Download MS Diagnostic Coding

MS Procedures
Dx and Tx
MHA
June 11, 2009
Irene Mueller, EdD, RHIA
Objectives
• 1st hour – Common MS Therapies
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Diagnostic Procedures
Pharmaceuticals
Physical Therapy
Therapeutic Procedures
• 2nd hour – Coding Common MS Tx
– ICD-9-CM
– CPT coding
• Resources
Diagnostic Imaging
• X-rays
– Planes of Views
– Positioning
– Projection
– Procedures
X-ray Planes of View
• Coronal/Frontal Plane (Ventral; Dorsal)
– Vertically divides body into
• Front and back; anterior/ventral; posterior/dorsal
• Sagittal Plane
– Vertically divides body into right and left halves
– Midsagittal – midline; two equal halves
• Transverse (Horizontal/Axial)
– Horizontally divides body into
• Superior/inferior OR cranial/caudal
Positioning & Projection
• Positioning is based on the part of the
body that is closest to x-ray film
• Projection is the path that the beams take
through the body
• PA = Posteroanterior projection
• AP = Anteroposterior
• Lat = Lateral or side view
• LPO = Left posterior oblique
MS X-ray Procedures
• Arthrography
– X-ray of joint after contrast material injection
• Computed axial tomography (CT/CAT)
– X-rays of “slices” of body
– Processed to make 3-D images
• Fluoroscopy
– Continuous x-ray beam creates “movie”
– Used for invasive procedures/operations
– Adjustments
• Magnetic Resonance Imaging (MRI)
– Noninvasive, 2-D, spinal cord, etc.
Bone Scans
• Used to dx
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• Nuclear medicine
procedure
Fractures
– Uses tracers (radionuclides).
Arthritis
– Tracers emit a type of
Paget disease of bone
radiation called gamma waves
Bone tumors
• Two Parts
– Injection
Infection of joints,
– Scan
replacements, or bone
• # of phases may be ordered
(osteomyelitis)
• SPECT sometimes ordered
Fibrous dysplasia
– Single Photon Emission
Avascular necrosis or
Computerized Tomography
impaired bone blood supply
– Visualizes anatomy AND
Unexplained bone pain
function
Metastatic ca from lung,
breast, prostate, etc.
Densitometry
• Dual energy X-ray absorptiometry (DXA, DEXA)
• Bone density test
– Special X-rays to measure # of grams of calcium and
other bone minerals in a segment of bone
– Usually done on bones most likely to break because
of osteoporosis
• Lumbar vertebrae (central)
• Neck of femur
• Wrist and forearm
• Heel, finger (peripheral) (screening)
DEXA
• Results
– T-score = bone density compared to expected in
healthy young adult of same sex.
• Number of units — standard deviations (SD) —
that bone density is above or below the standard
• Above -1 = Normal
• Between -1 and -2.5 = Osteopenia
• Below 2.5 = Osteoporosis
– Z-score = number of SDs above or below what's
normally expected for someone of similar
• Age, sex, weight, and ethnic or racial origin
Interpreting T-scores and Z-scores
http://www.mayoclinic.com/health/medical/IM03587
Procedural Tests
• Bone bx
• Myelography
• Aspiration from joint/bursa
– Arthrocentesis
Bone Biopsy
• Bone biopsy
• Dx
– Removal of part of actual bone
– Difference between
• Open
ca, non-ca tumors
• Fine-needle aspiration (closed)
– Bone pain &
• Core needle biopsy (closed)
tenderness, if x-ray,
– Local/general anesthetic is used
CT scan, or other
testing reveals a
– Small (1/8 inch) cut in the skin
problem
(closed)
– Osteomalacia
– Special drill needle is usual
– Osteomyelitis
– Bx needle is pushed/twisted into
bone
– Paget Disease of
bone
• Bone marrow exam = both
– Rickets
– Bone marrow bx – more solid part
– Bone marrow aspiration – liquid
http://www.webmd.com/a-to-z-guides/bone-biopsy
Myelography
• Dx
– Spinal tumors
– Spinal cord swelling, Spinal nerve injury
– Fractures, Back or leg pain
• Procedure
– Local anesthetic
– Positioned to open spaces between vertebrae
– Contrast is administered
– Fluoroscope (combines an x-ray with TV) takes images
• Mostly replaced by MRI -safer, simpler, more detailed
• Myelography w/ CT
