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CHAPTER 19
MUSCULOSKELETAL SYSTEM
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 1
Musculoskeletal System
• Subsection divided: Anatomic site
(Forearm and Wrist), then service
(e.g., excision)
• Used extensively by orthopedic
surgeons
– Many codes commonly used by
variety of physicians
• Extensive notes
(Cont’d…)
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Slide 2
Musculoskeletal System
(…Cont’d)
• Most common:
– Fracture and dislocation treatments
– “General” subheading
– Arthroscopic procedures
– Casting and strapping
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Slide 3
Fractures
• Questions to ask:
– Site of fracture or dislocation
– Type of treatment (open, closed)
– Manipulation performed and documented
– Was traction used; if so, what type
– Was percutaneous fixation used
– Was internal fixation applied (make sure this is not included
in code description)
– Was an external fixation system applied
– Did documentation support skin closure
– What type of anesthesia was used
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Slide 4
Fracture Treatment
• Open: Surgically opened to view or remotely opened to place
nail across fracture
– Open reduction with internal fixation (ORIF)
• Closed treatment, fracture site is not exposed by surgical
incision
• Percutaneous, neither open or closed. Fixation devices (such
as pins) are placed across the fracture site under imaging
• Treatment terms not to be confused with type of fracture
– Open fracture: Bone penetrates skin
– Closed fracture: Bone does not penetrate skin
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Slide 5
Fracture Treatment
• Type of treatment
depends on type
and severity
of fracture
• “Complicated”
in a code descriptor may
indicate excessive
hemorrhage, infection,
prolonged physician
work, or difficulty in
reaching the site or
depth of the site.
Figure: 19.1
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Slide 6
Traction
• Application of force to align bone
Figure: 19.4
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Slide 7
Skeletal Traction
• Use of force (distracting or traction force)
applied to internal device (e.g., wire, pin, screw,
or clamp) inserted into bone
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Slide 8
Skin Traction
• Application of force by means of adhesion
to skin
Figure: 19.6
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Slide 9
Manipulation
• Use of force to return a fractured bone
to normal alignment
• Fracture repair codes are often divided
based on whether manipulation was or
was not used
• AKA: Reduction
• Manipulation means a fracture has
been reduced
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Slide 10
Fracture Term
• Fractures are described by a physician
in terms of the direction of the fracture
line (horizontal, vertical, oblique,
spiral), and the direction and degree of
angulation (the most distal fragment)
• When the fracture results in more than
two fragments, it is comminuted
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 11
Dislocation
• Bone displaced from
normal joint position
• Treatment: Return
bone to normal
joint location
Figure: 19.7
From Dorland's
Illustrated Medical
Dictionary, ed 31,
Philadelphia,
2007, Saunders.
Vertebral dislocation/
Subglenoid dislocation
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Slide 12
Subheading “General”
(20005-20999)
• Begins “Incision”
• Depth: Difference between
Integumentary and Musculoskeletal
incision codes
• Musculoskeletal used when underlying
bone or muscle is involved
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Slide 13
General Subheading, Wound
Exploration (20100-20103)
• Traumatic penetrating wounds
• Divided on wound location (body site)
• Includes
– Enlargement
– Debridement
– Foreign body(ies) removal
– Ligation
– Repair of tissue and muscle
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Slide 14
General Subheading, Wound
Exploration (20100-20103)
(…Cont’d)
•
•
•
These procedures describe surgical
exploration to an already open wound
These codes are “separate procedure”
codes
They can be coded and reported in the
following circumstances:
1. If only procedure performed
2. If totally unrelated to another procedure
performed at the same session
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Slide 15
Biopsy
• Located in Excision subheading
(20200-20251)
• Biopsies for bone and muscle
• Divided by:
– Type of biopsy (bone/muscle)
– Depth
– Some by method
(Cont’d…)
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Slide 16
Biopsy
(…Cont’d)
• Can be percutaneous needle or excisional
– Coded separately
• If lesion is excised and biopsied, only the
excision can be billed
• If biopsy taken on one day and based on the
results an excision was performed, modifier -58
may be appropriate on excision code
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Slide 17
Introduction or Removal
(20500-20697)
• Within “General” subheading
• Codes for:
– Injections
– Aspirations
– Insertions
– Applications
– Removals
– Adjustments
(Cont’d…)
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Slide 18
Introduction or Removal
(20500-20697)
(…Cont’d)
• Therapeutic Sinus Tract Injection
Procedures:
– Not nasal sinus
– Abscess or cyst with a passage (sinus tract) to
skin
– Antibiotic injected with use of radiographic
guidance
(Cont’d…)
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Slide 19
Introduction or Removal
(20500-20697)
(…Cont’d)
• Removal: foreign bodies lodged in
muscle or tendon sheath
• Integumentary removal codes for
removal from skin
(Cont’d…)
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Slide 20
Introduction or Removal
(20500-20697)
(…Cont’d)
• Injection: Into tendon sheath, ligament,
or ganglion cyst, trigger joint
• Arthrocentesis: Injection “and/or”
aspiration of a joint
– Both an aspiration and injection are
reported with one code
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Slide 21
Arthrocentesis (20600-20610)
• Local anesthesia is integral to these
codes and should not be reported
