Lecture Notes to Accompany Jean Jurek Stacey Mosay

Lecture Notes to Accompany Jean Jurek Stacey Mosay Daphne Neris CPT Surgery: Musculoskeletal System Chapter 18 Part 1

Outline Organization Modifiers Intraoperative Services and Image Guidance Surgical Techniques General Musculoskeletal Procedures Fracture and Dislocation Treatment Copyright © F. A. Davis 2018 2

Learning Outcomes After completing this presentation, you should be able to: 1. Assign codes for procedures commonly performed on the muscles, bones, and joints. 2. Recognize when to use modifiers when coding orthopedic services. 3. Determine intraoperative services and imaging guidance work for orthopedic procedures and know when they are separately reportable. 4. Define common musculoskeletal system surgical techniques. 5. Understand the physical structure of the spine and its coding guidelines. 6. Describe the guidelines for coding fractures and explain the correct assignment of casting/strapping codes. 7. Describe the guidelines for the use of codes in the endoscopy/arthroscopy section of the musculoskeletal surgery codes in CPT. 8. Assign codes for common shoulder, elbow, and wrist procedures. 9. Discriminate between flexor and extensor tendons of the hand, describing common tendon repair procedures. 10. Assign codes for hip arthroplasty based on the components used. 11. Identify the compartments of the knee and assign arthroscopic procedure codes based on these structures. 12. Describe the differences between common bunionectomy techniques. Copyright © F. A. Davis 2018 3

Organization Copyright © F. A. Davis 2018 4

BOX 18. 1 Musculoskeletal Subheadings Incision Excision Introduction or Removal Repair, Revision, and/or Reconstruction Fracture and/or Dislocation Arthrodesis Amputation Other Procedures Copyright © F. A. Davis 2018 5

According to CPT guidelines, musculoskeletal procedure subheadings include: (Choose all that apply. ) A. Amputation B. Fracture or dislocation C. Excision D. Incision

Modifiers Copyright © F. A. Davis 2018 7

Applying Modifiers An orthopedist in Florida sees a winter visitor who had a fracture repair of the humerus in Michigan 1 week before traveling. The surgeon in Michigan should report 27447– 54. (Modifier – 54 is used to denote surgical care only. ) The surgeon in Florida would report 27447– 55. (Modifier – 55 is used to denote postoperative management only. ) Copyright © F. A. Davis 2018 8

Modifier _____ is used in place of modifier ‒ 80 to code for the services of an assistant physician for Medicare recipients. A. – 62 B. – 76 C. – 77 D. –AS

Intraoperative Services and Image Guidance Copyright © F. A. Davis 2018 10

Included Services 1. Local infiltration of medications, anesthetic, or contrast agent before, during or at the conclusion of the operation 2. Suture removal by operation or designee 3. Surgical approach, with necessary identification, isolation, and protection of anatomical structures, including hemostasis and nerve stimulation, or skin scar revision 4. Wound culture 5. Wound irrigation 6. Intraoperative photos or video recording, excluding ionizing radiation Copyright © F. A. Davis 2018 7. Intraoperative supervision and positioning of imaging or monitoring equipment by operating surgeon or assistant 8. Insertion, placement, and removal of surgical drain, re-infusion devices, irrigation tube, catheter, or suction device 9. Closure of wound and repair of tissues divided for the initial surgical exposure, partial or complete 10. Application of initial dressing, wound vacuum device, orthosis, continuous passive motion, splint. or cast, including traction, except where specifically excluded from the global package 11. Preparation and insertion of synthetic bone substitutes 11

Image Guidance Common Musculoskeletal Procedures Fluoroscopy (separate procedure) up to 1 hour physician time; other than 71023 or 71034 Fluoroscopic guidance for needle placement Application of external fixation with stereotactic computer-assisted adjustment including imaging Exchange of strut, each Computer-assisted surgical navigation procedure (list separately in addition to code for primary procedure) Computer-assisted navigational orthopedic procedure, with image-guidance based on fluoroscopic images Computer-assisted navigational orthopedic procedure, with image-guidance based on CT/MRI images Copyright © F. A. Davis 2018 Code(s) 76000 77002 20696 20697 + 20985 0054 T 0055 T 12

If a physician requires image guidance during a surgical procedure, the coder should determine if the service is separately reportable by first checking: (Choose all that apply. ) A. Any parenthetical notes in CPT B. Any CCI edits C. Any HCPCS Level II edits D. The code description

