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Musculoskeletal System List

STUDY
PLAY
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
...
The other subheadings are further divided by anatomic site, procedure type, condition, and description
...
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
...
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
...
The following tips will help you to choose the most correct code from this subsection:
1
...
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)
...
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
...
External cause/E codes from ICD-10-CM/ ICD-9-CM should also be assigned to describe accidents and injuries
...
3
...
Identify the most specific anatomic site
...
For example, when coding vertebral procedures, it is necessary to know whether the procedure was for cervical, thoracic, or lumbar vertebrae
...
4
...
Determine whether the code description includes grafting or fixation
...
If grafting or fixation is not listed within the major procedure code description, each may be reported as an additional procedure
...
5
...
Read the code carefully to determine whether it describes a procedure that was on a single site (e, each finger)
...
If the same procedure is performed on multiple sites (eg
...
, 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
...
6
...
Check any medical terms you do not understand in a medical dictionary or in the Glossary at the back of the book
...
FRACTURES AND DISLOCATIONS
Fractures are coded by treatment—open, closed, or percutaneous
...
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
...
g
...
, 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
...
The fracture, which is not a progressive, degenerative disease, was the reason for the treatment
...
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
...
e
...
, 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
...
19-2
...
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
...
g
...
, 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
...
e
...
, 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
...
19-4)
...
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
...
19-5)
...
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
...
19-6)
...
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
...
If the shoulder was dislocated, the physician might elevate the arm and rotate the humerus while applying pressure to the head of the humerus
...
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
...
19-9)
...
If external measures such as those just described do not relocate the joint, surgical reduction might be indicated
...
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
...
g
...
, gunshot, knife wound)
...
Wound Exploration codes include basic exploration and repair of the area of trauma
...
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
...
In the case of the bullet wound to the chest, the wound exploration is included in the thoracotomy and would not be reported separately
...
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
...
g
...
, 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
...
Biopsy codes in the Excision category of the General subheading are not to be reported for the excision of tumors of muscle
...
If the medical record indicates excision of a muscle tumor, you would have to choose a code from the correct Musculoskeletal subsection
...
For example, 24071 reports excision of a tumor, 3 cm or greater, from the soft tissue of the upper arm or elbow
...
Biopsy codes do not include the pathology workup that is performed on the sample
...
General Introduction or Removal

Within the Introduction or Removal category there is a wide variety of injection, aspiration, insertion, application, removal, and adjustment codes
...
Because the category is within the General subheading of the Musculoskeletal subsection, the codes also have a wide application in coding services
...
Therapeutic sinus tract injection procedure codes are within this category
...
You may initially think of the nasal sinuses, but these are not the sinuses that are being injected here
...
The term "sinus" refers to a cyst or abscess inside the body with a tract (known as a fistula) connecting to another surface—internal (to the gut) or external (to the skin)
...
The infection is treated by injecting an antibiotic or other substance into the sinus by way of the sinus tract
...
With certain sinus injections, a radiologist provides guidance to ensure the correct placement of the needle and the guidance is reported separately
...
For example, an interstitial abscess located perirectally develops a sinus tract opening perianally may be treated by instilling a caustic substance to stimulate healing
...
Other methods that may be used in treatment of the sinus tract are the incision or opening of the tract (fistulotomy) to promote healing or excision (fistulectomy) of the tract
...
Removal codes located in the Introduction or Removal category (20520-20525) report the removal of a foreign body lodged in muscle or tendon
...
Recall that the Integumentary System removal codes describe foreign bodies lodged in the skin
...
Injection codes in this category report injections made into a tendon, ligament, or ganglion cyst (cystic tumor)
...
An example of the use of these injection codes would be a corticosteroid injection as a ganglion cyst treatment
...
CODING SHOT
You must read the codes carefully
...
For most injection codes (i
...
e
...
, 20550, 20551, 20553) the code description states "Injection(s)
...
" This means that one or more injections can be reported with the same code with no modifier
...
CODING SHOT
The code descriptions for arthrocentesis indicate that the codes can be used for an aspiration, an injection, or both an aspiration and an injection
...
You would not report the performance of both an aspiration and an injection at the same session by using multiple codes, as that would be unbundling
...
You would instead report both services using a single code
...
Arthrocentesis is aspiration of a joint (Fig
...
19-12), and the codes to report such a service are in the range of 20600-20610
...
Arthrocentesis is a procedure commonly used in the treatment of joint conditions
...
The area over the involved joint is injected with anesthetic, a needle is inserted into the joint, and fluid is withdrawn
...
Code 20612 reports an aspiration and/or injection of a ganglion cyst, which is a rubbery swelling that may occur anywhere on the body but usually occurs over a joint or tendon of the wrist or foot
...
The treatment of a ganglion cyst is surgical removal, aspiration, or aspiration with injection of a corticosteroid
...
Often, ganglion cysts will appear in a cluster and if multiple cysts are treated, report the service with 20612 with modifier -59 appended
...
The arthrocentesis codes are divided according to whether the joint is small (finger, toe), intermediate (ankle, elbow), or major (shoulder, hip)
...
Note that while the shoulder is a major joint, the acromioclavicular joint, which is a part of the shoulder, is only an intermediate joint
...
This often leads to incorrectly coding the acromioclavicular joint as a major joint rather than as an intermediate joint
...
Lidocaine, Marcaine, and so forth, when used as anesthetics, are not reported separately
...
Any injected therapeutic drug such as a steroid is reported separately using a HCPCS J code (drug code)
...
Insertion of wires or pins to repair a bone (20650) is a procedure often used by orthopedic physicians
...
The procedure is performed using a local or general anesthetic
...
The bone is drilled through with a power drill and pins and/or wires are placed through the holes in the bone and allowed to emerge through the skin on each side of the bone
...
A traction device is then attached to the pins or wires to hold the bone immobile while healing takes place (refer to Fig
...
19-5)
...
This may sound painful, but actually, the procedure is used to allow well-aligned healing, as well as alleviate pain
...
CODING SHOT
The removal of the external skeletal wires or pins is included in the reimbursement for fixation
...
but for internal fixation removal, report separately using 20670, 20680
...
The codes to report the application of many of the devices used for fixation of the bones of the body during the healing process—cranial tong, cranial halo, pelvic halo, femoral halo, caliper, stereotactic frame—are located in this category
...
Each of the applications includes the removal of the device, unless the device is removed by another physician (20665)
...
When the application of these devices is performed through an open surgical procedure, the procedure is referred to as an open reduction with internal fixation (ORIF) and uses pins, wires, and screws to stabilize a fracture
...
Implant removal codes (20670, 20680) are available for reporting the services of removal of buried wires, pins, rods, etc
...
, previously implanted
...
If, for example, there is a complication, such as pain, the hardware may be removed
...
Diagnosis coding must support the necessity of removal of the deep hardware as a complication
...
If removed during the global period, report the service with modifier -58 (staged) appended to the procedure code
...
The implant removal codes are divided according to whether the implants are superficial or deep
...
External fixation is the application of a device that holds a bone in place, but unlike internal fixation, the device is placed on the outside of the body and pins or wires are placed into the bone from the outside (Fig
...
19-13)
...
These wires and pins, when fastened to the bone, hold the device or system immobile
...
This type of fixation is commonly used with comminuted fractures (fragmented) that are difficult to hold in place
...
External fixation is used primarily in cases of limb fracture, major pelvic disruption, osteotomy, arthrodesis, bone infection, and bone lengthening
...
Codes 20690 and 20692 report whether the device or system is placed on one surface (uniplane) or several surfaces (multiplane)
...
With the uniplane device, two or more pins are inserted above the fracture site and two or more pins are inserted below the fracture site
...
Multiplane devices are more complicated and are usually reserved for highly complex fractures (see Fig
...
19-13)
...
CODING SHOT
The fixation devices codes are reported in addition to the code for the treatment of the fracture, unless the application code specifically states that fracture repair is included
...
For example, see code 25545: "Open treatment of ulnar shaft fracture includes internal fixation, when performed
...
" This code specifies both the treatment of the fracture and the fixation
...
External fixation, if performed, would be reported separately
...
Note also that most of the codes in the Introduction or Removal categories are for unilateral services, so if a procedure is bilateral you would assign modifier -50
...
If the device is adjusted, the service is reported separately (20693)
...
Removal of external fixation devices or systems is usually accomplished under anesthesia and is reported separately from the application (20694)
...
However, if the removal does not require return to the operating room, you would not report the service separately but would consider the removal as being bundled into the application code
...
If the removal was performed outside the global period, some payers may reimburse the removal as an E/M service
...
Grafts (or Implants)
Codes 20900-20938 report the harvesting of bone, cartilage, fascia lata, tendon, or tissue through an incision separate from that used to implant the graft
...
Graft material is used in a wide variety of repair procedures
...
For example, if a tibial fracture has failed to heal in 20 weeks, the surgeon may decide that the fracture requires bone grafting to achieve healing
...
Bone grafting is also used in cases of large defects (
...
6 cm)
...
Some types of fractures commonly heal with difficulty, so after debridement the surgeon may decide to allow a 5- to 7-day healing period before the bone grafting procedure is performed
...
The grafts are obtained from the patient or a donor
...
Donors can be either living or deceased (cadaver)
...
The pieces of bone are shaped into bars or pegs and then used to repair the defect
...
Fascia lata grafts are taken from the mid-upper lateral thigh area because the fascia is thickest in this area
...
Fascia is the fibrous tissue that serves as connective tissue
...
it may be shaved off with an instrument called a stripper or it may be incised (cut) away
...
The fascia lata is then used in the repair procedure
...
Codes for obtaining the fascia lata graft are based on whether a stripper (20920) was used to remove the fascia or whether a more complex removal procedure (20922) was required to obtain the graft material
...
Tissue grafts include obtaining of the fat, dermis, paratenon (loose connective tissue from the tendon compartment), and other tissue types
...
Spine surgery codes 20930-20938 report the obtaining and shaping of the tissue, whether from the patient (autograft) or from a donor (allograft)
...
The obtaining and shaping of the spine graft material is reported in addition to reporting the implantation procedure, which is the primary procedure (definitive procedure), unless the description of the major procedure includes a graft
...
Other Procedures
Other Procedure codes (20950-20999) report monitoring muscles, bone grafting with microvascular technique, free osteocutaneous flaps with microvascular technique, electronic/ultrasound stimulation, and computer- assisted surgical navigation procedures
...
Monitoring of interstitial fluid pressure (20950) is a procedure in which the physician inserts a device into the muscle compartment to measure the pressure changes within the muscle
...
Increased pressure in the muscle indicates the tissue is not receiving a sufficient supply of blood due to accumulation of fluid
...
Bone grafts (20955-20962) are identified by the site from which the graft is obtained
...
When the bone grafts are removed, the small blood vessels remain attached to the graft
...
The graft is then inserted and the blood vessels are attached to vessels in the area of implant, using an operating microscope
...
The use of the operating microscope (69990) is included in the code descriptions for 20955-20962
...
As a reminder, there is a parenthetical statement following 20962 that states, "(Do not report 69990 in addition to codes 20955-20962)
...
"
Free osteocutaneous flaps (20969-20973) are bone grafts that include the skin and tissue that overlie the bone
...
The flap has an arterial pedicle that is attached (anastomosed) to an artery on the recipient site
...
The surgeon then utilizes the skin, tissue, and bone to reconstruct the defect, using an operating microscope
...
The codes are divided based on which part of the body the flap is taken from
...
Codes 20955-20962 are vascularized bone grafts that are used where there are large defects, usually in long bones, where a standard iliac bone graft or other types of nonvascularized bone grafts are not likely to heal
...
Electrical or ultrasound stimulation (20974-20979) is used to promote healing
...
Low-voltage electricity or ultrasound is applied to the skin, and both are often used in the treatment of fractures
...
Computer-assisted surgical navigation

Computer-assisted surgical navigation (20985) is the use of navigational assistance in musculoskeletal procedures
...
The code is listed in addition to the code for the primary procedure
...
Spinal Instrumentation and Fixation
Within the subheading Spine (Vertebral Column) (22010-22899), services are often based on the cervical (C1-C7), lumbar (L1-L5), and thoracic (T1-T12) spinal areas
...
For example, codes in the range 22210-22216 identify osteotomy of the cervical, lumbar, or thoracic spinal area
...
Codes are often further divided based on the exact spinal location
...
For example, codes in the range 22590- 22600 identify arthrodesis of three different cervical areas: occiput-C2, C1-C2, or cervical below the C2 segment
...
Of special note in the CPT manual is that the C1 is often referred to as the atlas and C2 is referred to as the axis
...
Arthrodesis can be performed with another surgical procedure, such as fracture care or a laminectomy
...
If arthrodesis is performed with a more major procedure, use modifier -51 on the arthrodesis code to indicate multiple procedures were performed
...
An exception to this rule is when the code is an add-on code, which is exempt from use with modifier -51
...
For example, 22614 is used to report an arthrodesis of multiple vertebral segments
...
A code from the 22600-22612 range reports the first segment, and 22614 is reported for each additional vertebral segment
...
Modifier -51 is, therefore, not required
...
CODING SHOT
When choosing codes for spine procedures, verify whether the code is describing a vertebral segment, the actual bony segment, versus an interspace (the space between two vertebral segments)
...
If reporting a procedure performed at L4-L5, you would choose the primary code to represent L4 and the add-on code to represent L5
...
If the procedure code description was by interspace, only one code would be assigned
...
Spinal instrumentation

