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Musculoskeletal System
Chapter Topics
Format
Fractures and Dislocations
General
Application of Casts and Strapping
Endoscopy/Arthroscopy


Learning Objectives
After completing this chapter you should be able to
1

Differentiate between fracture and dislocation treatment types

2

Understand types of traction

3

Identify services/procedures included in the General subheading

4

Analyze cast application and strapping procedures

5

Understand elements of arthroscopic procedures

6

Demonstrate the ability to code musculoskeletal services and procedures

FORMAT
The Musculoskeletal System subsection is formatted by anatomic site, such as General, Head, and Neck

...

The first subheading in this subsection is General, and it contains procedures that are applicable to many different anatomic sites

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The other subheadings are further divided by anatomic site, procedure type, condition, and description

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They usually include:
n Incision n Excision
n

Introduction or Removal
n Repair, Revision, and/or Reconstruction
n Fracture and/or Dislocation
n Arthrodesis
n Amputation
Any or all of these categories of procedures may be located under each subheading

The codes in the Musculoskeletal System subsection are reported extensively by orthopedic surgeons to describe the services provided to restore and preserve the function of the skeletal system

...

There are many codes, however, that are used frequently by a wide variety of primary care and family practice physicians, such as the splinting, casting, and fracture codes

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Your study of the Musculoskeletal subsection of the CPT will focus on the format of the subsection, fracture types and repair, application of casts and strapping, the General subheading, and endoscopic procedures

...

Thorough review of the medical record will help you to identify key information necessary for coding

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The following tips will help you to choose the most correct code from this subsection:
1

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Identify whether the procedure is being performed on soft tissue or bone

...

Many Musculoskeletal System Excision codes to report tumor excision are based on if the tumor is of the:
n

Subcutaneous soft tissue tumors (below the skin but above the deep fascia)
n Fascial or subfascial soft tissue tumors (within or below deep fascia, but not involving bone)
n Radical resection of soft tissue tumors (subcutaneous or subfascial but with wide margins, appreciable vessel exploration, and/or repair/ reconstruction of nerves)
n Radical resection of bone tumors (wide margins, appreciable vessel exploration, and/or repair reconstruction of nerves and complex bone repair/reconstruction)
Careful reading of Musculoskeletal section guidelines is a must before reporting excision of tumors

Determine whether treatment is for a traumatic injury (acute) or a medical condition (chronic)

...

The diagnosis codes indicating acute or chronic must match the treatment codes

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External cause/E codes from ICD-10-CM/ ICD-9-CM should also be assigned to describe accidents and injuries

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Identify the most specific anatomic site

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For example, when coding vertebral procedures, it is necessary to know whether the procedure was for cervical, thoracic, or lumbar vertebrae

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Determine whether the code description includes grafting or fixation

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If grafting or fixation is not listed within the major procedure code description, each may be reported as an additional procedure

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Read the code carefully to determine whether it describes a procedure that was on a single site (e

...

, each finger)

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If the same procedure is performed on multiple sites (e

...

, multiple fingers), you must indicate the number of units (such as 26060 3 2) or list the code multiple times

...

HCPCS modifiers are used to identify the digit treated, such as F6 for right hand, second digit

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Check any medical terms you do not understand in a medical dictionary or in the Glossary at the back of the book

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FRACTURES AND DISLOCATIONS
Fractures are coded by treatment—open, closed, or percutaneous

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Open treatment of a fracture is made when a surgery is performed in which the fracture is exposed by an incision made over the fracture and the fractured bone is visualized

...

Closed treatment is performed when the physician repairs the fracture without directly visualizing the fracture

...

The treatment method used—open or closed—depends on the type and severity of the fracture

...

A closed fracture (Fig

...

19-1) may receive either closed, open, or percutaneous fixation, whereas a more complicated compound fracture usually requires an open treatment to provide internal fixation

Types of fractures

...

Fractures
Greenstick
Avulsion
Impacted
Comminuted
Colles'
Simple (closed)
Compound (open)
Spiral
Oblique
Transverse
(e

...

, wires, pins, screws)

...

Fractures are coded to the specific anatomic site and then according to whether manipulation was performed

...

All fractures and dislocations are reported based on the reason for the treatment

...

For instance, if a hip replacement (arthroplasty) is performed for medical reasons, such as osteoarthritis, it is reported with 27130, located under the subheading Pelvis and Hip Joint, category Repair, Revision, and/or Reconstruction

...

The osteoarthritis that caused the breakdown of the bone of the hip requiring repair was the reason for the treatment

...