Surgical Techniques Copyright © F. A. Davis 2018 14

Significant Surgical Procedures Amputation Arthrodesis Examples Arthrotomy Arthroscopy Arthroplasty Copyright © F. A. Davis 2018 27590 Amputation, thigh, through femur, any level 28750 Arthrodesis, great toe; metatarsophalangeal joint 23040 Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body 29888 Arthroscopically aided anterior cruciate ligament repair and augmentation, reconstruction 25441 Arthroplasty with prosthetic replacement; distal radius 15

Significant Surgical Procedure (cont. ) Procedures Examples Endoscopy Exostectomy Lysis Manipulation Reduction Copyright © F. A. Davis 2018 29804 Arthroscopy, temporomandibular joint, surgical 28288 Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation 27860 Manipulation of ankle under general anesthesia 23505 Closed treatment of clavicular fracture; with manipulation 16

Significant Surgical Procedure (cont. ) Procedures Examples Release 28035 Release, tarsal tunnel (posterior tibial nerve decompression) Replantation 20838 Replantation, foot, complete amputation Revision Sequestrectomy Traction 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft 23170 Sequestrectomy (e. g. , osteomyelitis or bone abscess), clavicle 20661 Application of halo, including removal; cranial Copyright © F. A. Davis 2018 17

_____ occurs when a physician, either manually or surgically, places the fracture bones back into their original anatomical alignment. A. Reduction B. Release C. Replantation D. Revision

General Musculoskeletal Procedures Copyright © F. A. Davis 2018 19

Musculoskeletal Procedures Arthrocentesis Trigger point injections (TPI) Excisions Foreign body removal Coding Example Copyright © F. A. Davis 2018 Patient complains of shoulder pain when raising his or her right arm or when trying to lift, push, or pull objects. The physician diagnosed tendonitis and injected the shoulder with corticosteroids. CPT: 20610–RT. In the office, an orthopedic physician injects the right wrist with a mixture of lidocaine and Depo-Medrol with the use of a C-arm to confirm needle placement in the joint. Codes: 20605–RT , 77002, and J 1030. 25065 Biopsy, soft tissue of forearm or wrist; superficial 24200 Removal of foreign body, upper arm, or elbow area; subcutaneous 20

Fracture and Dislocation Treatment Copyright © F. A. Davis 2018 21

Fracture Treatments Closed Treatment Example 22305 Closed treatment of vertebral process fracture(s) 22310 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing 22315 Closed treatment of vertebral fracture(s). . . , with and including casting or bracing by manipulation or traction Copyright © F. A. Davis 2018 Open Treatment Examples Typically internal fixation is applied during open treatment. Fixation devices are often left inside the body permanently or for an extended period of time. 20670– 20680 If device is removed later 22

Additional Fracture Treatments Percutaneous Skeletal Fixation A fixation device or appliance is placed through the skin across the fracture site utilizing imaging assistance. No incision is needed. It usually involves a closed reduction. Fluoroscopy is considered integral to this service and is not coded separately. Copyright © F. A. Davis 2018 External Fixation Devices Any means of securing or fixing bone ends or fragments in proper anatomical alignment from outside the body without nailing, wiring, rodding, screwing, or plating the bones together on the inside. External fixation may be billed separately ONLY when it is not listed in the description for the procedure performed. 23

If a physician must remove a cast to assess the healing process, it is considered part of a bundled global procedure. (True or False? ) A. True B. False

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Steps in Coding Fractures and Dislocations Follow these decision steps to assign the appropriate fracture care code: 1. What is the site of the fracture or dislocation? 2. Is the treatment open or closed? 3. Was a reduction or manipulation of the fracture performed? 4. Was traction used at the same fracture site? If so, it is not coded separately and is considered part of the fracture care. Traction of another fracture site may be separately reported. 5. Was an internal or external fixation device applied? Copyright © F. A. Davis 2018 6. Was percutaneous pinning or skeletal fixation applied? 7. Was infection present, treatment delayed, or did the surgery take longer than usual? 8. Was electrical stimulation (to promote bone healing) used? If so, assign codes 20974 or 20975 plus a HCPCS code for the actual stimulator. 9. Was computer-assisted imaging used to navigate during the procedure? 10. Is this a re-reduction or an initial treatment? If this is a re-reduction in the global period, assign the appropriate modifiers. 26

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