– When more detail of spinal canal & bone needed
– If MRI not available/isn’t safe (person w/ heart pacemaker)
Arthrocentesis
• Using a needle to
remove synovial fluid
– Can be Tx also
– Effusion
• Dx
– Septic arthritis
http://jama.ama-assn.org/cgi/reprint/297/13/1510.pdf
PT
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MS and neuro insults
Traumas
Post-surgery
Sports/Work injuries
Aging process
Poststroke/other
neuro
• Assessment
– Gait, posture, ROM,
reflexes, strength,
physical insult
• Plan/Goals/Time
• Improve use of bones,
joints, muscles, nerves
• Reduce pain levels
• Prevention of disability
PT Tx
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Exercise
Heat
Light
Massage
Ultrasound
Electrical stimulation
Aquatic tx
• Pt Education
– Body Mechanics
– Posture
– Motion
– Home exercise
• Assist devices
– Ambulation/customized
• Crutches
• Walker
• Cane walking
Orthopedic Aftercare
• Usually for removal of wires, pins, plates,
external fixation devices (Planned)
• Other tissue and healing monitored
MS Drugs
• MS Pharmacology
– Analgesics
• Non-narcotic
• Narcotic
– Anti-inflammatories
– Muscle relaxants (HO)
– Anti-seizure meds
Analgesics
• Narcotic
• Non-narcotic
– Morphine
– OTC
– Codeine
• Acetaminophen
• NSAIDs
• Controlled Substances
Act of 1970 (HO)
– Non-Steroidal AntiInflammatory Drugs
– Aspirin, Naproxen,
Ibuprofen
– Prescription
• COX2 inhibitors (NSAID)
– Celebrex, Mobic
– Less gastric upset
– Prostaglandin Inhibitors
(HO)
Muscle Relaxants
• vs. Chronic Pain
• Acute Pain
– Persists after healing
– Begins suddenly, usually – Pain - weeks, months, years
sharp in quality
– Physical effects include
– Warns of disease/threat
• Tense muscles, limited mobility,
lack of energy, appetite
– Surgery
changes
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Broken bones
Dental work
Burns or cuts
Labor/childbirth
• Usu. acute pain < 6 mos.
• Disappears once etiology
treated/healed
•See HO for Chronic Pain Meds
– Emotional effects include
• Depression, anger, anxiety, and
fear of re-injury
• inability to work/enjoy leisure
– Common chronic pain
complaints
• Headache
• Pain - Low back, CA, Arthritis
• Pain – Neurogenic,
Psychogenic
MS Procedures
Fractures
• Reduction/Manipulation
– Closed
– Open
• Fixation
– Internal
– External
– Traction
Reduction
• Simple manipulation
• Closed reduction
– Usu. w/radiologic guidance OR
– Before/After x-rays
• Open reduction
– Extending open wound/another incision
– Debridement often required
• Application of fixation/traction devices
Internal Fixation
• Internal
– Use of pins, screws, staples, rods, plates
• Hardware
– Incision and Insertion into bone for alignment
– Can be done without manipulation
• Fx is aligned
• Reinsertion due to displacement/breakage
– Open (ORIF) or Closed (small incision does
not make open)
External Fixation
• Usually non-invasive
• Includes traction/immobilization (casts, etc)
• Can apply external fixation WITHOUT
reduction
• Using wires (Kirschner) or pins (Steinmann)
does NOT make internal fixation
Mini-Fixator
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External fixator device
Requires anesthesia
Holes drilled proximal and distal
Pins inserted thru bone and attached to frame
http://www.sushrut.com/img_umex_foot.jpg
Types of Traction
• Skin traction
– Tape, foam, felt;
longitudinal force
• Skeletal traction
– Into/through bone;
force to long bones
– Wires/pins
transversely thru bone,
exit thru skin
• Cervical spinal
– Baron tongs, Crutchfield
tongs, halo skull
• Upper extremity
– Dunlap skin traction
• Lower extremity
– Buck extension skin,
Charnley unit, HamiltonRussell, balanced
suspension, fixed skeletal
Dislocations
• Reduction
– Dr procedure w/in 15-30 minutes
– After that, under general anesthesia
– Pts may be trained for recurrent dislocation
– Shoulder most common joint
– Recurrent most common type in ERs
• Surgery for recurrent dislocation/joint
weakness
– Tighten ligaments