If the hip replacement was performed for a fracture, it is reported with 27236, located under the subheading Pelvis and Hip Joint, category Fracture and/or Dislocation

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The fracture, which is not a progressive, degenerative disease, was the reason for the treatment

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The CPT manual defines closed, open, and percutaneous treatments as follows:
Closed Treatment: This terminology is used to describe procedures that treat fractures by one of three methods: (1) without manipulation, (2) with manipulation, or (3) with or without traction

...

Manipulation is attempted reduction, which is an attempt to maneuver the bone back into proper alignment

...

The physician may bend, rotate, pull, or guide the bone back into position

...

Closed treatment without manipulation is a procedure in which the physician immobilizes the bone with a splint, cast, or other device but without having to manipulate the fracture into alignment

...

Code 25500 describes a closed treatment of a radial shaft fracture without manipulation

...

This code is correctly reported when a patient has a broken but stable radial shaft that is not displaced and the physician only applies a cast

...

Initial casting or splinting services are included in the fracture care, but the supplies used are not

...

Initial splinting or casting
of fractures performed by another physician as the only service can be reported by that physician (i

...

, an emergency department physician)

...

If the cast needs to be removed and reapplied during the global period, the surgeon that charged the global fee may report the cast/splint application with 29000-29799 and append modifier -58 (staged or related procedure/ service)

...

Only charge for cast removal without reapplication if the physician or physician group is not assuming care for the fracture

...

Closed treatment with manipulation is a procedure in which the physician has to reduce (put back in place) a fracture

...

Code 21320 describes a closed treatment of a nasal bone fracture with stabilization, as illustrated in Fig

...

This code is correctly reported when a patient has a displaced nose that requires manipulation to return it to the normal position

...

The physician would then apply external and/or internal splints to immobilize the nose

...

Open treatment is used when the fracture is opened (exposed to the external environment)

...

In this instance, the fracture (bone) is open to view and internal fixation (pins, screws, etc

...

) may be used

...

For example, 23630, open treatment of greater humeral tuberosity fracture, includes internal fixation when performed

...

The physician opens the site, reduces the fracture, and applies internal fixation, as needed to maintain anatomic position of the fracture

...

ICD-10-CM: Fractures are divided based on whether the fracture is pathological (occurred in an area of weakness) or traumatic (due to injury)

...

Fracture codes are reported with a 7th character to indicate whether the fracture care was:
n

Initial or a subsequent encounter
n Open or closed
Open means the fracture has broken through the bone cortex and the bone has been exposed to air (elements)

Closed means the fracture is not exposed to air

...

n

Healing was routine or delayed
n Nonunion
ICD-9-CM: Open treatment can also mean that a remote site (not directly over the fracture) is opened to place a nail (intramedullary) across the fracture site

Fracture is defined as open or closed fracture within the ICD-9-CM, the same as within the ICD-10-CM

...

n

Open means the fracture has broken through the bone cortex and the bone has been exposed to air (elements)

n

Closed means the fracture is not exposed to air

Percutaneous skeletal fixation describes fracture treatment that is neither open nor closed

...

In this procedure, the fracture is not open to view, but fixation (e

...

, pin, screw) is placed across the fracture site, usually under x-ray imaging

...

For example, percutaneous skeletal fixation of a fracture of the great toe, phalanx, or phalanges with manipulation (28496)

...

This procedure is performed entirely percutaneously

...

Areas of bones, as Fig

...

19-3 illustrates, are important to know when identifying the location of a fracture

...

For example, there may be an open
CODING SHOT
If the physician attempts a reduction of a fracture but is unable to align the fracture successfully, you still report a reduction service

...

List the attempted reduction service code and then list the more involved fracture care (i

...

, open, endoscopic) the physician successfully performed to reduce the fracture with modifier -58 (staged or related procedure/service) appended

...

Areas of the tibia

...

Proximal
Distal
Growth plate
Epiphyseal
Epiphyseal
Epiphysis Metaphysis
Diaphysis (shaft)
Metaphysis Epiphysis
FIGURE

19-3 19-5 Skeletal traction uses the patient's bones to secure internal devices to which traction is attached

Traction is the application of a pulling force to hold a bone in alignment

...

Skin traction utilizes strapping, wraps, or tape to which traction is attached

...

treatment of a proximal fibula fracture (27784), proximal being closer to the body, or of a distal fibula fracture (27792), distal being further from the body

...

Traction definitions are as follows:
Traction is the application of pulling force to hold a bone in alignment (Fig

...