Spinal instrumentation is used to stabilize the spinal column in some repair procedures
...
Segmental instrumentation is the attachment of a fixative device at each end of the area being repaired and at least one other attachment in the spinal area being repaired (Fig
...
19-14)
...
For example, if the repair was at T10 and T11 (thoracic vertebral bodies 10 and 11) and a rod was attached to T7 and L1, the repair rod may also be attached at T8, T9, T10, T11, and T12
...
Nonsegmental instrumentation is the application of the fixative device at each end of the area being repaired, as illustrated in Fig
...
19-15
...
For example, if the repair was of T10, the rod may be attached at T7 and T12
...
Many of the instrumentation codes are add-on codes (22840-22848 and 22851) and are reported in addition to the major procedure
...
Foot and Toe Repairs
A common procedure performed on the toe is a hallux valgus correction (bunion surgery)
...
Hallux is the great toe and valgus is the angulation of the toe away from the midline, as illustrated in Fig
...
19-16
...
A variety of procedures are performed to correct the defect, as represented by codes in the range 28290-28299
...
For example, the Keller type of procedure is reported with 28292 and describes a procedure in which a wire is inserted through the bones of a toe to hold the bones in correct alignment
...
Each code description indicates the procedure type that is included, many of which include specific eponyms (names of individuals for whom the procedures are named), so careful reading is necessary to choose the correct bunion repair code
...
APPLICATION OF CASTS AND STRAPPING
Application of Casts and Strapping codes (29000-29799) are used for the initial or subsequent treatment of fractures, ligament sprains/tears, and overuse injuries
...
They may also be reported for the initial stabilization of an injury until definitive restorative treatment can be provided
...
Because each injury is unique, each cast is unique in terms of size and position
...
The cast immobilizes the fracture with materials such as plaster, fiberglass, or thermoplastics
...
Each physician has a preference for the types of cast materials used
...
Strapping is the taping of a body part, as illustrated in Fig
...
19-17
...
Strapping is used to exert pressure on a body part to give it more stability, and is used in the treatment of sprains, strains, and dislocations
...
Splints are made of wood, cloth, metal, or plastic, as illustrated in Fig
...
19-18, and are used to immobilize, support, or protect a body part, thereby allowing rest and healing
...
The removal of the cast, strapping, or splint is included in each of the Application of Casts and Strapping codes
...
CODING SHOT
If a cast, strapping, or splint is applied as a part of a surgical procedure, you do not report codes from the Application of Casts and Strapping subheading because the musculoskeletal surgical procedure codes include the first cast, strapping, or splint as well as its later removal
...
The surgery, application, and removal are all bundled into the surgical code
...
If the cast, strapping, or splint is applied as a part of a fracture repair, the application service is not reported separately
...
The application service is bundled into all fracture repair codes, as is the removal
...
If a subsequent cast, strapping, or splint is applied within the follow-up period for either the surgical procedure or the fracture repair, you can bill the application with modifier -58 and also bill for the materials (A4580-A4590)
...
You can bill for a separate office visit during which a second cast, strapping, or splint is applied only if the patient is provided some additional, separate, and significant service
...
Modifier -25 would be appended to the E/M code
...
You can report the Application of Casts and Strapping codes only when the physician:
n
Applies an initial cast, strapping, or splint for stabilization prior to definitive treatment by another provider
n
Applies a subsequent cast, strapping, or splint
n
Treats a sprain or fracture and does not expect to provide any other type of restorative treatment
The subheading Application of Casts and Strapping is divided into three major categories:
n
Body and Upper Extremity
n Lower Extremity
n Removal or Repair (provided by a physician other than the one who initially applied it)

The subcategories of Body/Upper Extremity and Lower Extremity are:
n Casts
n Splints
n Strapping—Any Age
The codes in all subcategories are divided primarily according to the location of the cast, splint, or strapping on the body—head, hand, extremity—and often on the type—Minerva, Velpeau, static (nonmovable), dynamic (movable)
ENDOSCOPY/ ARTHROSCOPY
Arthroscopy is often the treatment of choice for many orthopedic surgical procedures
...
The incisions are smaller, which decreases the risk of infection and speeds recovery time
...
Several small incisions are made through which lights, mirrors, and instruments are inserted, as illustrated in Fig
...
19-19
...
The arthroscopy codes are located at the end of the Musculoskeletal subsection
...
If multiple procedures are performed through a scope, they are reported with modifier -51
...
Bundled into all surgical arthroscopic procedure codes is the diagnostic arthroscopy
...
You must not unbundle and report a diagnostic arthroscopy and a surgical arthroscopy if both were performed during the same encounter
...
Do not report separately services performed during a procedure that are considered part of the procedure, such as shaving, removing, evacuating, casting, splinting, or strapping
...
A note preceding the Endoscopy/Arthroscopy codes (29800-29999) states, "When arthroscopy is performed in conjunction with arthrotomy, add modifier -51
...
" This note indicates that if a surgeon performs an arthroscopy and during the procedure extends the procedure to an arthrotomy, both services are reported
...
For example, a physician performs an arthroscopic shaving of the articular cartilage and also performs an open capsulotomy (posterior capsular release) of the knee
...
Both the arthroscopic shaving (29877) and the capsulotomy (27435) would be reported, and to the least expensive procedure add modifier -51 (multiple procedures)
...
In arthroscopic procedures, it is also correct to report multiple procedures in different compartments in the joint area with one code
...
For example, in the knee, there are three compartments, the medial, lateral, and patellofemoral
...
If a meniscectomy (29881) is performed in the medial compartment, and a shaving (29877) is performed in the patellofemoral compartment, only the 29881 is reported as it includes the shaving
...
CODING SHOT
When coding arthroscopic procedures of the knee, note the use of basket forceps, which indicates a meniscectomy (meniscus removal) rather than a shaving and debridement
...
The codes in the Arthroscopy subheading are divided according to body area—elbow, shoulder, knee—and then according to the type and extent of procedure performed
...
An example of type of service is as follows: 29805 reports an arthroscopy of the shoulder for diagnostic purposes, whereas code 29806 is an arthroscopy of the shoulder for a surgical repair procedure
...
Not only are there two different codes for surgical and diagnostic arthroscopic procedures, but also the reimbursement for the surgical procedures is higher than the diagnostic procedure
...
So great care must be taken to select the code that correctly describes the services supported in the medical record and in code placement
...
If the procedure began as a diagnostic procedure, which is often the case, and converts to a surgical procedure, only the surgical procedure is reported
...
The reimbursement for the surgical procedure is higher than the reimbursement for the diagnostic procedure
...
For example, one payer's reimbursement was $424
...
86 for the diagnostic procedure (29805) and $979
...
21 for the surgical procedure (29806)
...
CODING SHOT
A diagnostic arthroscopy is always included in a surgical arthroscopy
...
Note the description for code 29805: "Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)
...
" You will find the statement "separate procedure" several times in the Endoscopy/Arthroscopy subheading because often a minor arthroscopic procedure is part of a more major procedure
...
You cannot report the service of the minor procedure unless it has been performed as an independent service, addressing a distinctly separate problem
...
Also note that the parenthetical information indicates the codes "(23065-23066, 23100-23101)" are to be reported if the procedure was done as an open (incisional) procedure rather than as an endoscopic procedure
...
STEP BY STEP BOOK I COMPLETED
...
INTRODUCTION TO CPT CODING
BOOK II
...
Section Objectives
Distinguish when to report excisions from the Musculoskeletal System
Understand the spine (vertebrae column)
Differentiate the various types of fracture treatments
...
Understand the reporting for Application of Casts and Strapping
Review the use of Endoscopy/Arthroscopy services
Assess various techniques for bunions and associated deformities
...
The Musculoskeletal System subsection of the Surgery section of the CPT codebook is organized by musculoskeletal anatomy
...
The subsection is further divided by a consistent theme of procedures:
...
incision
...
excision
...
introduction or removal
...
repair, revision, and/or reconstruction
...
fracture and/or dislocation
...
arthrodesis
...
and amputation
...
This format is repeated throughout the subsection by anatomy (see Figure 4-12)
...
The codes in the Musculoskeletal System subsection are for the reporting of procedures involving tendons, muscles, fractures and dislocations, spine surgery, bunions, and casting and strapping
...
Procedures performed via an arthroscope are specifically addressed at the end of the subsection, and terms related to the treatment of fractures are included in the introductory language of the Musculoskeletal System subsection in the CPT codebook
...
Sections of the Musculoskeletal System subsection are highlighted in this chapter along with a review of some basic coding guidelines associated with reporting excisions, fractures and dislocations, spine surgery, bunion procedures, and casting and strapping procedures
...
This chapter will provide an overview of the Musculoskeletal System codes (20005-29999) of the CPT codebook
...
(See Figures 4-13A and 4-13B
...
FIGURE 4-12 CPT Codebook Surgery Categories Regarding the Musculoskeletal System
...
• Subcutaneous soft tissue tumors, removal of
• Fascial or subfascial soft tissue tumors, removal of
• Radical resection of soft tissue tumors, removal of
• Radical resection of bone tumors, removal of Musculoskeletal Lesion Excisions
...
Musculoskeletal Lesion Excisions
There is often confusion in determining whether the excision of soft tissue tumors is reported with codes from the Integumentary system or the Musculoskeletal system
...
Musculoskeletal lesion excision codes pertain to subcutaneous, superficial, or deep soft tissues under the skin, which may include subcutaneous fat, fascia, muscle, and bone
...
Soft tissue excision codes are dispersed throughout the musculoskeletal section of the CPT codebook and are categorized by anatomic site
...
Be sure to review and understand the guidelines in this section
...
When coding musculoskeletal procedures, it is important to note that the excision must meet the criteria listed in the code descriptor
...
For example, in order to report code 26116, Excision, tumor, soft tissue, or vascular malformation, of hand or finger
...
subfascial (eg, intramuscular)
...
less than 1
...
5 cm, the tumor must be down to the muscle (ie, located between the fascia and muscle) or be intramuscular, such as a muscle sarcoma
...
There are different musculoskeletal tumors listed throughout this section, such as subcutaneous soft tissue tumors, fascial or subfascial soft tissue tumors, radical resection of soft tissue tumors, and radical resection of bone tumors
...
FIGURE 4-13A Muscular System, Front

FIGURE 4-13B Muscular System, Back
...
Subcutaneous soft tissue tumors, removal of: These involve the simple or marginal resection of tumors confined to subcutaneous fatty tissue below the skin, but above the deep fascia
...
Fascial or subfascial soft tissue tumors, removal of: These involve the resection of tumors confined to the tissue within or below the deep fascia, but not involving the muscle or bone
...
Included are digital (ie, fingers and toes) subfascial tumors that involve the tendons, tendon sheaths, or joints of the digit
...
Radical resection of soft tissue tumors, removal of: These involve the resection of a tumor, usually malignant, with wide margins of normal tissue
...
Radical resection of bone tumors, removal of: These involve the resection of the tumor with wide margins of normal tissue
...
Radical resection of bone tumors is usually performed for malignant tumors or very aggressive tumors
...
Similar to the guidelines for the Integumentary System, the code selection for musculoskeletal lesion excisions is determined by
...
measuring the greatest diameter of the tumor, in addition to the narrowest margin required for the complete excision of the tumor, based on the physician's judgment, at the time of the excision
...
The radical resection of soft tissue tumors may be confined to a specific layer, for instance, the subcutaneous or subfascial tissue, or it may involve the removal of tissue from one or more layers
...
Radical resection of soft tissue tumors is most commonly used for malignant or very aggressive benign tumors
...
1
...
List the different musculoskeletal tumors
...
The fracture or dislocation codes should not be reported based on the type of fracture (eg, closed, open), but rather by the type of treatment provided
...
For example, a closed fracture may require open treatment to accomplish the repair
...
Fractures and Dislocations
When fractures and dislocations are reported, it is important to have a clear understanding of the various types of treatment, as well as the anatomy
...
See Figures 4-14 through 4-16
...
In addition, before selecting the appropriate fracture/dislocation CPT code, it is important to note the following information in the medical record:
...
The site of the fracture
Type of treatment (e.g., open, percutaneous skeletal fixation)
With or without manipulation
Whether traction or internal or external fixation is performed
...
FIGURE 4-14A Skeletal System
FIGURE 4-14B Skull
...
Closed vs Open Treatment
Closed treatment of a fracture or dislocation specifically means that the fracture or dislocation site is not surgically opened
...
This treatment is used to describe procedures that treat fractures by one of the following three methods:
...
Without manipulation
With manipulation
With or without traction
...
Open treatment means that the fracture is surgically opened and visualized to allow internal fixation, or as noted in the musculoskeletal system guidelines of the CPT codebook, an intramedullary fixation of a fracture is also considered an open procedure, unlike percutaneous fixation
...
An incision remote to the fracture is required for insertion of the intramedullary rod, and the fracture site is often not visualized directly
...
This requires more work and skill in correct placement of the incision and accurate distal rod positioning compared with percutaneous insertion of a pin
...
FIGURE 4-15A Bones of Hand