http://www.cfpc.ca/cfp/2002/Mar/_images/Fig2b.jpg
Sprains and Strains
• RICE (Rest, Ice, Compression, Elevation)
– 1st 24-72 hours after injury
– R – no weight-bearing for 1st 24 hours
– I – ice pack ASAP, 20/30 minutes every 2 hrs
• Remove when numb
– C – elastic bandage
– E – limits circulation
• Minimizes swelling and limits internal bleeding
• Cast/Splint
• Surgery if sprain is large tear/heals poorly
Sprain Surgery
• Knee
– ACL (2 in each knee)
• Repair (reattaching ligament to bone, avulsion fx)
• Reconstruction (autograft or allograft)
• Open or Arthroscopic
• Ankle
– Lateral Ligament (Grade III = complete rupture
• Wrist
– Several Ligaments
– Arthroscopic repairs
Bunion (Hallux Valgus)
• Conservative tx
– Roomy shoes w/lower heels
– Padding, ice
– Analgesics/antipyretics
– Intra-articular corticosteroids injection
• Surgical Tx
– Bunionectomy
– Osteotomy
– Arthroplasty
Bunionectomy
• Many types (Eponyms)
– Term used generically to include
• Osteotomy and arthroplasty
• Simple bunionectomy (Exostectomy)
– Removing bony growth and related soft tissue
– Often done in combination w/other procedures
– Silver
• Modified McBride bunionectomy
– Removal of bunion, rebalancing of the big toe joint by
releasing the tight tendons on the lateral side
– Tightening the joint capsule on the medial side
– Sometimes removing one of the sesamoid bones
Bunion Osteotomy
• Many types
• More severe the bunion, more proximal
the osteotomy on the metatarsal bone
– Distal = less of an angle of divergence
– Proximal = more of an angle
Bunion Osteotomy
• Keller procedure
– Combined soft tissue release
– Removal of the medial eminence with
– Resection of the proximal end of proximal phalanx
• Akin procedure - hallux valgus interphalangeus
– Deformity is located at the interphalangeal joint
– Medially based closing-wedge osteotomy of the proximal
phalanx
– Medial eminence of the metatarsal head is resected
– Medial capsular reefing is done
– Usually performed w/ Silver or McBride procedure
Bunion Osteotomy
• First metatarsal head osteotomy
– Most commonly performed bunionectomy
– Depends on perceived etiology of the condition and amount
of correction required
• Chevron (Austin) osteotomy
– Younger patient, no joint arthrosis, mild/moderate deformity
• involves a "V" shaped osteotomy of the distal metatarsal
• allows the first metatarsal head to be shifted laterally
– Proximal metatarsal osteotomy for hallux valgus is indicated
for patients with moderate to severe deformities
– May be combined w/ Silver or McBride
Bunion Osteotomy
• Mitchell bunionectomy
– Moderate to severe deformities of the
intermetatarsal angle and hallux valgus
– Metatarsal osteotomy that displaces
metatarsal head laterally
– More proximal than the Chevron osteotomy,
can correct more severe deformities than
Chevron
• Myerson/Ludloff
Bunion Lapidus procedure
• Joint between the first metatarsal and the
cuneiform bone is fused with screws
(arthrodesis)
Bunion Arthroplasty
• Dx = Patients with arthritis of the big toe joint
associated with a bunion deformity
– Fusion of the joint or by
– Removing a portion of the joint (arthroplasty)
• Excision arthroplasty
– One or both articular ends of the bones are excised
– Gap is created between them
– Gap fills with fibrous tissue, or a pad of muscle or other
soft tissue may be sewn in between the bones
– Interposed tissue allows ROM, but joint often lacks
stability.
Bursitis
• Tx based on
infectious/noninfectious dx
• Conservative tx
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RICE (no ice for chronic)
Anti-inflammatories
Orthoses
Exercises
Massage
Diathermy - deep-heat tx
• Non-infectious bursitis
– Aspiration (dx, tx)
– Injection of corticosteriod
• Infectious bursitis
– Staph/Strep less
common
– Antibiotics
• IV sometimes
– Surgical Drainage
– Surgical Excision of
bursa/calcifications
• Bursectomy
Bursitis - Corticosteriods
• Injections into bursa
– Methylprednisolone
– Triamcinolone, etc.
