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MS Procedural Coding
MHA
June 11, 2009
Irene Mueller, EdD, RHIA
Objectives
• 2nd hour – Coding Common MS Tx
– ICD-9-CM
– CPT coding
• Resources
MS Procedure Coding
• Procedures
– ICD-9-CM
– CPT
Bone Bx
• ICD-9-CM
– 77.40-49 Bone Bx OR 41.31 Aspiration bone marrow
• CPT
– Bone biopsy - 20220
– Bone marrow aspiration performed alone
• 38220
– Bone marrow biopsy is performed
• 38221 (bone marrow biopsy)
• cannot report with CPT code 20220 (bone biopsy)
– 38220 and 38221 reported together
• If two procedures performed at separate sites or at separate
encounters
• Separate sites = different bones OR 2 skin incisions over same bone
– 38221 and 38220 performed at same site through same incision
• Only CPT 38221 is reported
Myelography
• ICD-9-CM
– 87.21
• CPT
– Myelography
• Brain 70010
• Spine
– Cervical 72240
– Lumbosacral 72265
– Thoracic 72255
– Total 72270
Arthrocentesis
• ICD
– 81.91 Arthrocentesis
• includes: Joint aspiration
• excludes:
– for arthrography (88.32)
– bx of joint structure (80.30-80.39)
– for injection of drug (81.92)
• CPT
– Arthrocentesis
• Intermediate Joint 20605
• Large Joint 20610
• Small Joint 20600
Fracture Reduction
• Type of fx doesn’t always correspond to type of tx
• ICD-9-CM - determine
• Open/closed (Remember open = MUST connect w fx site)
• Internal fixation used?
• Bone involved, part of bone
• Open reduction
– 79.6x Add’l code for debridement
– Extremities only
– Debridement included in open fx reductions of
• Skull, nasal, orbital, other facial, vertebral bones
CPT Fracture Mgt
• Many more specific fx
proc codes than ICD
• Pinning
• Closed tx
– w/ manipulation (reduction)
– w/o manipulation
– w/ or w/o skeletal traction
• Open tx (fx site is
surgically
opened/exposed)
• Percutaneous Skeletal
Fixation
– External fixation (removal
included in global pkge)
– Internal Fixation (ORIF)
• Application/Removal of
initial cast/splint
• Normal, uncomplicated
Follow up
Internal Fixation
• ICD-9-CM
– 78.5.x w/out fx reduction
• Fx w/good alignment
• IF device reinserted – displaced/broken
– IF with bone grafts, shortening/lengthening
bone, Int. Fix. is INCLUDED in those codes
• CPT
– Ex: ORIF of left mandibular fx 21470-LT
External Fixation
• ICD-9-CM
– Reduction w/
External fixator
device
• add’l code 78.1078.19
• Type of device –
add’l code
– Monoplanar – 84.71
– Ring system – 84.72
– Hybrid system (both
of above) – 84.73
– No reduction
• 93.4x – traction
• 93.5x – Other
immobilization, etc.
• 97.88 – Removal of
these devices
– Mini-fixator
• 78.1 Application –
add’l code to any fx
reduction
• 78.6 Removal
CPT External fixation
• 20692 - Add’l code, unless ext. fix included
• Ex: Closed tx of femoral shaft fx with
manipulation and external fixation system
application
– 27502, 20692-51
• Ex: Closed tx of tibial fx w/manipulation,
application of cast, partial skin
debridement of fx site
– 27752, 11040
Open Fx Debridement
• ICD-9-CM
– 79.6X Debridement of open fracture
– Used instead of 86.22, Excisional
debridement of wound, infection, or burn
• CPT
– 11010, 11011 and 11012
• Differ by extent of debridement
• Must meet open fx definition
Amputation Procedures
• Disarticulation OR
• Cutting thru bone
• ICD-9-CM
– 84.xx
• 3rd digit = upper/lower limb
• 4th digit = portion of limb
AND type of amputation
– 84.3 Revision of stump
– 84.1x – Revision of
current traumatic
amputation
• BKA = 84.15, AKA =
84.17
– If BKA converted to
AKA, code just the
AKA
• Metatarsal = toe
amputation
• Transmetatarsal =
foot amputation
Dislocations
• ICD-9-CM
– Associated
w/reduction of fx
• Dislocation reduction
incl. in fx reduction
code
– Not assoc. w/fx
• 79.7x Closed reduction
• 79.8x Open reduction
• CPT
– Body part
– Open
• Acute/chronic
• Internal Fixation or not
–
–
–
–
Closed
w/wout Manipulation
w/wout Anesthesia
Application and
removal of first cast or
traction included in
these codes
Casts and Strapping
• ICD-9-CM and CPT
– Application included in reduction code
– Reported when cast/splint is
• Replacement procedure
• Initial service w/out restorative tx
• When performed in ED setting
– for comfort and stabilization
– patient is to follow-up with another physician for
definitive treatment
– only splinting, strapping or casting service is reported
– Do NOT assign a CPT code for fracture treatment
without manipulation.