FIGURE 4-15B Tendons of Hand

FIGURE 4-16A Bones of Foot

FIGURE 4-16B Muscles of Foot
...
• Closed treatment
• Open treatment
• Percutaneous skeletal fixation
• Manipulation
• Sheaths
• Ligament
• Trigger point
...
Percutaneous Skeletal Fixation
This type of treatment is neither open nor closed
...
In this procedure, the fracture fragments are not visualized, but fixation (eg, with pins) is placed across the fracture site, usually under X-ray imaging
...
Manipulation
The term manipulation is used in many sections of the CPT codebook
...
The definition used here applies to codes in the Musculoskeletal System section
...
Manipulation is the attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by applying forces
...
2
...
How many types of fracture treatments are there? Briefly describe each
...
3
...
List the different methods of closed treatment
...
Injections
The Musculoskeletal System section includes codes to report injections into tendon sheaths, ligaments, muscles, and trigger points
...
Code 20550, Injection(s)
...
single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia"), is used to report single or multiple injections per single anatomic tendon sheath, ligament, or aponeurosis
...
Code 20551, Injection(s)
...
single tendon origin/insertion, is used to report single or multiple injections per single tendon origin or insertion
...
When multiple injections to the same tendon are performed, they are reported only once
...
When injections to multiple tendon sheaths, ligaments, tendon origins, or tendon insertions are performed, they are reported one time for each injection
...
See Figure 4-17
...
The codes for trigger point injections, 20552 and 20553, are intended to be reported once per session, regardless of the number of trigger points or muscles injected
...
Whenever radiological imaging guidance is performed in addition to the injection procedures, the appropriate radiology code 76942 should be reported in addition to the injection codes to describe the imaging guidance
...
A 40-year-old female presents with stenosing tenosynovitis of the right index finger
...
She is treated with two steroid injections into the flexor tendon sheath
...
Code 20550 is reported one time for the two steroid injections because multiple injections to the same tendon would be reported only once
...
A 60-year-old male presents with a three-month history of pain in the low left back above the posterior iliac crest with radiation of pain into the left buttock
...
He undergoes injection of the trigger point in the multifidus muscle left of the L5 spinous process and an injection in the gluteus medius muscle
...
Code 20552 is reported for the two injections because this code is intended to be reported once per session
...
FIGURE 4-17 Trigger Point Injection


Closed treatment: The fracture or dislocation site is not surgically opened
...
Open treatment: The fracture is surgically opened and visualized to allow internal fixation
...
Percutaneous skeletal fixation: Utilizes a type of treatment that holds the position of a fracture by the use of external pins inserted across the skin into bone
...
Manipulation: The attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by applying forces
...
Please note that this definition applies to codes in the Musculoskeletal System section
...
Sheaths: Any enveloping structure, such as the membranous covering of a muscle, nerve, or blood vessel
...
any sheathlike structure
...
Ligament: A band or sheet of fibrous tissue connecting two or more bones, cartilages, or other structures or serving as support for fasciae or muscles
...
Trigger point: A specific point or area where stimulation by touch, pain, or pressure induces a painful response
...
When an arthrocentesis, aspiration, or injection of a major joint or bursa (20610) is performed, the insertion of needle into major joint or bursa for the injection of
...
therapeutic or diagnostic agent, aspiration, or arthrocentesis is included in the procedure, and should not be reported separately
...
See Figure 4-18
...
When performing the halo application for a thin skull osteology (20664), a cranial halo is placed on the head of a child whose skull is unusually thin due to congenital or developmental problems
...
See Figures 4-19A and 4-19B
...
Figures 4-20 and 4-21 are examples of types of stabilization devices
...
Codes 20690 and 20692 describe the placement of types of external fixation devices
...
The method of stabilization depends upon fracture grade (degree of soft tissue injury or skin integrity disruption), type ( comminuted, spiral, impacted), and location (extremity, pelvis)
...
Spine Surgery
When coding for spine surgery, the coder must consider and apply various guidelines that are included in the beginning of the Spine subsection in the CPT codebook
...
These guidelines include various coding components such as bone grafting, arthrodesis, and spinal instrumentation
...
Careful review of these instructions along with each code descriptor is also imperative to ensure that the correct codes are selected
...
FIGURE 4-18 Arthrocentesis, Aspiration, or Injection of Major Joint or Bursa

FIGURE 4-19A Halo Application for Thin Skull Osteology

FIGURE 4-19B Halo Application for Thin Skull Osteology

FIGURE 4-20A Uniplane External Fixation System

FIGURE 4-20B Uniplane External Fixation System
...
• Interspace
• Segment
• Vertebral components
• Arthrodesis
• Segmental instrumentation
• Nonsegmental instrumentation

It is important to understand various anatomic terms when spine surgeries are coded
...
It is important to understand various anatomic terms when spine surgeries are coded
See Figure 4-22
...
The Key Terms on
...
page 98 offer further definitions for spine surgery
...
The spine (vertebral column) consists of a series of bones known as vertebrae
...
There are 33 vertebrae in an adult human, which are divided into the following five types
...
Cervical vertebrae C1-7 neck area
Thoracic vertebrae T1-12 upper back area
Lumbar vertebrae L1-5 lower back
Sacral vertebrae S1-5 the sacrum
Coccygeal vertebrae coccyx the tailbone
...
FIGURE 4-21 Multiplane External Fixation System
...
Interspace: The nonbony compartment between two adjacent vertebral bodies that contains the intervertebral disc and includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates
...
Segment: The basic constituent part into which the spine may be divided
...
It represents a single complete vertebral bone with its associated articular processes and laminae
...
Vertebral components: The vertebral body, spinous process, laminae, facets, and intervertebral disc
...
Arthrodesis: The surgical fusion or fixation of a joint
...
Segmental instrumentation: The fixation at each end of the construct and at least one additional interposed bony attachment
...
Nonsegmental instrumentation: The fixation at each end of the construct, possibly spanning several vertebral segments without attachment to the intervening segments
...
FIGURE 4-22A Thoracic Vertebra, Superior View

FIGURE 4-22B Lumbar Vertebra, Superior View

FIGURE 4-22C Lumbar Vertebrae, Lateral View
...
Sometimes spinal procedures include reporting codes from the Nervous System subsection in addition to codes from the Musculoskeletal System subsection for reporting various procedures such as laminectomy and spinal cord decompression
...
When multiple surgeons act as primary surgeons on the basis of the complexity of the procedure(s), modifier 62 can be appended to certain appropriate codes to reflect that surgeons worked together as primary surgeons
...
Modifier 62 may not be appended to the spinal instrumentation codes and spinal bone graft codes
...
Grafts (or Implants)
Codes 20930-20938, located under the Grafts (or Implants) subsection of the Musculoskeletal procedures of the CPT codebook, describe various types of bone graft procedures used for spine surgery (ie, allograft, autograft, structural, morselized)
...
It is imperative to understand the terms used in the bone graft code descriptors before selecting the correct code
...
Allograft: A donor bone obtained from a bone bank
...
Autograft: Cancellous or bone cortex surgically removed from another area of the patient's own body
...
Morselized bone graft: Small pieces of bone obtained either from a bone bank or from the patient's own body
...
Structural bone graft: A whole piece of cancellous and/or bone cortex obtained from a bone bank or removed from the patient's own body
...
When performing the reconstruction of the mandibular rami (21196), the mandibular ramus is reconstructed to lengthen, set back, or rotate the mandible
...
See Figure 4-23
...
When performing percutaneous vertebroplasty (22520), augmentation of a vertebral fracture is achieved by percutaneous injections of polymethylmethacrylate under fluoroscopic guidance
...
See Figure 4-24
...
Vertebral Body, Embolization, or Injection
Percutaneous vertebroplasty describes a procedure in which a sterile biomaterial such as polymethylmethacrylate is injected from one side or both sides into the damaged vertebral body to act as a bone cement to reinforce the fractured or collapsed vertebra
...
Various polymethylmethacrylate cements are commonly used
...
however, a cement indicated for craniofacial defect repair mixed with commercially available barium sulfate may be used
...
• Allograft
• Autograft
• Morselized bone graft
• Structural bone graft
...
FIGURE 4-23 Reconstruction of Mandibular Rami

FIGURE 4-24 Percutaneous Vertebroplasty
...
This procedure is indicated primarily for relief of pain related to vertebral compression fractures secondary to osteoporosis
...
However, other conditions such as aneurysmal bone cysts, hemangioma, giant-cell tumor, or metastatic malignancy may also result in vertebral compression fractures
...
It is important to note, however, that these conditions are merely provided as examples
...
The percutaneous vertebroplasty code set, 22520-22522, is intended to report a unilateral or bilateral injection and is delineated based upon spinal level (ie, thoracic or lumbar)
...
• Percutaneous vertebroplasty
• Kyphoplasty
...
Vertebroplasty is performed on T3, T4, and T5
...
Code 22520 is reported one time for the first level (T3)
...
Code 22522 is reported twice, one time for each additional level (T4 and T5)
...
Kyphoplasty
Percutaneous vertebral augmentation (kyphoplasty) is a minimally invasive surgical technique for treating fractures of the spine that occur because of osteoporosis, usually in postmenopausal women
...
Mechanical devices (miniature expandable jacks, curved tamps, expandable balloon tamps, etc) were developed to provide physicians with new tools and options to treat vertebral body compression fractures
...
Codes 22523-22525 describe vertebral fracture augmentation and injection of polymethylmethacrylate (bone cement)
...
It is important to note that cavity creation using a mechanical device at a single thoracic and lumbar vertebral body is included in codes 22523 and 22524
...
In addition, fracture reduction and bone biopsy are incidental to the procedure and should not be reported separately
...
An exclusionary parenthetical note following 22525 instructs to preclude the use of the deep bone biopsy code 20225 with the vertebral augmentation codes 22523-22525
...
Add-on code 22525 describes each additional thoracic or lumbar vertebral body on which percutaneous vertebral augmentation is performed
...
A parenthetical note following this code instructs users to delineate the reporting of 22525 in conjunction with 22523 and 22524, as appropriate
...
4
...
Is it appropriate to report deep bone biopsy (code 20225) in addition to a vertebral augmentation procedure?
...
The radiological supervision and interpretation (RS&I) portions of the percutaneous vertebroplasty and percutaneous vertebral augmentation procedures are reported separately based upon the type of guidance used: fluoroscopic guidance (72291) or computed tomographic (CT) guidance (72292)
...
Code 22526 and add-on code 22527 describe the performance of intradiscal electrothermal annuloplasty
...
This procedure is performed by inserting a needle or catheter, which is subsequently heated, into a disc to effect a thermal change in the annular tissue
...
This modulates the nerve fibers in a disrupted disc's annulus and stabilizes the collagen of the annulus as a treatment for back pain
...
Code 22526 is reported one time only when performed bilaterally
...
Code 22527 is also reported one time for electrothermal annuloplasty of additional levels, regardless of the number of additional levels treated in a single session
...
As indicated in the code descriptor, fluoroscopic guidance is included in codes 22526 and 22527
...
Therefore, codes 77002 and 77003 should not be reported separately in addition to the electrothermal annuloplasty codes
...
Percutaneous vertebroplasty: A procedure in which a sterile biomaterial such as methylmethacrylate is injected from one side or both sides into the damaged vertebral body to act as a bone cement to reinforce the fractured or collapsed vertebra
...
Kyphoplasty: A new, minimally invasive surgical technique for treating fractures of the spine that occur because of osteoporosis, usually in postmenopausal women
...
Arthrodesis
Spinal arthrodesis is performed on vertebral segments of the spine to firmly join joint surfaces by promoting the proliferation of bone cells and new bone
...
Codes 22800-22819 describe arthrodesis procedures performed for scoliosis or kyphosis
...
Codes 22532-22632 describe arthrodesis procedures performed for a reason other than to correct a spinal deformity and are categorized by the anatomic approach (anterior, posterior, or lateral)
...
See Figure 4-25 for the arthrodesis by anterior approach
...
Figure 4-26 shows an example of an exposure technique used to reach anterior cervical vertebrae for spinal procedures (eg, discectomy, arthrodesis, spinal instrumentation) (22554)
...
while Figure 4-27 shows an example of an exposure technique used to reach anterior lumbar vertebrae for spinal procedures (eg, discectomy, arthrodesis, spinal instrumentation) (22558)
...
FIGURE 4-25 Arthrodesis (Anterior Transoral Technique)

FIGURE 4-26 Anterior Approach for Cervical Fusion

FIGURE 4-27 Anterior Approach for Lumbar Fusion (Anterior Retroperitoneal Exposure)
...
Spinal Instrumentation
Insertion of spinal instrumentation is reported with codes 22840-22848 and 22851
...
The insertion of spinal instrumentation is separately reported in addition to the arthrodesis procedure and any definitive procedure(s) performed
...
These codes are categorized as follows by the type of instrumentation performed:
...
Posterior nonsegmental instrumentation (fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments): 22840 (See Figure 4-28
...
Posterior segmental instrumentation (posterior approach fixation at each end of the construct and at least one additional interposed bony attachment): 22842-22844 See Figure 4-29
...
FIGURE 4-28 Nonsegmental Spinal Instrumentation