• Report the drug separately with a “J”
code
• HCPCS modifiers used to report
specific digits: “FA to F9” or “TA to T9”
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Slide 22
External Fixation (20690, 20692)
• Application of a device
that holds bone in place
• These codes include the
removal of the fixator
• If it is necessary to adjust
or revise an external
fixator see 20693. Code
20694 describes removal
under anesthesia and
includes imaging
(Cont’d…)
Figure: 19.13A
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Slide 23
External Fixation (20690, 20692)
(…Cont’d)
• Uniplane—pins or wires in one plane (flat,
smooth surface)
• Multiplane—requires complex adjustments
and correction in alignment. Bedside
adjustments are not separately billed
• Code fracture treatment and external fixation
– Unless treatment and fixation are both included in
code description
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Slide 24
Grafts (or Implants)
(20900-20938)
• Used to report harvesting through separate incision
of:
–
–
–
–
Bone
Cartilage
Fascia lata
Tissue
• Involve “morselized” or “structural” bone taken from
a donor (allograph) or from the patient (autograph)
– Morselized—small pieces of bone
– Structural—a segment of bone machined into the space
• Report only one bone graft code per operative
session
(Cont’d…)
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Slide 25
Grafts (or Implants)
(20900-20938)
(…Cont’d)
• Fascia lata grafts: From mid-upper
thigh where fascia is thickest
• Some codes include obtaining
grafting material
– Then not coded separately
– Composite grafts involve combinations of
autogenous material and allograft or
alloplast
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Slide 26
Other Procedures (2095020999)
• Monitoring muscle fluid pressure
(interstitial)
– Pressure increases when blood supply
decreases due to increased accumulation
of fluids
(Cont’d…)
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Slide 27
Other Procedures (2095020999)
(…Cont’d)
• Bone grafts are identified by site they
are taken from (donor site)
• Free osteocutaneous flaps: bone grafts
– Taken along with skin and tissue
overlying bone
(Cont’d…)
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Slide 28
Other Procedures (2095020999)
(…Cont’d)
• Electrical or ultrasound stimulation
– Used to speed bone healing
• Placement of stimulators externally or
internally
• Often used in treatment of fractures
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Slide 29
Spine (Vertebral Column)
(22010-22899)
• Divided by repair location:
– Cervical (C1-C7)
• C1 = Atlas
• C2 = Axis
– Thoracic (T1-T12)
– Lumbar (L1-L5)
– Sacral (SI)
– Coccyx (tailbone)
From Buck CJ:2011 ICD-9-CM for
Hospitals, Volumes 1, 2, & 3,
Professional Edition, St. Louis, 2011,
Saunders.
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Slide 30
Incision (22010, 22015)
• Open incision and drainage of deep
abscess of spine
• Divided by location
– Cervical, thoracic, or cervicothoracic
– Lumbar, sacral, or lumbosacral
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Slide 31
Arthrodesis (22532-22819)
• Fixation of joint
(arthro = joint, desis = fusion)
– Fixation with pins, wires, rods, etc., to immobilize
the joint
• Often performed with other procedure
– Such as fracture repair
– Use -51 on arthrodesis code
– Unless service reported with add-on code
• Coded by approach, site, and number of
interspaces or segments
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Slide 32
Spinal Instrumentation
(22840-22865)
• Types of Spinal
Instrumentation
– Segmental: Devices at
each end of repair area
plus at least one other
attachment
– Nonsegmental: Devices at
each end only
• Extensive notes
Figure: 19.15
• Report in addition to definitive procedure
without the -51 modifier
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Slide 33
Subsequent Subheadings
• After first subheading, General, divided
by anatomic location
– Anatomic subheadings divided based by
type procedure
(Cont’d…)
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Slide 34
Subheadings
(…Cont’d)
• Example subheading “Head” divided by procedure
(21010-21499):
– Incision
– Excision
– Manipulation
– Head Prosthesis
– Introduction or Removal
– Repair, Revision, and/or Reconstruction
– Fracture and/or Dislocation
– Other Procedures
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Slide 35
Casting and Strapping
(29000-29799)
• Replacement procedure or initial
placement stabilizes without additional
restorative treatment
• Initial fracture treatment includes
placement and removal of first cast
– Subsequent cast applications are coded
separately
(Cont’d…)
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Slide 36
Casting and Strapping
(29000-29799)
(…Cont’d)
Initial cast
• Not coded when part of a surgical procedure
• Removal is bundled into surgical procedure
• Supplies are reported separately
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Slide 37
Endoscopy/Arthroscopy
(29800-29999)
• Surgical arthroscopy always includes diagnostic
arthroscopy
• Codes divided by joint
– Subdivided on procedure
• Diagnostic arthroscopy codes only reported for
cases where no surgical scope is performed
(exception is diagnostic scope that determines need
to do open surgery, same day)
– Use modifier -51 on the diagnostic scope
(Cont’d…)
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Slide 38
Endoscopy/Arthroscopy
(29800-29999)
(…Cont’d)
• Note: Parenthetical information following codes indicates
which code to use if procedure was an open procedure
• Most arthroscopies include the following procedures:
–
–
–
–
–
–
–
–
–
Local infiltration of medication
Suture removal by operating surgeon
Surgical approach
Wound culture
Intraoperative photos and video imaging
Isolation of neurovascular structures
Stimulation of the nerves for identification
Placement of drains and suction devices
Wound closure
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Slide 39
Conclusion
CHAPTER 19
MUSCULOSKELETAL SYSTEM
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 40