Sprain/Strain Surgery
• ICD-9-CM
– Repair
• CPT
– Codes often include graft
harvesting
• Ligament (see also
• Ligament, Repair
Arthroplasty) 81.96
– Knee Joint 27405 - 27409
– collateral, knee
NEC 81.46
• Knee, Reconstruction
– cruciate, knee NEC 81.45
– Ligament 27427 - 27429
– Reconstruction >
Construction and repair
• Knee, Repair
• Knee (joint) NEC 81.47
– Collateral ligaments 81.46
– Cruciate ligaments 81.45
– Five-in-one 81.42
– Triad 81.43
–
–
–
–
–
Ligament 27405 - 27409
Collateral 27405
Collateral and Cruciate 27409
Cruciate 27407 – 27409
Arthroscopic 29888 29889 (not in Index here)
Bunion Surgery
• ICD-9-CM
• Bunionectomy (radical) 77.59
– with
•
•
•
•
Arthrodesis 77.52
Osteotomy of first metatarsal 77.51
Resection of joint with prosthetic implant 77.59
Soft tissue correction NEC 77.53
CPT Bunionectomy Codes
• Hallux valgus repair codes
– 28290-28299
– Bunion Repair
•
•
•
•
•
•
•
•
•
•
Chevron Procedure 28296
Concentric Procedure 28296
Joplin Procedure 28294
Keller Procedure 28292
Lapidus Procedure 28297
Mayo Procedure 28292
McBride Procedure 28292
Mitchell Procedure 28296
Silver Procedure 28290
with Implant 28293
Bunion Surgery Examples
• Austin Bunionectomy and Reverse Austin Bunionectomy
– 28296 Hallux valgus (bunion) correction, w/ or w/out
sesamoidectomy; with metatarsalosteotomy
(eg, Mitchell, Chevron, or concentric type procedures).
• Distal modified McBride bunionectomy, correction of
angular deformity of the first metatarsal w/ proximal
osteotomy
– 28292, Correction, hallux valgus (bunion), w/ or w/out
sesamoidectomy; Keller, McBride, or Mayo type procedure,
28306 -59, Osteotomy, w/ or w/out lengthening, shortening or
angular correction, metatarsal; first metatarsal,
– reported with modifier 59 because this code describes the
proximal metatarsal osteotomy performed at another site on the
metatarsal (usually requiring a separate incision)
Bursitis Procedures
• ICD-9-CM
– 83.03 Bursotomy
• includes: Removal of calcareous deposit of bursa
• excludes: aspiration of bursa (percutaneous) (83.94)
– 83.5 Bursectomy (incl. debridement of bursa)
– 83.96 Injection bursa (therapeutic agent)
• CPT
– Many more codes than CPT
– Bursa, Bursocentesis, I&D, etc.