FIGURE 4-29 Segmental Spinal Instrumentation
...
Anterior instrumentation (anterior approach fixation at each end of the construct and at least one additional interposed bony attachment): 22845-22847
Pelvic fixation: 22848
...
Code 22849 should not be reported in conjunction with codes 22850, 22852, and 22855 at the same spinal levels
...
Code 22849 describes reinsertion of a spinal fixation device
...
This code may be used for all types of devices, as the type of instrumentation is not specified in the code descriptor
...
Code 22851 describes application of intervertebral biomechanical device(s) to a vertebral defect or interspace
...
This code is reported only one time per interspace, regardless of the number of devices placed at that same interspace
...
There are occasions when metal cages are placed at two different vertebral interspaces
...
In these instances, code 22851 may be reported once for each interspace
...
See Figure 4-30
...
Codes 22850, 22852, and 22855 describe the various procedures associated with removal of instrumentation
...
It is important to note that codes 22849, 22850, 22852, and 22855 may be appended with modifier 51 if reported with other definitive procedure(s) including arthrodesis, decompression, and exploration of fusion
...
Codes 22857, 22862, and 22865 are used to report the variations of lumbar disc replacement surgery
...
The placement of an artificial disc requires anchoring plates to the vertebral end plates on the vertebrae above and below the intradiscal space
...
The artificial disc is sandwiched between these plates
...
These codes describe an anterior approach through the abdomen to access the anterior portion of the spine without disruption of the spinal cord area
...
Code 22857 describes initial placement of a lumbar artificial disc in a single interspace
...
The placement of one or more additional discs in additional interspaces is reported with Category III add-on code 0163T
...
Code 22862 describes the revision and replacement of an existing lumbar artificial disc at a single level
...
Category III code 0165T is reported for revision of other previously placed discs at other interspaces
...
Code 22865 describes the removal of an existing lumbar artificial disc at a single level
...
The removal of lumbar artificial discs at additional levels is reported with Category III add-on code 0164T
...
FIGURE 4-30 Spinal Prosthetic Devices

When performing a partial hip replacement with or without bipolar prosthesis (27125), the femoral neck is excised so the physician can measure and then replace the femoral stem
...
See Figure 4-31
...
When performing a total hip replacement (27130), the femoral head is excised, osteophytes are removed, and acetabulum is reamed out before replacement is inserted in the femoral shaft
...
See Figure 4-32
...
When performing a percutaneous treatment of a femoral fracture (27235), the femoral fracture is treated without fracture exposure
...
See Figure 4-33
...
With an open treatment of a femoral fracture (27236), the femoral fracture is treated by internal fixation device (with fracture exposure)
...
See Figure 4-34
...
FIGURE 4-31 Partial Hip Replacement With or Without Bipolar Prosthesis

FIGURE 4-32 Total Hip Replacement

FIGURE 4-33 Percutaneous Treatment of Femoral Fracture

FIGURE 4-34A Open Treatment of Femoral Fracture

FIGURE 4-34B Open Treatment of Femoral Fracture
...
Code 22849 should not be reported in conjunction with codes 22850, 22852, and 22855 at the same spinal levels
...
Not all bunion deformities are the same, and different techniques are needed to repair different levels of deformity
...
A common deformity of the first metatarsophalangeal (MTP) joint is a hallux valgus (bunion)
...
The CPT code set includes codes for reporting various techniques used to correct bunion deformities
...
Figures 4-35 through 4-42 illustrate the various techniques, such as:
Hallux Valgus correction (28290), which is the simple resection of the medial eminence (Silver-type procedure)
...
FIGURE 4-35 Hallux Valgus Correction

Keller-type procedure (28292), which is the simple resection of the base of the proximal phalanx with removal of the medial eminence
...
A hemi implant is optional
...
FIGURE 4-36 Keller-Type Procedure

Keller-Mayo procedure with Implant (28293), which is a total double stem implant, is usually used
...
FIGURE 4-37 Keller-Mayo Procedure with Implant

Joplin procedure (28294), in which a tendon transplant is an important part of the procedure
...
FIGURE 4-38 Joplin Procedure

Mitchell procedure (28296), which is a complex, biplanar, double step-cut osteotomy through the neck of the first metatarsal
...
Also called Mitchell Chevron (Austin) procedure
...
FIGURE 4-39 Mitchell Procedure

Lapidus-Type procedure (28297), in which a metatarsocuneiform fusion of bones and a distal bunion repair are performed to correct a valgus deformity
...
FIGURE 4-40 Lapidus-Type Procedure

Phalanx osteotomy (28298), which is the Akin procedure that involves removal of a bony wedge from the base of the proximal phalanx to reorient the axis
...
FIGURE 4-41 Phalanx Osteotomy

Double osteotomy (28299), which is a technique that depicts both a medial resection of the first metatarsal with correction of the hallux valgus, and also a hallux valgus correction
...
FIGURE 4-42A Double Osteotomy

FIGURE 4-42B Double Osteotomy

All the codes in the 28290-28299 series include integral components when performed at the first MTP joint
...
The following procedures, therefore, are not reported separately:
...
Capsulotomy
Arthrotomy
Synovial biopsy
Neuroplasty
Synovectomy
...
Tendon release
Tenotomy
Tenolysis
...
Excision of medial eminence
Excision of associated osteophytes
Placement of internal fixation
...
Scar revision
Articular shaving
Removal of bursal tissue
...
Application of Casts and Strapping
The guidelines at the beginning of the Musculoskeletal System section in the CPT codebook indicate that the services listed include the application and removal of the first cast or traction device only
...
Subsequent replacement of a cast and/or traction device may require an additional listing with the 29000-29799 series of codes from the Application of Casts and Strapping subsection
...
These codes have specific guidelines pertaining to their use
...
It is important to develop a good understanding of these guidelines to appropriately code for the application of casts and strapping
...
Application of casts and strapping may be reported for the following:
...
A replacement cast or strapping procedure during or after the period of normal follow-up care
An initial service performed without restorative treatment or procedures to stabilize or protect a fracture, injury, or dislocation and/or to relieve pain
...
An initial cast or strapping service when no other treatment or procedure is performed or expected to be performed by the same physician
...
An initial cast or strapping service when another physician provides a restorative treatment or procedure(s)
The following are two questions to consider before reporting an initial cast or strapping with a casting and strapping code:

1
...
Will any restorative treatment or procedure(s) (eg, surgical repair, closed or open reduction of a fracture or joint dislocation) be performed, or is treatment expected to be performed?
2
...
Will the same physician assume all subsequent fracture, dislocation, or injury care?
Answering these questions will assist in establishing a good basis for deciding whether the casts and strapping codes should be reported
...
5
...
What questions should you ask yourself when trying to establish whether the casts and strapping codes should be reported?
...
Endoscopy/Arthroscopy
Codes 29800-29999 are used to report endoscopic and arthroscopic musculoskeletal procedures
...
(See Figure 4-43) The guidelines at the beginning of this category of codes in the CPT codebook indicate that surgical arthroscopy always includes a diagnostic arthroscopy, as the diagnostic arthroscopy is considered an integral component of surgical arthroscopy
...
When an arthroscopy of the knee (29870-29887) is performed, the portal incisions are made on either side of the patellar tendon and compartments of the knee are examined using the arthroscope and a probe
...
Additional treatment is performed as needed
...
(See Figure 4-44
...
) When an arthroscopy of the ankle (29894-29899) is performed, incisions are made allowing the ankle to be examined using the arthroscope and a probe
...
Additional treatment is performed as needed
...
See Figure 4-45
...
General guidelines for coding endoscopic and arthroscopic procedures are as follows:
...
The coder should look up endoscopy, arthroscopy, or laparoscopy in the index and locate the organ or system being examined or treated with a scope
...
The codes in that system or organ section should be reviewed to find an endoscopy, arthroscopy, or laparoscopy heading
...
If there is no endoscopy, arthroscopy, or laparoscopy heading in that section, a code with a descriptor that includes the suffix "-oscopy" and describes the procedure performed should be selected
...
FIGURE 4-43 Arthroscopy, Shoulder, Distal Claviculectomy (Mumford Procedure)
FIGURE 4-44 Arthroscopy of the Knee
FIGURE 4-45 Arthroscopy of the Ankle
...
If there is no heading for endoscopy, arthroscopy, or laparoscopy or there is no specific code mentioning the use of an endoscope in its descriptor, the codes described in that section are for open surgical procedures and should not be used to report a procedure using an endoscopic approach
...
The physician should be asked to clarify that the procedure was performed with an endoscope or laparoscope
...
If there is no specific code for the endoscopy/arthroscopy/laparoscopy procedure in question, the unlisted procedure code in the Endoscopy/Arthroscopy subsection is used to report the procedure
...
When an unlisted code is reported, a copy of the operative report should be submitted to the insurance company when the claim is filed
...
1
...
subcutaneous soft tissue tumors, fascial or subfascial soft tissue tumors, radical resection of soft tissue tumors, and radical resection of bone tumors
2
...
There are three types of fracture treatments
...
i
...
Closed treatment of a fracture or dislocation specifically means that the fracture or dislocation site is not surgically opened
...
ii
...
Open treatment means that the fracture is surgically opened and visualized to allow internal fixation
...
iii
...
Percutaneous Skeletal Fixation is neither open nor closed
...
The fracture fragments are not visualized, but fixation (eg, with pins) is placed across the fracture site, usually under X-ray imaging
...
3
...
Without manipulation
With manipulation
With or without traction
4
...
No, the intraoperative services includes deep bone biopsy (code 20225)
...
An exclusionary parenthetical note following 22525 instructs to preclude the use of the deep bone biopsy code 20225 with the vertebral augmentation codes 22523-22525
...
5
...
a
...
Will any restorative treatment or procedure(s) (eg, surgical repair, closed or open reduction of a fracture or joint dislocation) be performed, or is treatment expected to be performed?
b
Will the same physician assume all subsequent fracture, dislocation, or injury care?
...
BOOK II COMPLETED
...
PRINCIPLES OF CPT CODING
BOOK III
Musculoskeletal System
Coding procedures and services from the Musculoskeletal System subsection of the CPT code set can be challenging for even the advanced coder, largely because of the scope of the procedures in this section
...
Therefore, it is essential that one develop a clear understanding of the general guidelines in the Musculoskeletal System subsection and of the additional guidelines that appear throughout the remainder of this section
...
One should become familiar with the arrangement of codes, because similar arrangements and sequences are common throughout this section
...
Figures 4-6 through 4-13 provide an anatomical view of this system
...
Section Layout
The first heading in the Musculoskeletal System subsection is General
...
Some examples of the procedures found in this section include codes for wound exploration, codes describing replantation procedures, codes describing bone biopsy procedures,
...
codes describing joint and tendon sheath injection, codes describing the application of external fixation, and codes to report obtaining autogenous bone, cartilage, tendon, fascia lata, or other tissue grafts
...
These codes typically may be applied to several anatomic locations
...
thus, they are not located in the specific anatomic subsections
...
This heading and its codes are followed by a "head-to-toe" arrangement of the remainder of the Musculoskeletal System subsection
...
Within each anatomic heading, there is a consistent theme of the types of procedures or services described
...
Generally, there are codes used for procedures involving incision
...
excision
...
introduction or removal
...
repair, revision, and/or reconstruction
...
fracture and/or dislocation
...
arthrodesis
...
and amputation
...
This format is repeated throughout the Musculoskeletal System subsection
...
The following sections describe some of the highlights of the Musculoskeletal System subsection of the CPT code set,
...
reviewing some basic guidelines associated with reporting fractures and dislocations, spine surgery, incision, injections, removal of hardware, bunion procedures, arthroscopies, re-exploration procedures, and the guidelines for reporting casting and strapping procedures
...
Fractures and Dislocations
...
When procedures for the treatment of fractures and dislocations are coded, the type of fracture (eg, closed, open) has no coding correlation with the type of treatment (eg, closed, open, or percutaneous) provided
...
For example, a closed fracture may require open treatment to accomplish the repair
...
Closed Treatment
...
Closed treatment of a fracture or dislocation specifically means that the fracture or dislocation site is not surgically opened (exposed to the external environment and directly visualized)
...
Closed treatment includes procedures that treat fractures by the following three methods:
Without manipulation
With manipulation
With or without traction
...
Open Treatment
Open treatment implies that the fractured bone is either:
surgically opened (exposed to the external environment) and the fracture (denoted by bone ends) is visualized to allow internal fixation
...
or
the fracture bone is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site (the fracture site is not opened and visualized)
...
Percutaneous Skeletal Fixation
Percutaneous skeletal fixation fracture treatment is neither open nor closed
...
In this procedure, the fracture fragments are not visualized directly, but fixation (eg, using pins) is placed across the fracture site, usually under X-ray imaging
...
FIGURE 4-6
Skeletal System
FIGURE 4-7
Muscular System, Front