• Iontophoresis
– Using an electrical current to push a
corticosteroid medication through the skin
directly over the inflamed bursa or tendon
Bursitis Surgery
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Depends on location of bursitis
Can be arthroscopic or open
Open drainage with excision of the bursa
Partial bursectomy (posterior wall)
Knee
• Arthroscopy
• Arthroplasty
http://www.nlm.nih.gov/medlineplus/ency/presentations/100117_1.htm
Knee Arthroscopies
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Diagnostic vs. Therapeutic
Lateral, Medial, Patellofemoral Compartments
Removal or repair of a torn meniscus (cartilage)
Ligament reconstruction (ACL)
Removal of loose debris
– Loose body, joint mice
• Trimming damaged cartilage
Knee Arthroplasty
• Total
– Femur and tibia ends replaced
• Partial
– Only one end replaced
• Computer-assisted
• Minimally-invasive
• May need to be repeated
– Patient will be shorter
Osteoporosis
• Calcium
– Carbonate
– Carbonate w/sodium
fluoride
• Phosphate
• Vitamin D
• HRT (estrogen)
• Bisphosphonate
– Fosamax
– Actonel
• Calcitonin (nasal)
• Parathyroid hormone
• Exercise to slow
– Avoid in later stages
• Analgesics
• Muscle relaxants
Osteoarthritis Treatments
• Osteoarthritis
– Tx goal – reduce inflammation
– Nutrition
• Fish oil
• Glucosamine / Chondroitin
• Drug tx
– Analgesics
– Muscle relaxants
– NSAIDs
– Injections of steroids
Osteoarthritis Treatments
• PT
– ROM
– Heat/Cold
– Massage
• Support
– Wraps, splints
– Cane, walker
– Braces, crutches
• Rest
– Surgery for severe
cases
• Arthroplasty
–Hip, Knee
common
–Ankle, wrist,
elbow, shoulder
• Arthrodesis
–Vertebrae
–Cervical, Lumbar
Rheumatoid Arthritis Tx
• Early, aggressive tx to prevent deformity now standard
• NSAIDs/Analgesics (oldest tx)
• Glucocorticoids or Prednisone
– Low doses slow joint damage
• Disease Modifying Antirheumatic Drugs (DMARDs)
– Used w/ NSAIDs and/or prednisone, slows joint destruction
• methotrexate, injectable/oral gold, penicillamine,
azathioprine, chloroquine, hydroxychloroquine,
sulfasalazine
• Protein-A Immunoadsorption Therapy
– not drug, filters blood, removes antibodies and
immune complexes that promote inflammation
RA Tx
• Biologic Response Modifiers
– Directly modify immune system by inhibiting
proteins called cytokines
• abatacept, etanercept, infliximab, adaliumumab
and anakinra
• Combination tx – more aggressive
– Methotraxate plus BRMs
• lefluonomide (Arava), etanercept (Enbrel), adalimumab
(Humira) and infliximab (Remicade).
RA Surgery
• Synovectomy
– One/ two joints affected more severely
– Reduces inflammatory tissue
– May result in less swelling/pain; slows/prevents further
damage
• Arthroscopic Surgery
– Surgeon views damage, then
– Bx, Remove loose cartilage, Repair tears, Smooth
rough surfaces, Remove synovial tissue
– Knee and shoulder most commonly
• Osteotomy
– Increase stability, Redistributes weight on joint.
– Not often used for RA
RA Surgery
• Joint Replacement Surgery or Arthroplasty
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Prevents going into wheelchair
Removal of joint
Resurfacing and relining ends of bones
Replacing joint w/ man-made component
Usually recommended for people 50+ or w/ severe
disease progression
– Typically, new joint lasts 20 to 30 years
• Arthrodesis or fusion
– Fuses two bones together
– Limits movement, Decreases pain
– Increases stability of ankles, wrists, fingers, toes, and
spine
Rickets/Osteomalacia
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Tx underlying cause if 2ndary
Vitamin D
Calcium
Phosphate
Special bracing to position body
appropriately as the bones grow
• Surgery for severe skeletal deformities
– Bone removed and external fixation devices
Carpal Tunnel
• Outpatient procedure
• Open
– Longer healing time
• Endoscopic
– More risk of nerve injury
– Not for DM pts
– ORLive video (listed in Resources)
Bone Cancer Dx
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X-ray
Bx, needle and/or open
CT scan w/o and w/ contrast
MRI (contrast)
Bone scan
PET scan
Blood tests
– alkaline phosphatase
Bone Cancer Staging
• TNM
• Basis for tx decisions
