intervertebral disc--most common surgical problem encountered as a result of back injury Surgeon usually refers to two vertebral segments (eg, L2-L3) Description reports the work done in the space between L2-L3 Represents only one unit of work

40. CPT Procedure Coding Corpectomy (63081-63091, 63101-63103) Corpectomy—removal of a vertebral body When surgery is performed on the vertebral body, such as a corpectomy Unit of service is each vertebral body Laminectomy (63170-63200, 63250-63290) Laminectomy—removal of the lamina of the vertebrae to allow access to the disc, intervertebral joint, facet joint, and to provide nerve decompression posteriorly

41. The End