FIGURE 4-8
Muscular System, Back

FIGURE 4-9
Skull

FIGURE 4-10
Bones, Muscles, and Tendons of Hand

FIGURE 4-11
Bones and Muscles of Foot

FIGURE 4-12
Second Lumbar and 12th Thoracic Vertebrae

FIGURE 4-13
Lumbar Vertebrae (1-3)
Manipulation
The term manipulation is used throughout the musculoskeletal fracture and dislocation subsections to indicate the attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the application of manually applied forces
...
Orthopedists typically refer to the manipulation of a fracture or dislocation as a reduction, which is the contracted form for the phrase manipulative reduction
...
Although the term manipulation is used in other sections of the CPT code set, this definition is used only for codes appearing in the Musculoskeletal System subsection
...
Excision of subcutaneous soft tissue tumors
These excisions involve the simple or marginal resection of tumors confined to subcutaneous tissue below the skin but above the deep fascia
...
Simple or intermediate repair is included
...
These tumors are usually benign and are resected without removing a significant amount of surrounding normal tissue
...
Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor
...
The margins refer to the most narrow margin required to adequately excise the tumor, based on the physician's judgment
...
The measurement of the tumor plus margin is made at the time of the excision
...
Vessel exploration and/or neuroplasty should be reported separately
...
Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair, which should be reported separately
...
Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision
...
Excision of fascial or subfascial soft tissue tumors
These excisions involve the resection of tumors confined to the tissue within or below the deep fascia, but not involving the bone
...
Simple or intermediate repair is included
...
These tumors are usually benign, are often intramuscular, and are resected without removing a significant amount of surrounding normal tissue
...
Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor
...
The margins refer to the most narrow margin required to adequately excise the tumor, based on individual judgment
...
The measurement of the tumor plus margin is made at the time of the excision
...
Vessel exploration and/or neuroplasty should be reported separately
...
Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately
...
Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision
...
Incision
Code 20005 is used for an incision and drainage procedure that involves the soft tissue below the deep fascia (subfascial)
...
This code should not be reported for "deep" incision and drainage procedures
...
Codes 10060 and 10061 should be reported for cutaneous or subcutaneous incision and drainage procedures
...
Injections
Code 20527 is used to report the injection of an enzyme (eg, collagenase) into the palmar fascial cord (ie, Dupuytren's cord) for the treatment of Dupuytren's contracture
...
A parenthetical reference in the CPT code set directs the user to report code 26341 for manipulations of palmar fascial cord post enzyme injection
...
Dupuytren's contracture is a painless thickening of connective tissue beneath the palm and fingers (see Figure 4-14)
...
One or more small nodules form under the skin—eventually forming tough bands of tissue resulting in a thick cord that can cause one or more finger(s) to bend (flex) toward the palm
...
One or more small, tender lumps (nodules) form in the palm, producing a rigid deformity of the hand(s), most commonly involving the inward bending of the ring and little finger, but sometimes progressing to involve all the fingers
...
Although more than one injection may be performed in a single cord, code 20527 should be reported only once for the injection(s) of the enzyme collagenase [collagenase clostridium histolyticum] into a palmar fascial cord
...
For example, a contracted fascial cord is injected in 3 separate but proximate locations with enzyme
...
Code 26341 is reported for the manipulation of the palmar fascial cord performed on a day subsequent to the enzyme injection(s)
...
The manipulation process includes manual traction placed across the contracted finger until the rupture of the fascial cord is felt and the digit fully extends
...
This process can be repeated two more times at 10-minute intervals, if full extension is not initially achieved
...
FIGURE 4-14
Dupuytren's Contracture
CODING TIP The custom orthotic is not included in code 26341 and should be reported using an appropriate HCPCS Level II code
...
Codes 20550 and 20551 are used to report single or multiple injections per single anatomic tendon sheath or ligament
...
Thus, multiple injections to the same tendon would be reported only once, while injections to multiple tendon sheaths, ligaments, tendon origins, or tendon insertions would be reported one time for each injection
...
For injections of Morton's neuroma, see CPT codes 64445 and 64632
...
Codes 20552 and 20553 are used to report trigger-point injections
...
These codes are reported once per session, regardless of the number of trigger points or muscles injected
...
The appropriate radiology codes (77002, 77021, 76942) should be reported in addition to the injection codes for imaging guidance
...
Code 20555 is used to report placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application for the treatment of soft tissue sarcomas
...
The appropriate radiology codes (77776-77778, 77785-77787) should be reported for the interstitial radioelement application
...
For placement of needles or catheters into specific organ sites the following codes are reported: for breast, codes 19296-19298
...
for muscle or soft tissue of the head and neck, code 41019
...
for the prostate, code 55875
...
for the pelvic organs or genitalia (except prostate) for interstitial radioelement application, code 55920
...
Application of External Fixation
External fixation uses skeletal pins with an attaching device or mechanism for temporary or definitive treatment of bony deformities or fractures
...
When procedures for treatment of fractures or deformities include external fixation, it is important to closely read the code descriptor to make sure that the external fixation is not included as part of the basic procedure
...
For example, open treatment of a femoral shaft fracture with insertion of an intramedullary implant includes external fixation, if applied
...
Application of unilateral multiplane external fixation systems are differentiated as either performed by computer-assisted adjustment of struts or standard application or adjustment without struts, requiring anesthesia
...
Computer-assisted external fixation consists of two rings fixed externally to bone fragments with the rings connected by six telescopic struts
...
This type of external fixation system requires strut adjustment by means of computer-assisted software that generates a patient-specific schedule for the adjustment
...
The initial application and subsequent alignments are reported with code 20696
...
In addition to the initial application, patients can require 2 or 3 strut changes
...
Strut replacements are performed in the office setting and are separately reported with code 20697
...
The removal of the strut is included in code 20697
...
When coding for computer-assisted external fixation, radiology imaging is not separately reported
...
Removal of Hardware
When the fracture is stable or healed, all forces are borne by the bone
...
At this point, the external fixation is no longer needed and can be safely removed
...
Subsequent casting, bracing, or surgery may also follow the removal of external fixation
...
While codes 20690-20697 relate to the application, adjustment, and removal, of an external fixation system, code 20694 would be appropriately reported only when anesthesia is required to perform removal of the external fixator system
...
Removal of an external fixator performed without anesthesia is not a separately reportable procedure because local infiltration of medication(s), anesthetic, or contrast agent before, during, or at the conclusion of the procedure is an inclusive service of codes 20670, 20680, and 20690
...
Code 20680 is used for a unit of service that is reported only once provided the original injury is located on one site, regardless of the number of screws, plates, rods, or incisions
...
An example would be the removal of a single implant system, which may call for "stab" or multiple incisions (eg, intramedullary [IM] nail and several locking bolts)
...
Multiple use of code 20680 would be appropriate only when the hardware removal was performed for another fracture in a different anatomical site unrelated to the first fracture (eg, ankle and humerus)
...
In these circumstances, modifier 59 would be appended to subsequent uses of the code
...
For example, two different and noncontiguous implants are removed from two different bones or two different (noncontiguous) sites on the same bone using multiple incisions
...
Depending on whether the implants were superficial or deep, code 20680 may be reported twice, or codes 20680 and 20670 may each be reported
...
If there was an extraordinary amount of work, or unusual effort involved in the removal (eg, bone buried screws or an exceptional scar), then modifier 22, Increased procedural services, may be appended to the code for the procedure and submitted with the usual accompanying documentation
...
CODING TIP The method of stabilization depends upon fracture grade (degree of soft tissue injury/skin integrity disruption), type (eg, comminuted, spiral, impacted), and location (eg, extremity, pelvis)
...
Spine Surgery
When coding for spine surgery, there are many sets of guidelines to consider
...
At the beginning of the Spine subsection, there are general guidelines that apply to the entire section
...
Additional guidelines throughout the remainder of the Spine subsection can be found under various subheadings
...
Read and apply these guidelines carefully when coding for spine surgery procedures
...
Careful review of each code descriptor is also imperative to ensure that the correct codes are selected
...
The vertebral column (spine) consists of a series of bones known as vertebrae
...
An adult human possesses 33 vertebrae divided into the following five types:
...
Seven cervical vertebrae (C1-C7)—neck area
Twelve thoracic vertebrae (T1-T12)—upper back area
Five lumbar vertebrae (L1-L5)—lower back area
Five sacral vertebrae (S1-S5)—the sacrum
Four coccygeal vertebrae—the coccyx or tailbone
...
The sacral vertebrae are typically fused into a single bone known as the sacrum
...
The coccygeal vertebrae are sometimes fused into a single bone known as the coccyx
...
Therefore, the actual number of bones in the vertebral column may be 26 to 29, depending on whether the coccygeal vertebrae are fused
...
Between each pair of vertebrae is a disc (intervertebral disc) that cushions the spinal column
...
Vertebrae are commonly named by a letter that corresponds to the region of the vertebral column to which the vertebra belongs, followed by a number that indicates where in the region the vertebra is located
...
For example, the most superior cervical vertebra is called C1, with the next cervical vertebra down designated as C2
...
The most superior thoracic vertebra is T1, with the next one down designated as T2
...
A vertebral interspace is the nonbony compartment between two adjacent vertebral bodies that contains the intervertebral disc and includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates
...
A vertebral segment is the basic constituent part into which the spine may be divided
...
It represents a single complete vertebral bone with its associated articular processes and laminae
...
A good understanding of medical terminology pertaining to spine anatomy is important for accurate coding of spine procedures
...
Coders should review the illustrations provided in this chapter as well as any standard anatomy text
...
become familiar with the anatomy of the vertebral column
...
learn the various components of the vertebrae, including the vertebral bodies, spinous processes, laminae, facets, and intervertebral discs
...
and learn the difference between a vertebral segment and an interspace
...
Developing this basic knowledge will assist in understanding the code descriptors and appropriately reporting the codes for spine surgery
...
This section of the CPT code set contains various subheadings and code descriptors within each
...
Codes can be found for procedures that involve excision, osteotomy, fracture and/or dislocation, manipulation, arthrodesis, exploration, and spinal instrumentation
...
Additional codes for reporting procedures of the spine and spinal cord can be found in the Nervous System subsection of the Surgery section
...
Codes in the 62263-64999 series are available for reporting various procedures of the spine and spinal cord
...
In some instances, to completely code for spinal procedures performed, it will be necessary to report codes from the Nervous System subsection in addition to codes from the Musculoskeletal System subsection
...
Coders should read and follow the guidelines, instructional notes, and parenthetical notes found throughout both of these sections of the CPT code set
...
Some of the specific guidelines for reporting procedures of the spine (vertebral column) follow
...
However, coders should always refer to the current CPT code set for complete code descriptors and guidelines
...
Two Surgeons Reporting—Using Modifier 62
CODING TIP Modifier 62 can be added to additional procedural codes only if both surgeons agree to continue to work together as primary surgeons on the basis of the complexity of the case
...
Co-surgery may be required because of the complexity of the procedure(s), the patient's condition, or both
...
The additional surgeon does not act as an assistant at surgery in these circumstances but performs a distinct portion of the procedure as stated in the language for modifier 62
...
The definition of this modifier indicates the following
...
Two surgeons
When two surgeons work together as primary surgeons performing distinct parts of a procedure,
...
each surgeon should report his or her distinct operative work by adding modifier 62 to the procedure code and any associated add-on codes for that procedure, as long as both surgeons continue to work together as primary surgeons
...
Each surgeon should report the co-surgery once with the use of the same procedure code
...
If additional procedures (including add-on procedure[s]) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added
...
Note: If a co-surgeon acts as an assistant in the performance of an additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported by means of separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate
...
The modifier 62 language denotes the role of each surgeon and is intended to assist in discerning when to append either modifier 62 and/or, as appropriate, modifier 80 or 82 to each code reported
...
Modifier 62 is used in the event additional procedure(s) (including add-on procedure[s]) are performed during the same surgical session
...
Those separate code(s) may also be reported with the modifier 62 appended
...
CODING TIP If the co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session,
...
those service(s) may also be reported by that physician or other qualified health care professional using the appropriate procedure code(s) with the modifier 80 or modifier 82 appended
...
Modifier 62 is not to be used with instrumentation or bone graft codes
...
Documentation to establish medical necessity for both surgeons is required for some services
...
It is suggested that before a scheduled surgery, the approach and spine surgeons discuss what portion of the operation each is expected to perform on the basis of case complexity
...
If because of complexity it is agreed that the approach surgeon is needed as a co-surgeon (both the spine and approach surgeons serve as primary surgeons) to perform additional procedures, modifier 62 can be appended to these agreed-on procedures
...
When an approach surgeon only opens and closes the patient, then modifier 62 should be appended to the distinct principal procedure along with any additional level(s) that require approach work by only the approach surgeon
...
Modifier 62 can be added to additional procedural codes only if both surgeons agree to continue to work together as primary surgeons on the basis of the complexity of the case
...
Modifier 80 can be appended to additional procedural code(s) by the approach surgeon if both surgeons agree that the approach surgeon is needed to continue to work as an assistant to the spine surgeon
...
Procedure
Anterior Thoracic Two-Level Arthrodesis, Anterior Single-Level Discectomy, Anterior Plate Instrumentation, Structural, Autograft Iliac Crest Bone Graft
...
EXAMPLE 1
Approach Surgeon Performs Approach and Closure Only
Surgeon Performing Approach Only
22556 62
22585 62
...
Surgeon Performing the Spine Procedure
22556 62
22585 62
63077 51
22845
20938
...
EXAMPLE 2
Approach Surgeon Performs as Co-surgeon with Spine Surgeon for Entire Case
...
Surgeon Performing Approach and Serving as Co-surgeon for Entire Case
22556 62
22585 62
63077 62 51
...
Surgeon Performing the Spine Procedure
22556 62
22585 62
63077 62 51
22845
20938
...
CODING TIP Codes 22520 and 22521 are reported for a single vertebral body only, and when performed, a bone biopsy is included
...
If percutaneous vertebroplasty is performed on additional thoracic or lumbar vertebral bodies during the same session, then add-on code 22522 should be additionally reported for vertebroplasty of each additional vertebral body
...
EXAMPLE 3
Approach Surgeon Performs Approach and Closure and Performs Rest of Case as Assistant to Spine Surgeon
Surgeon Performing Approach and Serving as Assistant for Entire Case
22556 62
22585 62
63077 80 51
...
Surgeon Performing the Spine Procedure
22556 62
22585 62
63077 51
22845
20938
...
General Guidelines for Spine Surgery
Osteotomy When two surgeons work together as primary surgeons performing distinct parts of an anterior spine osteotomy, each surgeon should report his or her distinct operative work by adding modifier 62 to the procedure code
...
In this situation, modifier 62 may be appended to the procedure code(s) (22210-22214, 22220-22224), as appropriate, and to the associated additional segment add-on code(s) (22216, 22226), as long as both surgeons continue to work together as primary surgeons
...
Osteotomies are performed as part of the procedure to correct spinal deformities
...
The procedure involves cutting and removing a portion of the vertebral segment for re-aligning the spine as part of the spinal deformity correction
...
When the osteotomy is performed from a posterior approach, the osteotomy is performed through either a one-column or a three-column technique
...
When coding for spinal osteotomies, it is important to understand the anatomy of the spine, specifically the vertebral segment
...
Coding a three-column osteotomy involves understanding the anatomy of the anterior, middle, and posterior columns
...
The anterior column includes the anterior two-thirds of the vertebral body
...
the middle column includes the posterior third of the vertebral body and the pedicle
...
the posterior column includes the articular facets, lamina, and spinous process
...
The operative report should be reviewed closely to determine whether the osteotomy is performed by a one-column or a three-column technique
...
Codes 22206-22208 address spinal osteotomies through all 3 columns from a posterior approach
...
Procedures that are an integral part of the three-column osteotomy when performed at the same level include laminectomy and discectomy (63001-63048)
...
discectomy and decompression (63075-63078)
...
corpectomy (63081-63091)
...
lateral extracavitary decompression (63101-63103)
...
transpedicular decompression (63055-63066)
...
and exploration of fusion (22830)
...
Arthrodesis and instrumentation are reported separately when performed
...
Codes 22210-22216 are reported for a one-column osteotomy performed from a posterior approach
...
Codes 22220-22226 are reported for a one-column osteotomy through an anterior approach
...
Codes 22210-22226 are not reported in conjunction with codes 22206-22208
...
Code 22208 is an add-on code and reported for each additional vertebral segment
...
Modifier 51 would not be appended to report the additional vertebral segments
...
Fracture and/or Dislocation When two surgeons work together as primary surgeons performing distinct part(s) of open fracture and/or dislocation procedure(s), each surgeon should report his or her distinct operative work by adding modifier 62 to the procedure code
...
In this situation, modifier 62 may be appended to the procedure code(s) (22318-22327), as appropriate, and to the associated additional fracture vertebrae or dislocated segment add-on code (22328), as long as both surgeons continue to work together as primary surgeons
...
Vertebral Body, Embolization or Injection Percutaneous vertebroplasty is a minimally invasive, radiologically guided vertebral augmentation procedure
...
that uses radiological imaging to identify a fractured vertebral body and monitor the injection of polymethylmethacrylate (PMMA), an acrylic polymer cement
...
In addition to injection of the PMMA, vertebroplasty also involves fluoroscopic or computed tomography (CT) guidance, which is separately reportable, to aid in proper needle placement before injection of the polymer cement
...
In addition to stabilizing the fractured vertebral body, vertebroplasty often immediately alleviates the pain caused by the fracture
...
Osteoporotic compression fractures comprise about 90% of the vertebroplasty candidate cases
...
The other 10% of cases are either metastatic lesions of myeloma or painful hemangiomas
...
Percutaneous vertebroplasty is a significantly different procedure from "open" surgical augmentation using PMMA, which is reported with code 22851
...
Refer to Spinal Instrumentation, discussed in this chapter
...
Because percutaneous vertebroplasty does not require creation of an open surgical wound, it is not appropriate to report this procedure by using code 22851
...
22520
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection
...
thoracic
22521

