Vol. 12 Issue 23
Muscle Your Way Through Musculoskeletal System CPT Coding
This is the second to last column for 2002 and we will be discussing the often-difficult area of musculoskeletal system coding for CPT. As you know, this CPT code range includes 20000-29999. We will start with some important concepts, divided by differing topics, AHA/CPT Assistant direction, and will then provide a quiz to test these concepts. Due to limits on space, only the codes are presented. Please refer to your CPT code book for descriptions.
1. The musculoskeletal subsection is the biggest section in the CPT surgery area. The organization is by anatomic site (starting with the head) and then by procedures performed. There are extensive notes throughout each subsection that must be read by the coder to get to the right code. For example, closed, open and percutaneous treatments are extensively described in the beginning of the chapter.
2. Pay attention to the code descriptions. Many include words such as "with fixation," "with manipulation," "with anesthesia" etc. The code assigned will be determined by these descriptions in many cases. See 23500, 23505.
3. Be wary of terms in the CPT codes that include "each digit," "each," "single," "one toe," etc. You may need to assign multiple codes/modifiers based on this information. See 23405, 23406, 24305, 24560, 24565.
4. Be sure to check the actual section fully before assigning a code directly based on the CPT index. The CPT index can be misleading and incomplete concerning some procedures.
1. The wound explorations cover codes 20100-20103. There is a specific note in the beginning of the section that addresses the conditions. They are organized by body site.
2. Basically, the open wound must be extended so that the physician can determine the extent of the injury. The exploration must be for an acute injury, it must be a penetrating wound and deeper structures of the muscle fascia and beyond must be explored. If only the skin and subcutaneous tissue are explored, the coder must refer to the integument system.
3. Layered closures, drain placements, removal of foreign bodies, ligation or coagulation of minor subcutaneous or muscular blood vessels are all included in the wound exploration codes. See note in CPT on major blood vessel and structure repairs.
Example: A patient is brought in with a gunshot wound to the right lower abdomen. The wound is enlarged and explored, and a bullet is removed. The wound is closed in layers of muscle and skin closure. Assign code 20102. The re-moval of bullet and layered closures are included.
1. Codes exist for an "open" vs. a "closed" treatment of fracture. Open treatment is used when the fracture is surgically exposed to the external environment. The fracture is visualized and internal fixation may be used. Closed treatment specifically means that the fracture site is not surgically opened. The codes do NOT relate to the type of fracture, but to the type of fracture TREATMENT performed. Look now at the notes from the beginning of the Musculoskeletal subsection, which describe the definitions used.
2. Codes for treatment of fractures include the application and removal of the initial cast and/or traction device only. Do not code the initial cast separately. Subsequent replacement of the cast/traction device requires a code from 29000 to 29799. Effective in 1996, the cast/splint application may be utilized by a physician not expected to deliver further care to the patient, as in the ER.
3. Reduction of a fracture is used commonly in the medical community, yet the term "reduction" is not found often in the CPT. Instead the term "manipulation" is used. When the terms "reduce" or "reduction" is found in the record to describe treatment of a fracture, use a code that describes "manipulation."
4. Exercise caution in coding fractures, especially when differentiating between the type of fracture and the type of treatment. Be sure to identify: the site of the fracture; open, percutaneous or closed treatment; with or without manipulation; and whether the procedure included internal or external skeletal fixation of the fracture.
Example: The patient was involved in a motor vehicle accident and sustained a fracture of the patella. The patient was taken to the operating room where the surgeon performed an open reduction with internal fixation of the fracture and repair of the tendons and muscles. Part of the patella was removed. Assign 27524 for this procedure.
Bone Grafts and Biopsies
1. Codes for obtaining autogenous (from the patient) bone, cartilage, tendon, fascia or other tissue grafts through separate incision are to be assigned only when the graft is not listed as part of the basic procedure.
2. For biopsy of soft tissue, choose the code according to site and whether the biopsy is superficial or deep.
3. For needle or trochar bone biopsies, choose code 20220 or 20225, depending on the site.
4. For needle or trochar bone marrow biopsy, use code 38221. Interpretation is coded to 88305 when performed.
5. Terms specific to bone grafts include: "Allograft, morselized," which are small pieces of bone from other than the patient; "Allograft structural," which is a larger segment of bone from a donor other than the patient that is machined by tools into the interspace; "Autograft, local," which is taken from the ribs, spinous process or laminar fragments that is harvested through the same incision; "Autograft morselized," which is usually taken from the iliac crest; and "Autograft, structural."
Casting, Splinting and Strapping Guidelines
"Splints are rigid or semi-flexible devices used for the immobilization of displaced or fractured parts of the body. A splint may be a first aid measure or it may be a means of fixation to immobilize the bones until healing is complete. Thus, it is used for both temporary and permanent treatment. Any material that offers the degree of resistance required may be used for a temporary splint, e.g., cloth, gauze, plaster or metal. Splints made of plastic and fiberglass are now molded to fit specific parts of the body. Air splints are made of rubber or plastics that can be blown up to effectively immobilize the limb." (Excerpted from the AHA Coding Clinic for HCPCS, 2Q 2001 p. 7.)