Arthroscopy
• ICD
– Converted to open, code only open w/ V64.43
– 80.20-80.29
• CPT
– Dx – visualization and synovial Bx ONLY
• 29870 (separate procedure)
– Surgical – anything else done
• Includes dx
• # of compartments important for some codes
Decompression of Medial Nerve
(CTS)
• ICD-9-CM
– 04.43 Release of carpal tunnel
– (Decompression = main term)
• CPT
– Carpal Tunnel
• Injection
– Therapeutic 20526
– Carpal Tunnel Syndrome
• Decompression 64721
– Arthroscopic 29848
Arthroplasty (Joint Replacement)
• ICD-9-CM coding
–
–
–
–
Based on joint and total/partial replacement
81.5x = lower extremity joints
81.8x = upper extremity joints
Add’l Codes
• Hip replacement – type of bearing surface
– 00.74 metal on polyethylene
– 00.75 metal on metal
– 00.76 ceramic on ceramic
• Bone-growth stimulator – add’l code
– 78.9x
– Bilateral replacement – code assigned X 2
Arthroplasty (Joint Replacement)
• CPT coding
– 27125 Hemiarthroplasty, hip, partial (eg, femoral stem
prosthesis, bipolar arthroplasty) notices: For prosthetic
replacement following fracture of the hip, use 27236
– 27130 Arthroplasty, acetabular and proximal femoral prosthetic
replacement (total hip arthroplasty), with or without autograft or
allograft
– 27132 Conversion of previous hip surgery to total hip
arthroplasty, with or without autograft or allograft
– 27134 Revision of total hip arthroplasty; both components, with
or without autograft or allograft
– 27137 acetabular component only, with or without autograft or
allograft
– 27138 femoral component only, with or without allograft
Prosthesis replacement
• Due to infection
• ICD-9-CM coding (Dx)
– 1st admission
• 996.66, 80.0x
• Infection must be cleared (1-2 months)
– 2nd admission
• 736.x (Acquired deformity)
• Joint revision code
Joint Replacement Revision
• Adjust or remove and replace
• ICD-9-CM coding
– Includes removal of component(s)
•
•
•
•
•
•
•
•
81.53 hip component NOS
00.70-00.73 (hip components) add’l code
81.54 knee component NOS
00.80- 00.84 (knee components) add’l code
84.57 removal of joint spacer (cement) add’l code
81.59, 81.97 joint revision NEC (upper/lower extremities)
00.74 – 00.76 add’l code (if known)
V43.6 Joint replacement status, if significant for pt care
Joint Replacement Revision
• CPT Coding
– 27134 Revision of total hip arthroplasty; both
components, with or without autograft or
allograft
– 27137 acetabular component only, with or
without autograft or allograft
– 27138 femoral component only, with or
without allograft
• Many other joint arthroplasties in CPT
Bone Ca Surgery
• Usual tx – current surgical techniques allow 9
out of 10 pts w/bone cancer in arm/leg to keep
limb
• ICD-9-CM
– Excision, lesion, bone (no distinction for type)
• CPT
– Inconsistent Index
• Tumor, Excision, Bone, Malignant
• Go to specific bone
– Tumor (usu. Means ca), Radical, etc.
CPT Spine Procedures
• Distinguish bet. Spinal segments from interspaces
– T1 = one vertebra/one segment
– T1-T2 = one interspace OR two segments
• Bone grafts – sep. codes
– Only one code per operation, even if more than one level
• Instrumentation procedures – sep. codes
• Arthrodesis procedures – sep. codes
• -62 modifier for 2 surgeons
CPT Spine Osteotomy
• Anterior/Posterior approach
• Osteotomy code includes
– Corpectomy, discectomy, laminectomy
Spinal Fusion
• 3 basic approaches
– Anterior, posterior, lateral
transverse
• ICD-9-CM coding
– Anterior (81.02-81.36)
• Incision of neck/abdomen
• Front of vertebrae
(anterior annulus)
– Posterior (81.03 –
81.38)
• Incision of back, directly
over vertebrae
– Lateral Transverse
(81.07, 81.37)
• Incision of side
• Lamina approach
• Add’l Codes
– Insertion of interbody
fusion device – 81.51
• Bak cage, ray-threaded
fusion cage, synthetic
cage, spacer, bone
dowels
– Number of fused discs
• 81.62 – 2-3
• 81.63 – 4-8
• 81.64 – 9+
360° Spinal Fusion
•
•
•
•
Both anterior & posterior portions