– T = tumor extent
• Common elements in
– N = spread to lymph
most systems
nodes
– Location of primary tumor
– M = metastasis
– Tumor size and #
– # = size/extent of tumor
and spread (after each
– Lymph node involvement
letter)
– Cell type and tumor grade
• Osteosarcoma (rare)
– Metastasis
– Enneking staging system
(3 stages)
• Grade, size, spread
• I to III (A or B)
– AJCC system (4 stages)
• I to IV
TNM Ca Staging
• Primary Tumor (T)
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TX can’t evaluate
T0 No evidence
Tis Carcinoma in situ
T1, T2, T3, T4 Size and/or extent of tumor
• Regional Lymph Nodes (N)
– NX can’t evaluate
– N0 No regional lymph node involvement
– N1, N2, N3 Involvement of regional lymph nodes
• Distant Metastasis (M)
– MX can’t evaluate
– M0 No distant metastasis
– M1 Distant metastasis
TNM Ca Staging
Stage
Stage 0
Stages I – III
Stage IV
Definition
Carcinoma in situ (early cancer that
is present only in the layer of cells in
which it began)
Higher numbers indicate more
extensive disease
Cancer has spread to another organ
Different combinations of TNM levels =
different stages for different CAs
Source: http://www.cancer.gov/cancertopics/factsheet/Detection/staging
Bone Cancer Tx
• Surgery
– Remove tumor
– Limb-sparing,
reconstructive
surgery
– Amputation
• Chemotherapy
– Combination of drugs
– NOTchondrosarcoma
• Radiation therapy
– Chondrosarcoma,
ESFTs
– Combined with
surgery
• Cryosurgery
– Liquid nitrogen
• Clinical trials
Marfan Syndrome
• Scoliosis/Kyphosis
– Curve > 20°, <40°
• Brace to prevent worsening (23 hours/day)
• TLSO thoracolumbosacral orthosis
• Boston, Wilmington, Providence, Charleston
– Curve = 40 ° to 50 °
• Inserting metal rods and/or fusing spine
• Posterior/Anterior approach
Marfan Syndrome (Chest)
Pectus excavatum - Funnel chest - Chest sinks in
• Open surgery - Incision
across chest front
– Deformed cartilage
removed, rib lining
remains
– Breastbone cut and
moved aside
– Rib/metal strut keeps
sternum in normal
position
– Metal struts removed in 6
mos via small cut under
the arm (Outpt)
• Closed - No cartilage/bone
removed
– Two small incisions, one
under each arm
– Curved steel bar inserted
thru incisions, placed
under sternum, guided by
horacoscope
– Special instrument rotates
the bar/lifts sternum
– Bar left in place for 2
years +
Marfan Syndrome
• Pectus carinatum
– Pigeon breast -Chest sticks out
– Brace
– Surgery
• Removal of affected cartilages bilaterally
• Excess cartilage over sternum removed
• Reverse wedge osteotomy of sternum
• Bracing, compression system
Slipped Disc/Sciatica
• Conservative tx
– Hot/cold packs
– Muscle relaxants/analgesics
– Epidural injections
– PT
• Surgical tx
– Percutaneous diskectomy
– Diskectomy
– Micro-diskectomy
– Removal w/laminectomy w/ fusion of
vertebrae
Percutaneous discectomy
• Usually Outpt procedure
• Several percutaneous procedures
– All involve inserting small instruments between
vertebrae and into middle of disc
• Fluoroscopy is used to guide instruments
• Remove disc tissue by
– Cutting
– Aspirating the center of the disc
– Using lasers to burn or evaporate the disc
http://66.132.168.42/images/lumbar.gif
Diskectomy
w/Laser Ablation
• Minimally invasive
• Still investigative stage, insurance may not
cover
Micro-diskectomy
• Microdiscectomy uses microscope
– Smaller incision, less damage to surrounding
tissue
– Removes the portion of the disc protruding
into the spinal canal
– Disc space may also be explored, any loose
fragments removed
– Usually done Inpt using general anesthesia
– Can be done in an outpatient surgical center
Minimally-invasive arthroplasty
• Alternative to spinal fusion
• Replace degenerated disc nucleus
– Artificial disc prostheses
– Total or partial (entire disc or just nucleus)
Discectomy w/ laminectomy w/
fusion of vertebrae
• DX – spondylolisthesis, spinal stenosis,
degenerative disc disease
• Open procedure (posterior approach)
• Removes large parts of lamina and
spinous processes
• 3-7 days in hospital
• Fusion may also be done to stabilize spine
• Fusion = Arthrodesis = artificial ankylosis
Break Time