Skeletal traction is the use of internal devices, such as pins, screws, or wires

...

The devices are inserted into the bone through the skin, with ends of the pins, screws, or wires sticking out through the skin, so traction devices can be attached (Fig

...

Skin traction involves strapping, elastic wrap, or tape that is fastened to the skin or wrapped around the limb

...

Weights are then attached to apply force to the fracture (Fig

...

Dislocations
Dislocation is the displacement of a bone from its normal location in a joint (Fig

...

19-7), and the treatment of the dislocation injury is to return the bone to its normal location (anatomic alignment) by a variety of methods

...

For example, if a finger was dislocated and the bone did not protrude through the skin, the physician may administer a digital block (Fig

...

19-8) and apply gentle traction until the finger realigns

...

A splint would then be applied to keep the finger immobile for about 3 weeks

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If the shoulder was dislocated, the physician might elevate the arm and rotate the humerus while applying pressure to the head of the humerus

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Or the patient might lie face down on a table with the arm hanging off the edge while a weight is attached to the hand

...

the weight is sufficient to pull the arm back into place (Fig

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If external measures such as those just described do not relocate the joint, surgical reduction might be indicated

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GENERAL

The first subheading in the Musculoskeletal subsection is General

As the name implies, this subheading includes miscellaneous procedures that are not specific to an anatomic site

...

Incision

The first code is 20005 used to report the incision and drainage of a soft tissue abscess that is below the deep fascia (subfascial)

There are codes in the Integumentary System for incisions that are for skin only

...

What makes 20005 different from those in the Integumentary System is that 20005 is reported when the abscess is associated with the deep tissue and possibly even down to the bone that underlies the area of abscess

...

The physician would make an incision into the abscess, explore and clean the abscess, and debride it (remove dead tissue)

...

This procedure is very different from the procedures you report with Integumentary System codes for incision of an abscess

...

Wound Exploration
The Wound Exploration codes (20100-20103) report traumatic wounds that result from a penetrating trauma (e

...

, gunshot, knife wound)

...

Wound Exploration codes include basic exploration and repair of the area of trauma

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These codes are used specifically when the repair requires enlargement of the existing wound for exploration, cleaning, and repair

...

Included in the Wound Exploration codes are not only the exploration and enlargement of the wound but also debridement, removal of any foreign body(ies), ligation of minor blood vessel(s), and repair of subcutaneous tissues, muscle fascia, and muscle, as would be necessary to repair the wound (Fig

...

19-10)

...

If the wound does not require enlargement, you would report a code from the Integumentary System, Skin Repair codes

...

If, however, the wound is more severe than a Wound Exploration code would indicate, the repair code would come from the specific repair by anatomic site codes

...

For example, for a bullet wound to the chest with suspicion of cardiac injury, the treatment will be thoracotomy of any approach, as illustrated in Fig

...

19-11, with control of the hemorrhage and repair of any injured intrathoracic organ

...

The thoracotomy code is located in the subsection Respiratory System under the subheading Lungs

...

As you can see from this example, you have to assess the extent of the procedure carefully, reading the medical record to ensure you are in the correct area so you can choose the correct code

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In the case of the bullet wound to the chest, the wound exploration is included in the thoracotomy and would not be reported separately

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Excision
The Excision category (20150-20251) codes are for the biopsies of muscle and bone

...

The codes are divided based on the type of biopsy (muscle, bone), the depth of the biopsy (superficial, deep), and, in some codes, the method of obtaining the biopsy (e

...

, percutaneous needle)

...

The procedure for a muscle or bone biopsy typically includes the administration of local anesthetic into the biopsy area, an incision into the area allowing exposure of the muscle or bone, removal of tissue for biopsy, and suturing of the area

...

A percutaneous biopsy, as represented in 20206, differs in that the area is not opened to the physician's view

...

A trocar (hollow needle) or needle is placed into the muscle or bone by passing the needle through the skin and into the muscle or bone and withdrawing a sample

...

When the percutaneous method is used to obtain a biopsy, the area does not require suturing

...

If the biopsy is extremely complicated, the surgeon may request the assistance of ultrasound to be able to view the biopsy area during the procedure and receive guidance as to the placement of the needle

...

Notice the guideline in the CPT following 20206 directs you to the radiology codes if imaging guidance is utilized during the procedure

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Biopsy codes in the Excision category of the General subheading are not to be reported for the excision of tumors of muscle

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If the medical record indicates excision of a muscle tumor, you would have to choose a code from the correct Musculoskeletal subsection

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