Air Casts are considered splints according to the AHA Coding Clinic for HCPCS Vol. 1, #2, 2nd Quarter 2001 under "Ask the Editor." Splints can be applied to sprains and dislocations, not only fractures.
Casts/Splints in the Emergency Room
Some coders are confused about how to code a fracture treatment in the emergency department (ED). If a patient has a fracture splinted in the ED, should the CPT code for application of a splint, or fracture treatment be used? Does it make a difference if the patient is referred to an orthopedic doctor? This question has come up many times, and seminars offer different advice.
How you code this scenario depends on what treatment the patient receives in the ED. If a splint is applied and the patient is referred to another physician for fracture treatment, it is appropriate to code the splint application. If the application of the splint in the ED is considered to be the fracture treatment without further referral or is applied after fracture treatment, it is not appropriate to code both the fracture treatment and the application of the splint. The documentation in the medical record must indicate the procedures performed. Usually, an ED physician will just splint or cast a fracture to get the patient to an orthopedic surgeon, who may actually perform the fracture reduction or treatment after swelling decreases.
If the physician is actually manipulating the fracture and setting it without other physician follow up for example, the reduction of fracture codes for the site listed should be utilized without the cast/strapping/sling codes. The initial cast/strapping/sling codes are included in fracture therapy CPT codes.
1. Arthroscopies performed on the differing joints have their own section in CPT, 29800-29999. Many arthroscopic procedures actually include integral procedures that are NOT separately coded. Below is an example from American Academy of Orthopaedic Surgeons "Global Service Data for Orthopaedic Surgery:"
Sample of "Integral Procedures" Associated with Arthroscopic Meniscectomy
29880 Medial and Lateral Meniscectomy
Arthroscopic partial or total resection of both the medial (located on the inner side of the knee) and lateral (located on the outer aspect of the knee) meniscus. A basket forceps, motorized shaver, scissors or knives may be used to resect the meniscus.
Minor synovial and/or fat pad resection for visualization; incidental articular shaving, debridement and/or chondroplasty in the SAME compartment limited synovectomy, removal of loose bodies and/or surgical debris; plica and/or synovial resection; debridement and/or shaving of meniscus or cruciate stump (the torn end of an anterior cruciate ligament); meniscal tissue removal; lavage and drainage, diagnostic arthroscopy; splinting/casting."
2. If an arthroscopic procedure does not have its own unique code, be sure to use the unlisted arthroscopic code rather than resorting to an open code for the arthroscopic procedure unless it states "any method."
3. The following CPT Assistants will be helpful to review in depth: Anatomy of the knee, CPT Assistant, August 2001, p. 5, Category: Coding Communication; Knee arthroscopy, CPT Assistant, August 2001, pp. 5-7-12, Category: Coding Communication.
4. More physicians are performing shoulder surgery through the arthroscope. Many techniques involve both arthroscopic and open procedures combined. It is important for the coder to read the entire operative report to ensure that correct codes have been assigned based on physician documentation. A new code for arthroscopy of shoulder with distal claviculectomy had been created in 2002, 29824.
5. For a shoulder arthroscopy with decompression of subacromial space with partial acromioplasty, with or without coracoacromial release and arthroscopic rotator cuff repair, CPT has directed to use codes 29826 and 29999. There is not yet an arthroscopic procedure code for the arthroscopic rotator cuff repair.
Now answer the following questions. Research the CPT Assistant if applicable, after answering from memory. Due to limits on space, only the codes are presented. Please refer to your CPT code book for descriptions. Assign CPT codes for the facility. (Professional fee codes will be available in the answer key)
A) A patient undergoes arthroscopy of the right shoulder with extensive debridement and subacromial decompression and resection of the acromioclavicular joint. An arthroscopic partial rotator cuff repair was performed for a chronic rotator cuff tear. A bursectomy was performed as well.
1. 29999, 23929
2. 29823-RT, 29826-RT, 29999
3. 29823-RT, 29826-RT, 23412-RT
4. 23412-RT, 23076-RT, 23420-RT, 23929
B) Open repair of right Galeazzi fracture.
C) A patient undergoes a right proximal phalanx osteotomy and distal first metatarsal osteotomy to correct a severe hallux valgus.
1. 28298-T5, 28296-T5
D) An ED physician applies a right short arm splint that allows movement to the patient, who will see the orthopedic surgeon for definitive treatment in a few days, after swelling has decreased.
E) Pes Cavus is another name for
1. Contracture of the toes
2. Flat feet
3. High arch
Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, education and contract coding for hospitals. The corporate office is headquartered in Pawley's Island, SC.
Coding Clinic is published quarterly by the American Hospital Association
"CPT only " 2001 American Medical Association. All Rights Reserved."
A) 2. 29823-RT, 29826-RT, 29999. Because there is no code for the arthroscopic
rotator cuff repair, use the unlisted code. (Prof fee coding is 29826, 29823-51,
B) 3. 25525-RT (Galeazzi fracture is of the shaft of the radius with dislocation
of the distal radioulnar joint) (25525 for Prof fee);
C) 2. 28299-T5 (This is an example of a double osteotomy. Prof fee is 28299.);
D) 1. 29126;
E) 3. High arch