lumbar
22522
...
each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)
CODING TIP Do not report codes 22520-22522 with codes 20225, 22310-22315, 22325, 22327 when performed at the same level
...
Selecting the appropriate code depends on the anatomic area of the spine undergoing the vertebroplasty
...
Code 22520 (see Figure 4-15) is reported for percutaneous vertebroplasty performed on the thoracic spine, whereas code 22521 is reported for vertebroplasty of the lumbar spine
...
EXAMPLE
Vertebroplasty is performed on T6, T7, and T8
...
The physician or other qualified health care professional would report code 22520 one time for the first level
...
Code 22522 would be reported twice, one time for each additional level
...
Because code 22522 is an add-on code, modifier 51 would not be appended to report the additional levels
...
Radiological supervision and interpretation (S&I) is separately reported with either code 72291, under fluoroscopic guidance, or code 72292, under CT guidance
...
The S&I code selected should accurately reflect the type of guidance used and be reported for each vertebral body for which vertebroplasty is performed
...
Open vertebral procedures are sometimes followed by arthrodesis and may include bone grafts and instrumentation
...
Bone grafting procedures are reported separately and in addition to the vertebral procedure, arthrodesis, and instrumentation, when performed
...
Add-on codes 20930-20938 are used to report the various types of bone grafts used for spine surgery
...
These codes are located under the heading of General, Grafts (or Implants)
...
As indicated in the code descriptors, these codes apply only to bone grafts used for spine surgery
...
The parenthetical notes following codes 20930-20938 indicate the specific codes with which they are appropriately reported
...
For other grafts, see codes 20900-20926
...
FIGURE 4-15
Percutaneous Vertebroplasty: 22520
Understanding the terms used in the bone graft code descriptors is essential to choosing the correct code
...
The term allograft refers to donor bone, usually obtained from a bone bank
...
Autograft is cancellous bone or cortical bone surgically removed from another area of the patient's own body
...
A morselized bone graft consists of small pieces of bone, often cancellous, removed from the patient's own body or obtained from a bone bank
...
A structural bone graft consists of a whole piece of cancellous and/or bone cortex, obtained either from the patient's own body or from a bone bank, used to reconstruct and support vertebral segments or spinal arthrodesis
...
If bone marrow is aspirated for grafting in an arthrodesis, CPT code 38220 is used to report the separate aspiration procedure
...
The placement of the bone marrow aspirate is included as part of the arthrodesis procedure reported
...
CODING TIP For needle aspiration of bone marrow for the purpose of bone grafting, use 38220
...
Do not report 38220-38230 for bone marrow aspiration for platelet rich stem cell injection
...
For bone marrow aspiration for platelet rich stem cell injection, use 0232T
...
Percutaneous intradiscal electrothermal annuloplasty (22526, 22527)
...
is performed by insertion of a needle or catheter (subsequently heated) into a disc to effect a thermal change in the annular tissue,
...
modulating nerve fibers in a disrupted disc's annulus, and stabilizing the collagen of the annulus as a treatment for back pain
...
When performed bilaterally, code 22526 is reported once
...
Code 22527 is also reported only one time regardless of the number of additional levels treated in a single session
...
Because fluoroscopic guidance is an inclusive component of codes 22526 and 22527, it would not be appropriate to report codes 77002 or 77003
...
Code 22899, Unlisted procedure, spine, should be reported for percutaneous intradiscal annuloplasty by any method other than electrothermal
...
Fluoroscopic guidance should be separately reported with codes 77002 and 77003
...
CT guidance (77012) and magnetic resonance imaging (MRI) (77021) guidance and localization for needle placement and annuloplasty are also additionally reported, when performed
...
Spinal Arthrodesis
Arthrodesis is defined as the surgical fusion/fixation of a joint by a procedure designed to firmly join joint surfaces by promoting the proliferation of bone cells and new bone
...
Spinal arthrodesis is performed on vertebral segments of the spine
...
Arthrodesis performed for spinal deformities such as scoliosis or kyphosis is reported with codes 22800-22812
...
When two surgeons work together as primary surgeons performing distinct part(s) of an arthrodesis for spinal deformity, each surgeon should report his or her distinct operative work by adding modifier 62 to the procedure code
...
In this situation, modifier 62 may be appended to the procedure code(s) (22800-22819), as long as both surgeons continue to work together as primary surgeons
...
If the arthrodesis is performed for a reason other than to correct a spinal deformity, the codes used to report arthrodesis are categorized by the anatomic approach, as follows:
...
Anterior or anterolateral approach (22548-22585)
Posterior, posterolateral, or lateral transverse process technique (22590-22632)
...
Combined posterior or posterolateral approach (22633-22634)
Lateral extracavitary approach technique (22532-22534)
Spinal arthrodesis may be performed in the absence of other spinal procedures
...
When arthrodesis is combined with another definitive procedure (eg, osteotomy, fracture care, vertebral corpectomy, or laminectomy), then modifier 51 should be appended to the arthrodesis code reported
...
When the code for arthrodesis is listed as the primary procedure, modifier 51 is not appended
...
The arthrodesis codes 22534, 22585, 22614, 22632, and 22634 are add-on codes, indicating that modifier 51 should not be used with these codes
...
CODING TIP When the discectomy code 63075, is performed, the operating microscope code 69990 should not be reported because use of the operating microscope is considered to be inclusive
...
When two surgeons work together as primary surgeons and perform distinct part(s) of anterior interbody arthrodesis, each surgeon should report his or her distinct operative work by adding modifier 62 to the procedure code
...
In these situations, modifier 62 may be appended to the procedure code(s) (22554-22558), as appropriate, and to the associated additional interspace add-on code (22585), as long as both surgeons continue to work together as primary surgeons
...
Excision of an intervertebral disc may be performed at the same operative session as an arthrodesis
...
Separate CPT codes are used to report the disc excision
...
To report an open surgical approach for intervertebral disc excision by laminotomy or laminectomy, report codes in the 63020-63035 series
...
However, intervertebral disc excision performed to prepare the vertebral surface for the bone graft is considered part of the arthrodesis procedure and not reported separately
...
CODING TIP For percutaneous endoscopic approach, report codes 0274T or 0275T, as appropriate
...
If the surgeon removes a disc and/or a bony endplate only to prepare the vertebrae for fusion for anterior or posterior interbody technique (22554, 22630), then no additional code(s) in the 63000 series should be reported
...
The appropriate code(s) for laminectomy, facetectomy, and foraminotomy codes 63045-63048
...
and discectomy/decompression codes 63075-63078 should be reported when the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve roots in addition to removing the disc and preparing the vertebral endplate
...
This requires work in excess of that normally performed when a posterior lumbar interbody fusion, PLIF is performed
...
To report code 22554 in addition to code 63075, the surgeon must perform the additional procedure(s) and work that lead to the decompression of neural elements
...
In most cases, the dura and/or neural elements are exposed to ensure decompression, which is considered over and above the work included in code 22554
...
Therefore, the decompression procedure 63075 (with modifier 51 appended) would be reported in addition to code 22554
...
Additional procedures include drilling off the posterior osteophytes with the use of the operating microscope, opening the posterior longitudinal ligament to look for free disc fragments (decompressing the spinal cord), or removing far lateral disc fragments to decompress the nerve roots
...
To report code 22630 (see Figure 4-16) in addition to code 63047 51, additional procedure(s) must also be performed
...
For example, in spinal procedures performed on patients with lateral lumbar stenosis, the surgeon may perform additional work above and beyond that included in the PLIF, such as facetectomy and/or foraminotomy, to adequately decompress the nerve roots
...
In this case, code 63047 51 would be reported in addition to code 22630
...
FIGURE 4-16
Arthrodesis, Posterior Interbody Technique: 22630
The issue of laterality (unilateral vs bilateral procedures) should be considered because codes 22554 and 63075 involve a midline anterior approach
...
It would not be appropriate to use modifier 50 or report these codes twice, once for each side
...
These codes should be reported only one time per interspace
...
Code 22554 is used for removing as much disc as necessary to prepare the disc space
...
Code 22630 is used for a technique involving a bilateral posterior approach
...
Surgical practice has evolved to the point where the procedure is now performed from a unilateral approach
...
Laterality has never been part of the descriptor of code 22630
...
Code 22630 should be reported without modifier 50 appended, because there is no separation in the descriptor to differentiate whether the procedure was performed with a unilateral or a bilateral approach
...
To further clarify, code 22630 may also require that a posterior fusion be performed, which involves bone grafting and placement of posterior spinal instrumentation
...
These additional procedures should be reported
...
If the surgeon placed a structural intervertebral biomechanical device (for example, a synthetic cage) in the vertebral defect or disc space, code 22851 is reported
...
If any other type of bone graft is performed, the appropriate bone graft code should be reported using the appropriate spinal bone graft code (20930-20938)
...
CODING TIP If the operating microscope is required, code 69990 is reported
...
Code 22554 may be used for the anterior fusion procedure requiring bone grafting and placement of anterior spinal instrumentation
...
In this circumstance, the appropriate bone grafting code and anterior spinal instrumentation code should be reported in addition to code 22554
...
Codes 63040-63044 are the only codes that can be reported for procedures performed on a recurrent herniated nucleus pulposus at each previously explored cervical or lumbar interspace
...
The term re-exploration refers to the repeat surgical exposure of a surgical tract and target at the same site on the same patient at a time after an initial surgical procedure(s) was performed
...
As with other CPT code descriptors, the time frame associated with the re-exploration procedure is not specifically stated
...
Should re-exploration be required within the operative period of an initial procedure, then the appropriate re-exploration code(s) should be reported with modifier 78 appended
...
Re-exploration Procedures
Codes 63040-63044 are reported for procedures performed on a recurrent herniated nucleus pulposus at each previously explored cervical or lumbar interspace
...
Re-exploration refers to the repeat surgical exposure of a previous surgical tract and target at the same site on the same patient at a time after an initial surgical procedure(s) was performed
...
The time frame associated with the re-exploration procedure is not specifically stated, however, should reexploration be required within the operative period of an initial procedure, then the appropriate re-exploration code(s) should be reported with the modifier 78 appended
...
The 63040-63044 code series delineates the following conditions:
Re-exploration laminotomy or hemilaminectomy is considered a unilateral procedure
...
Anatomically, either the right and/or left lamina or disc material may be excised
...
Therefore, if right and left hemilaminectomies are performed at a cervical or lumbar interspace, codes 63040-63044, as appropriate, should be reported with modifier 50 appended
...
Re-exploration procedure involves a single interspace, as opposed to an entire region of the spine (eg, cervical, lumbar)
...
In certain instances, other spinal procedures may be performed at the time of the re-exploration procedure that involve vertebral segment(s) or interspace(s) not previously explored
...
Therefore, the appropriate bone graft, arthrodesis, and/or spinal instrumentation codes should be additionally reported
...
In this circumstance, modifier 51 should be appended to code 63040 or 63042
...
It is not appropriate to append modifier 51 to add-on code 63043 or 63044
...
For example, if a laminectomy, facetectomy, and foraminotomy are performed concurrently unilaterally or bilaterally
...
with decompression of the spinal cord, cauda equina, and/or nerve roots on a single vertebral segment at the lumbar level and this segment has not been previously explored, then it would be appropriate to report code 63047
...
Code 63048 is an add-on code that may be reported only when 63047 has been reported for the first lumbar vertebral segment procedure and it is necessary to report procedures for one or more additional segments
...
For coding purposes, a segment is defined as a single complete vertebral bone with associated articular processes and laminae
...
When two surgeons work together as primary surgeons performing distinct part(s) of a spinal cord exploration/decompression operation,
...
each surgeon should report his or her distinct operative work by adding modifier 62 to the procedure code , and any associated add-on codes for that procedure code, as long as both surgeons continue to work together as primary surgeons
...
In this situation, modifier 62 may be appended to the definitive procedure codes 63075, 63077, 63081, 63085, 63087, 63090
...
and, as appropriate, to associated additional interspace add-on codes 63076, 63078 or additional segment add-on codes 63082, 63086, 63088, 63091, as long as both surgeons continue to work together as primary surgeons
...
When two surgeons work together as primary surgeons and perform distinct parts of an anterior or anterolateral approach
...
for an intraspinal excision, each surgeon should report his or her distinct operative work by adding modifier 62 to the single definitive procedure code
...
In this situation, modifier 62 may be appended to the definitive procedure codes 63300-63307, as appropriate, and to the associated additional segment add-on code 63308, as long as both surgeons continue to work together as primary surgeons
...
The Nervous System subsection in this chapter provides further discussion of other spinal cord, vertebrectomy, and intraspinal excision codes
...
Spinal Instrumentation
CODING TIP Codes 22840-22855 should be separately reported when procedures are performed in conjunction with fracture, dislocation, arthrodesis, or exploration of fusion of the spine
...
The parenthetical notes following codes 22840-22851 will indicate the specific codes with which they are appropriately reported
...
Instrumentation procedure add-on codes 22840-22848 and 22851 are reported without appending modifier 51
...
Insertion of spinal instrumentation is reported separately in addition to arthrodesis and any definitive procedure(s) performed
...
In addition, modifier 62 may not be appended to the definitive or add-on spinal instrumentation procedure code(s) (22840-22848, 22850-22852)
...
Code 22849, for reinsertion of spinal fixation, and code 22855, for removal of anterior spinal instrumentation, may be reported with modifier 62 appended
...
The Spine subsection guidelines reflect the use of modifier 62 with the spinal instrumentation codes
...
The notes preclude the use of modifier 62 with the spinal instrumentation codes 22840-22848 and 22850-22852
...
Codes 22840-22855 should be separately reported when procedures are performed in conjunction with fracture, dislocation, arthrodesis, or exploration of fusion of the spine (codes 22325-22328, 22532-22534, 22548-22812, and 22830)
...
Add-on codes 22840-22848, and 22851 are reported in conjunction with code(s) for the definitive procedure(s) without modifier 51
...
The guidelines further clarify that codes 22849, 22850, 22852, and 22855 for reporting revisions of previous instrumentation procedures are subject to modifier 51 if reported with other definitive procedure(s), including arthrodesis, decompression, and exploration of fusion
...
Only the appropriate insertion code (22840-22848) should be reported when previously placed spinal instrumentation is being removed or revised during the same session where new instrumentation is inserted at levels including all or part of the previously instrumented segments
...
Do not report the reinsertion (22849) or removal (22850, 22852, 22855) procedures in addition to the insertion of the new instrumentation (22840-22848)
...
Segmental instrumentation is defined as fixation at each end of the construct and at least one additional interposed bony attachment
...
See Figure 4-17
...
Nonsegmental instrumentation is defined as fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments
...
See Figure 4-18
...
Notice that fusion of two adjacent vertebrae is considered nonsegmental, even when pedicle screws are used
...
Codes are available for reporting the following:
Posterior nonsegmental instrumentation (22840)
Posterior segmental instrumentation (22842-22844)
Anterior instrumentation (22845-22847)
Pelvic fixation (22848)

