Transcript Musculoskeletal System

By Alex Munoz, CPC, NCICS
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Subsection divided: Anatomic
site
(Forearm and Wrist), then service
(e.g., excision)
Used extensively by orthopedic
surgeons
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Many codes commonly used by
variety of physicians
Extensive notes
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Most common:
Fracture and dislocation treatments
 “General” subheading
 Arthroscopic procedures
 Casting and strapping
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Questions to ask:
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Site of fracture or dislocation
Type of treatment (open, closed)
Manipulation performed and documented
Was traction used; if so, what type
Was percutaneous fixation used
Was internal fixation applied (make sure this is not included in
code description)
Was an external fixation system applied
Did documentation support skin closure
What type of anesthesia was used
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*Open: Surgically opened to view or remotely opened to place
nail across fracture
 Open reduction with internal fixation (ORIF)
*Closed treatment, fracture site is not exposed by surgical incision
*Percutaneous, neither open or closed. Fixation devices (such as
pins) are placed across the fracture site under imaging
Treatment terms not to be confused with type of fracture
 Open fracture: Bone penetrates skin
 Closed fracture: Bone does not penetrate skin
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Type of treatment
depends on type
and severity
of fracture
*“Complicated”
in a code descriptor may
indicate excessive
hemorrhage, infection,
prolonged physician
work, or difficulty in
reaching the site or
depth of the site.
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Use of force (distracting or traction force)
applied to internal device (e.g., wire, pin, screw,
or clamp) inserted into bone
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Application of force by means of adhesion
to skin
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Use of force to return a fractured bone to
normal alignment
Fracture repair codes are often divided based
on whether manipulation was or was not used
AKA: Reduction
Manipulation means a fracture has been
reduced
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Fractures are described by a physician in terms
of the direction of the fracture line (horizontal,
vertical, oblique, spiral), and the direction and
degree of angulation (the most distal fragment)
When the fracture results in more than two
fragments, it is comminuted
• Bone displaced from
normal joint position
• Treatment: Return
bone to normal
joint location
Vertebral dislocation/
Subglenoid dislocation
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Begins “Incision”
Depth: Difference between Integumentary and
Musculoskeletal incision codes
Musculoskeletal used when underlying bone or
muscle is involved
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Traumatic penetrating wounds
Divided on wound location (body site)
Includes
Enlargement
 Debridement
 Foreign body(ies) removal
 Ligation
 Repair of tissue and muscle
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These procedures describe surgical exploration
to an already open wound
These codes are “separate procedure” codes
They can be coded and reported in the
following circumstances:
1.
2.
If only procedure performed
If totally unrelated to another procedure performed
at the same session
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Located in Excision subheading
(20200-20251)
Biopsies for bone and muscle
Divided by:
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Type of biopsy (bone/muscle)
Depth
Some by method
Cont…..
• Can be percutaneous needle or excisional
– Coded separately
• If lesion is excised and biopsied, only the excision
can be billed
• If biopsy taken on one day and based on the
results an excision was performed, modifier -58
may be appropriate
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Within “General” subheading
Codes for:
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Injections
Aspirations
Insertions
Applications
Removals
Adjustments
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Therapeutic Sinus Tract Injection Procedures:
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Not nasal sinus
Abscess or cyst with a passage (sinus tract) to skin
Antibiotic injected with use of radiographic
guidance
Cont……
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Removal: foreign bodies lodged in muscle or
tendon sheath
Integumentary removal codes for removal
from skin
Cont….
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Injection: Into tendon sheath, ligament,
or ganglion cyst, trigger joint
Arthrocentesis: Injection “and/or” aspiration of
a joint
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Both an aspiration and injection are reported with
one code
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Local anesthesia is integral to these codes and
should not be reported
Report the drug separately with a “J” code
HCPCS modifiers used to report specific digits:
“FA to F9” or “TA to T9”
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Application of a device
that holds bone in place
These codes include the
removal of the fixator
If it is necessary to adjust
or revise an external
fixator see 20693. Code
20694 describes removal
under anesthesia and
includes imaging
Cont…
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Uniplane—pins or wires in one plane (flat,
smooth surface)
Multiplane—requires complex adjustments
and correction in alignment. Bedside
adjustments are not separately billed
Code fracture treatment and external fixation
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Unless treatment and fixation are both included in
code description
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Used to report harvesting through separate incision of:
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Bone
Cartilage
Fascia lata
Tissue
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Morselized—small pieces of bone
Structural—a segment of bone machined into the space
Involve “morselized” or “structural” bone taken from a
donor (allograph) or from the patient (autograph)
Report only one bone graft code per operative session
Cont….
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Fascia lata grafts: From lower thigh where
fascia is thickest
Some codes include obtaining
grafting material
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Then not coded separately
Composite grafts involve combinations of
autogenous material and allograft or alloplast
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Monitoring muscle fluid
pressure (interstitial)
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Pressure increases when
blood supply decreases due
to increased accumulation of
fluids
Cont…..
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Bone grafts are
identified by site
they are taken from
(donor site)
Free osteocutaneous
flaps: bone grafts
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Taken along with skin
and tissue
overlying bone
Cont…
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Electrical or ultrasound stimulation
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Used to speed bone healing
Placement of stimulators externally or
internally
Often used in treatment of fractures
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Divided by repair location:
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Cervical (C1-C7)
 C1 = Atlas
 C2 = Axis
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Thoracic (T1-T12)
Lumbar (L1-L5)
Sacral (SI)
Coccyx (tailbone)
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Open incision and drainage of deep abscess of
spine
Divided by location
Cervical, thoracic, or cervicothoracic
 Lumbar, sacral, or lumbosacral
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Fixation of joint
(arthro = joint, desis = fusion)
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Often performed with other procedure
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Fixation with pins, wires, rods, etc., to immobilize
the joint
Such as fracture repair
Use -51 on arthrodesis code
Unless service reported with add-on code
Coded by approach, site, and number of
interspaces or segments
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Types of Spinal
Instrumentation
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Segmental: Devices at
each end of repair area
plus at least one other
attachment
Nonsegmental: Devices at
each end only
Extensive notes
Report in addition to definitive procedure
without the -51 modifier
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After first subheading, General, divided by
anatomic location
Anatomic subheadings divided based by type
procedure
Example subheading “Head” divided by procedure
(21010-21499):
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Incision
Excision
Head Prosthesis
Introduction or Removal
Repair, Revision, and/or Reconstruction
Other Procedures
Fracture and/or Dislocation
Manipulation
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Replacement procedure or initial placement
stabilizes without additional restorative
treatment
Initial fracture treatment includes placement
and removal of first cast
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Subsequent cast applications are coded separately
Cont….
Initial cast
 Not coded when part of a
surgical procedure
 Removal is bundled into
surgical procedure
 Supplies are reported
separately
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Surgical arthroscopy always includes diagnostic
arthroscopy
Codes divided by joint
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Subdivided on procedure
Diagnostic arthroscopy codes only reported for cases
where no surgical scope is performed (exception is
diagnostic scope that determines need to do open
surgery, same day)
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Use modifier -59 on the diagnostic scope
Cont….
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Note: Parenthetical information following codes indicates which
code to use if procedure was an open procedure
Most arthroscopies include the following procedures:
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Local infiltration of medication
Suture removal by operating surgeon
Surgical approach
Wound culture
Intraoperative photos and video imaging
Isolation of neurovascular structures
Stimulation of the nerves for identification
Placement of drains and suction devices
Wound closure
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Buck, C. (2010). Step by Step. Elsevier.