FIGURE 4-17
...
Segmental Spinal Instrumentation: 22842-22844

Fixation at each end of the construct and at least one additional interposed bony attachment
...
FIGURE 4-18
Nonsegmental Spinal Instrumentation: Add-on Code 22840
...
Fixation at each end of the construct
A special note about add-on code 22841, Internal spinal fixation by wiring of spinous processes: This code should not be reported when wiring is performed with other types of segmental or nonsegmental instrumentation
...
Minimal wiring is considered an inclusive component of the segmental and nonsegmental instrumentation codes
...
Three codes are available for reporting removal of instrumentation:
22850
...
Removal of posterior nonsegmental instrumentation (eg, Harrington rod)
22852 Removal of posterior segmental instrumentation
22855 Removal of anterior instrumentation
Code 22849 is used to report reinsertion of a spinal fixation device
...
The type of instrumentation in this code is not specified
...
Therefore, it would be used for all types of devices
...
It is appropriate to separately report removal of spinal instrumentation (22850, 22852, 22855) in addition to code 22849 for the reinsertion
...
Code 22851 is used to report application of an intervertebral biomechanical device (eg, synthetic cage, threaded bone dowel, methylmethacrylate) to a vertebral defect or interspace
...
This code is to be reported only one time per interspace, regardless of the number of devices placed at that interspace
...
However, if, for example, metal cages are placed at two different vertebral interspaces, then add-on code 22851 may be reported once for each interspace
...
Consider the following two examples:
EXAMPLE 1
Two metal cages are placed at the L3-L4 interspace
...
Add-on code 22851 would be reported one time
...
EXAMPLE 2
A metal cage is placed at the L3-L4 interspace, and another metal cage is placed at the L5-S1 interspace
...
Add-on code 22851 should be reported for each device placed at L3-L4 and L5-S1 interspaces
...
The modifier 59 may be appended to indicate that more than one cage was inserted at more than one spinal level
...
It is important to note that a single cage or methylmethacrylate used to cover a defect spanning two or more interspaces is reported with add-on code 22851 one time
...
For example, a single metal cage spanning the L3-L5 interspaces would be reported with add-on code 22851, one time
...
Codes 22857, 22862, and 22865 are used for variations of anterior-approach lumbar disc replacement surgery involving placement of an artificial disc anchored to the vertebral end plates on the vertebrae above and below a single lumbar intradiscal space
...
The anterior approach (through the abdomen to access the anterior portion of the spine, without disruption of the spinal cord area) and the fluoroscopic imaging are not reported separately
...
However, any procedures for spinal cord or nerve root decompression are not included and therefore are appropriately reported with codes 63001-63048
...
CODING TIP The use of the operating microscope is an inherent component of CPT code 22861 and should not be reported separately
...
Initial placement of a lumbar artificial disc in a single interspace is reported with code 22857
...
The lumbar arthrodesis (22558), anterior instrumentation (22845), applications of intervertebral biomechanical devices (22851), and exploration of the retroperitoneal area (49010), should not be additionally reported when performed at the same level
...
The revision and replacement of an existing lumbar artificial disc at a single level is reported by code 22862
...
Codes 22558, 22845, 22851, and 49010 are not reported in addition to 22862 when performed at the same level
...
Code 22865 for the removal of the previously placed artificial disc is also not additionally reported, as removal is inherent in code 22862
...
Category III code 0165T is reported for revision of other previously placed discs at other interspaces
...
Similarly, the revision and replacement of an existing cervical artificial disc, code 22861, also includes codes 22845 and 22851 as well as code 63075
...
Therefore, those codes are not additionally reported when performed at the same level
...
Removal of an existing lumbar artificial disc at a single level is reported by means of code 22865
...
Code 49010 for exploration of the retroperitoneal area is included in 22865
...
however, removal of the disc requires other surgical interventions (ie, fusion) to stabilize the former site of the artificial disc
...
Therefore, codes 22558, 22845, and 22851 are not excluded from reporting with code 22865
...
Category III code 0164T is reported for removal of lumbar artificial disc performed at additional levels
...
Codes 0163T-0165T are not reported with code 22851 or 49010 when performed at the same level
...
Approach for Spine Surgery
CODING TIP Codes 22857-22865 represent single lumbar interspace procedures
...
For additional interspace procedures, Category III codes 0163T-0165T are used
...
Anterior approach is an inclusive component of codes 22857-22865 and 0163T-0165T, as is fluoroscopic guidance, if performed
...
Under certain circumstances, one surgeon performs the approach procedure for spine surgery, including making the incision and exposing the area requiring surgery
...
Another surgeon then performs the definitive procedure on the spine
...
After the completion of the definitive procedure, the first surgeon returns to perform the closure of the operative site
...
The approach and the closure are considered inclusive components of the definitive procedure performed
...
Only one total procedure listed in the CPT code set is performed by two surgeons
...
This circumstance is reported by means of modifier 62
...
Each surgeon reports his or her services by reporting the primary procedure code and appending modifier 62
...
If one surgeon does not use modifier 62, the third-party payer may assume that the surgeon reporting the procedure without a modifier performed the entire procedure, despite the second surgeon's reporting the procedure with modifier 62
...
Alternatively, if a co-surgeon acts as an assistant in the performance of additional procedures during the same surgical session, those services may be reported by means of separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate
...
Therefore, the two-surgeon modifier 62 may indicate the following circumstances:
Two surgeons continued to work together as primary surgeons performing distinct part(s) of a procedure and any associated add-on code(s) for that procedure
...
and
In addition to either of the above instances where modifier 62 is used, the co-surgeon acts as an assistant (see modifiers 80 and 82) in the performance of additional procedure(s) during the same surgical session
...
Both surgeons should document their individual level of involvement with the surgery in separate operative reports and include copies of their reports when the procedure is reported to the third-party payer
...
This will allow the third-party payer to determine reimbursement for each surgeon on the basis of the level of involvement of each surgeon in performing the procedure
...
EXAMPLE 1
Co-surgeon involvement for exposure/closure of procedure and associated add-on codes
...
A patient's surgery includes arthrodesis of two interspaces of the thoracic spine by anterior interbody technique, with anterior instrumentation of three vertebral segments
...
Morselized autograft is used, which is obtained through a separate incision
...
Physician A performs a thoracotomy at the start of the surgical session, carefully preserving major vasculature to expose the vertebral segments
...
Physician B performs the arthrodesis and spinal instrumentation
...
On completion of the arthrodesis and spinal instrumentation, Physician A closes the operative site
...
The surgeons in this example would code the services as follows:

Physician A
22556 62
Physician B 22556 62, +22585, +22845, +20937
...
EXAMPLE 2
Co-surgeon involvement for exposure and closure of procedure and associated add-on codes, and continued involvement as an assistant
...
A patient's surgery includes arthrodesis of 2 interspaces of the thoracic spine by anterior interbody technique, with anterior instrumentation of three vertebral segments
...
Morselized autograft is used, which is obtained through a separate incision
...
Physician A performs a thoracotomy at the start of the procedure, carefully preserving major vasculature to expose the vertebral segments
...
Physician B performs the arthrodesis and spinal instrumentation
...
Physician A continues to work with Physician B as a co-surgeon for the multiple arthrodesis procedures and elects to act as an assistant for the bone graft and spinal instrumentation procedures
...
On completion of the arthrodesis and spinal instrumentation, Physician A closes the operative site
...
The surgeons in this example would code their services as follows:

Physician A
22556 62, 22585 62, 22845 80, 20937 80
...
Physician B 22556 62, 22585 62, +22845, +20937
Note: Modifier 62 is not appended to either the spinal instrumentation (22845) or the bone graft (20937) code
...
Distal Radius and Ulnar Styloid Fracture Treatment
Distal radial fractures occur with various degrees of complexity
...
Open treatment is differentiated by the type of repair required: intra-articular (25608, 25609) and extra-articular (25607)
...
Code 25608 is used for fractures that require the fixation of two fragments, while 25609 is used for fractures that require the fixation of three or more fragments
...
CODING TIP Closed treatment of an ulnar styloid fracture (25650) should not be reported in addition to the distal radial fracture codes 25600, 25605, and 25607-25609
...
When closed treatment of a distal radial fracture is performed, the closed repair of the ulnar styloid is included when performed on the same extremity
...
Therefore, it is not appropriate to report code 25600 or 25605 in conjunction with 25650
...
Even though fractures of the distal radius are often associated with ulnar styloid fractures, ulnar styloid fracture treatment is usually not performed at the time of treatment of the radial fracture
...
Therefore, neither percutaneous nor open treatment of an ulnar styloid fracture is included in the work of percutaneous skeletal fixation of a distal radial fracture or epiphyseal separation (25606)
...
Percutaneous (25651) and open (25652) ulnar styloid repairs should be reported in addition to codes 25606, 25607, and 25609
...
External fixation (20690) should be reported separately if performed in addition to the internal fixation corresponding to code 25606
...
CODING TIP For application of external fixation in addition to internal fixation, 20690 and the appropriate internal fixation code should be used
...
Bunion Procedures
Hallux valgus (bunion) is a common deformity of the first metatarsophalangeal (MTP) joint
...
Coding for the correction of a bunion and its associated deformities can be challenging
...
Not all bunion deformities are the same, and different techniques are needed to repair different levels of deformity
...
CPT codes 28290-28299 are used for the various techniques used to correct bunion deformities
...
To code appropriately for the treatment of bunion deformities, one must understand the specific procedures included when reporting the codes for bunion (hallux valgus) correction
...
All the codes in the 28290-28299 series include the following procedures when performed at the first MTP joint
...
These are integral components of the operation and are not to be reported separately:
Capsulotomy
Arthrotomy
Synovial biopsy
Neuroplasty
Synovectomy
Tendon release
Tenotomy
Tenolysis
...
Excision of medial eminence
Excision of associated osteophytes
Placement of internal fixation
Scar revision
Articular shaving
Removal of bursal tissue
...
28290 Correction, hallux valgus (bunion), with or without sesamoidectomy simple exostectomy, Silver-type procedure
...
CODING TIP As per the parenthetical instruction following code 28760, For hammertoe operation or interphalangeal fusion, use 28285, code 28285
...
may be reported for interphalangeal fusion involving partial or total phalangectomy for other than hammertoe, mallet toe repair
...
28292
Correction, hallux valgus (bunion), with or without sesamoidectomy
Keller, McBride, or Mayo type procedure
28294
Correction, hallux valgus (bunion), with or without sesamoidectomy
with tendon transplants, Joplin type procedure
28296
Correction, hallux valgus (bunion), with or without sesamoidectomy
with metatarsal osteotomy, Mitchell, Chevron, or concentric type procedures
28297
Correction, hallux valgus (bunion), with or without sesamoidectomy
Lapidus-type procedure
28298
Correction, hallux valgus (bunion), with or without sesamoidectomy
by phalanx osteotomy
28299
Correction, hallux valgus (bunion), with or without sesamoidectomy
by double osteotomy
Code 28299 represents a combination of codes 28296 and 28310-28315
...
Bunion surgery has evolved, and it is now common practice to perform a double osteotomy
...
For the correction of hallux valgus deformities with double osteotomy, two operative procedures must be performed
...
The first is a chevron osteotomy of the distal first metatarsal with correction of the hallux valgus, followed by an osteotomy of the proximal phalanx to correct additional angular deformity
...
In addition to learning the inclusive components of bunion correction procedures, the following illustrations of various techniques of bunion correction (see Figures 4-19 through 4-25) will assist in coding for these procedures
...
FIGURE 4-19
Hallux Valgus Correction: 28290

Simple resection of the medial eminence (Silver type procedure)
...
FIGURE 4-20
Keller-Type Procedure: 28292

Code 28292 is a simple resection of the base of the proximal phalanx with removal of the medial eminence
...
A hemi-implant is optional
...
FIGURE 4-21
Joplin Procedure: 28294

Tendon transplant is an important part of the procedure
FIGURE 4-22
Mitchell Procedure: 28296

A complex, biplanar, double step-cut osteotomy through the neck of the first metatarsal
also called the Mitchell Chevron (Austin) procedure
...
FIGURE 4-23
Lapidus-Type Procedure: 28297

A metatarsocuneiform fusion of bones and a distal bunion repair to correct valgus deformity
...
FIGURE 4-24
Phalanx Osteotomy: 28298

The Akin procedure involves removal of a bony wedge from the base of the proximal phalanx to reorient the axis
...
FIGURE 4-25
Double Osteotomy: 28299
...
When a hammertoe correction (28285) is performed with a corresponding metatarsophalangeal joint capsulotomy (28270) during the same surgical encounter, both codes may be reported as both procedures may be required during the same surgical session to completely correct a complex ray deformity
...
A hammertoe is defined by a digital contracture at the distal interphalangeal joint and/or proximal interphalangeal joint
...
A contracted metatarsophalangeal joint is a dorsiflexory positioning of the proximal phalanx on the metatarsal head
...
Because the percutaneous release of the joint contracture is not inclusive of code 28285, code 28270 should be reported with the modifier 59 appended to separately identify each procedure performed
...
Casting and Strapping
The guidelines at the beginning of the Musculoskeletal System subsection indicate that the services listed in this section of the CPT code set include the application and removal of the first cast or traction device only
...
Subsequent replacement of a cast and/or traction device may require an additional listing with the 29000-29799 series of codes
...
CODING TIP The 29000-29799 series of codes is also used to report the application of replacement casts used during or after the period of follow-up care
...
The codes in the 29000-29799 series have specific guidelines pertaining to their use
...
It is important to develop a good understanding of these guidelines to appropriately code for the application of casts and strapping
...
Following is a summary of the guidelines for reporting the application of casts and strapping
...
The application of casts and strapping codes may be used to report the following:
...
A replacement cast/strapping procedure, during or after the period of normal follow-up care
An initial service performed without restorative treatment or procedure(s) to stabilize or protect a fracture, injury, or dislocation and/ or to afford comfort to a patient
...
An initial cast/strapping service when no other treatment or procedure is performed or is expected to be performed by the same individual
...
An initial cast/strapping service when another individual provides a restorative treatment or procedure
Before an initial cast/strapping is reported with a casting and strapping code, the following questions should be considered:
...
Will any restorative treatment or procedures, surgical repair, closed or open reduction of a fracture or joint dislocation, be performed, or is treatment expected to be performed?
...
Will the same individual assume all subsequent fracture, dislocation, or injury care?
...
By answering these questions, the coder will establish a good basis for deciding whether the casts and strapping codes should be reported
...
Once these questions have been answered, the general guidelines should be consulted for specific rules when a final code is selected
...
All the facts must be considered when the decision is made to use the 29000-29799 series of codes for initial cast/strapping application
...
When it is not clear whether the same individual who places the cast/strapping will also provide all subsequent care, it is appropriate to ask the individual to confirm his or her role in managing the patient's care
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Another important consideration when deciding whether to report a code for the application of casts and strapping vs a code for treatment of fracture and/or dislocation is the surgical "package" concept
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The CPT surgical package, discussed in this chapter, applies to the treatment of fracture and/or dislocation codes found throughout the Musculoskeletal System subsection of the CPT code set
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By reporting a treatment of fracture code, the service of a surgical package is reported
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If the cast is placed after some type of restorative surgical treatment of a fracture, dislocation, or other injury (open treatment or closed manipulation), the cast should not be reported separately with the 29000-29799 series of codes
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The first cast, splint, or strapping application is included in the treatment of fracture and/or dislocation code
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Generally, codes for treatment of fracture and/or dislocation are reported only if the same individual is responsible for the initial cast, follow-up evaluation(s), and the management of the fracture/ dislocation until healed
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The casting and strapping guidelines also address the application of temporary casts/strapping placed preoperatively
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A temporary cast/splint/ strap is not considered part of preoperative care
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Therefore, the use of modifier 56 for preoperative management is not appropriate
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An individual who applies the initial cast, strap, or splint and assumes all subsequent restorative fracture, dislocation, or injury care
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cannot use the application of casts and strapping codes as an initial service, because this is included in the restorative treatment of fracture and/or dislocation codes
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The codes for application of casts and strapping include the removal procedure
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Therefore, codes for removal of casts are to be reported only when a cast is removed that was applied by another individual
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If the cast/strapping is applied in the office, supplies/ materials can be billed separately by means of CPT code 99070 or Healthcare Common Procedure Coding System HCPCS Level II codes, as appropriate
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In addition, if the key components of an E/M service are met at the time of a cast/ strapping application, the appropriate level of E/M service is also reported with modifier 25 appended
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Endoscopy and Arthroscopy
The last category of codes in the Musculoskeletal System subsection includes codes for reporting endoscopic and arthroscopic procedures
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The guidelines at the beginning of this category of codes indicate that surgical arthroscopy always includes a diagnostic arthroscopy
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This is also indicated by the separate procedure designation of the diagnostic scope codes
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This designation may indicate that a procedure or service is considered an integral component of another procedure and service, ie, diagnostic arthroscopy is considered an integral component of surgical arthroscopy
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General guidelines for coding endoscopic procedures are as follows:

1
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Look up endoscopy/ laparoscopy/arthroscopy in the index, and locate the organ or system being examined or treated with a scope
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2
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Look at the codes in that system or organ section to find an endoscopy or laparoscopy heading
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3
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If there is no endoscopy/laparoscopy/ arthroscopy heading in that section, look for a code with a descriptor that includes a suffix -oscopy and describes the procedure performed
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4
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If there is no heading of endoscopy/laparoscopy/ arthroscopy or there is no specific code describing the use of an endoscope in its descriptor, one may be certain the codes listed in that section are open surgical procedures and should not be used to report a procedure using an endoscopic approach
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5
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Clarify that the procedure was performed with an endoscope, laparoscope, or arthroscope
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6
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If it is determined there is no specific code for the endoscopic/laparoscopic/arthroscopic procedure one is attempting to code, use the unlisted procedure laparoscopy/endoscopy/ arthroscopy code to report the procedure
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In this case, a copy of the operative report should be submitted to the insurance company when the claim is filed
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(Refer to Chapter 1 for further discussion of unlisted codes
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)
Knee Arthroscopy
Knee arthroscopy, particularly arthroscopic meniscectomy, is one of the most common orthopedic procedures performed today
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It offers the advantages of smaller incisions in the knee, same-day surgery, less pain than with an open procedure, and shorter recovery time
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In coding arthroscopic knee surgery, it is important to understand the anatomy of the knee
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The knee is subdivided into the following three compartments: medial, lateral, and patellofemoral
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Coding arthroscopic knee procedures requires close review of the operative report
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If more than one arthroscopic procedure is performed in the same compartment, then it should not be assumed that all procedures may be reported
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With arthroscopic menisectomy (either medial, lateral, or medial and lateral), the typical patient also will have a chondroplasty performed on the same knee, either in the same compartment(s) or separate compartment(s)
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Other arthroscopic knee procedures can appropriately be reported on the same day due to the potentially complex nature of the surgical case
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The most common of these is the removal of loose bodies, 29874, Arthroscopy, knee, surgical
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for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)
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To illustrate, if an arthroscopic meniscectomy and debridement/shaving of articular cartilage (chondroplasty) is performed in the lateral compartment of the knee, only code 29881 would be reported
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Similarly, if an arthroscopic medial meniscectomy with removal of loose bodies (medial compartment) is performed, only code 29881 would be reported
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In both examples, the debridement of articular cartilage and removal of loose bodies were performed in the same compartment as the meniscectomy and are therefore not reported separately
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In the instance in which the arthroscopic procedures were performed in two separate knee compartments, the procedures performed in each compartment would be reported separately with modifier 59 appended to the secondary procedure
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Arthroscopic major synovectomy involves removal of the synovium and plica in two or more compartments
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This procedure is reported with code 29876
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However, in the instance in which there is a resection of the synovium, which may include partial resection of the plica in one compartment, code 29875 is reported for a limited synovectomy because it involves only one compartment
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It is important to note that codes 29875 and 29876 should not be reported together, because the limited synovectomy is considered to be an inclusive component of the major synovectomy
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BOOK III COMPLETED
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