Single incision (usually lateral)
1st – fusion or refusion procedure
2nd – ALIF, PLIF, OR TLIF
– Anterior Lumbar Interbody Fusion
• 81.06, 81.36
– Posterior Lumbar Interbody Fusion
• 81.08, 81.38
– Transforaminal Lumbar Interbody Fusion
• 81.08, 81.38
Refusion of Spine
• Pseudoarthrosis
– False joint due to inadequate immobilization
of fx bone
– Greater original fusion, more likely
pseudoarthosis will occur, need refusion
• 81.34, 81.35, 81.36, 81.39 = Refusion
– Various sites, various approaches
Kyphoplasty for Compression fxs
• Kyphoplasty – reestablish vertebral height
–
–
–
–
Uses inflatable balloon to gain height
Injection of Polymethylmethacrylate to stabilize
ICD-9-CM - 81.66
CPT
• 22523 Percutaneous vertebral augmentation,
including cavity creation (fracture reduction and
bone biopsy included when performed) using
mechanical device, one vertebral body, unilateral
or bilateral cannulation (eg, kyphoplasty); thoracic
• 22524 lumbar
• 22525 each add’l thoracic or lumbar vertebral body
(List separately in addition to code for primary
procedure)
Vertebroplasty for Compression fxs
• Stabilize/strengthen bone
– Insertion of cement (glue) into body
• Polymethylmethacrylate
– NO balloon
– ICD-9-CM – 81.65
– CPT
• 22520 Percutaneous vertebroplasty, one
vertebral body, unilateral or bilateral
injection; thoracic
• 22521 lumbar
• 22522 each additional thoracic or lumbar
vertebral body
• Add’l code for fluoroscopic/CT guidance
Spinal Disc Prostheses
• ICD-9-CM Coding
– Type of prosthesis – total/partial
– Spinal segment
•
•
•
•
Cervical – 84.61, 84.62
Thoracic – 84.63 (total/partial – same code)
Lumbarsacral – 84.64, 84.65
No location – 84.60
– Revision/replacement – 84.66-84.69
• Synchronous insertion of new prosthesis
CPT Spine procedure Examples
• Arthodesis of T1-T3; autograft from ribs
Dual rods inserted w/multiple hooks/wires
– 22610, 22614, 22614 – 3 fusions
– 22842 - rods
– 20936 – autograft
• Surgical repair of L1-2 and L3-L4 by 2
surgeons (distinct parts of procedure)
– 22612-62 (reported by each surgeon)
– 22614-62 (reported by each surgeon)
Answers to Dx Coding Exercises
• Primary osteoarthritis of hip
– 715.95 (Localized NOT documented)
• Admitted for removal of internal fixation
nail that has protruded into surrounding
tissue, causing pain
– Main term? Complication, mechanical
– Type of care? NOT routine follow-up
– Code? 996.40
Answers to Dx Coding Exercises
• Compound fracture, shaft of radius and ulna, due to
tackle in football game
– 813.93, E886.0, E849.4
• Aftercare for fracture of L4 vertebra
– V54.17
• Cervical strain due to MVA, 2ndary to loss of control and
collision w/tree. Pt was restrained driver.
– 847.0, E816.0 (tree off highway) OR E815.0 (fallen tree on hwy)
• Derangement of knee due to fall from ladder while
working on house
– 836.2, E881.0, E849.0
Homework
• View ORlive http://www.or-live.com/
–
–
–
–
Previous webcasts
Browse by specialty
Orthopaedics
April 7, 2009
Spotlight on Beth Israel Orthopedics, New York
City
Need Adobe Flash Player
– Code the 4 operations
– Dx? Procedures – ICD and CPT
[email protected]
Resources (Books)
• Brown, F. ICD-9-CM Coding Handbook with
Answers, 2006. AHA Press.
• Frazier, M. S. & Drzymkowski, J. W. Essentials of
Human Diseases and Conditions, 4th ed.,
Saunders, 2009
• Green, M. A. 3-2-1 Code It! 2nd ed. 2010. Delmar.
• Moisio M. A. & E. W. Moisio, Understanding
Laboratory and Diagnostic Tests, Delmar, 1998
(2nd ed? later)
• Scott, A. S. & Fong, E. Body Structures and
Functions, 11th ed., Delmar, 2009
Resources (Videos)
• ORlive http://www.or-live.com/
• Laminectomy Back Surgery Video. SpineHealth.
– http://www.spine-health.com/video/laminectomy-back-surgery-video
• Microdiscectomy: Lumbar Microdecompression
Spine Surgery Video. Spine-Health.
– http://www.spine-health.com/video/microdiscectomylumbar-microdecompression-spine-surgery-video
Resources (Videos)
• Minimally Invasive Discectomy. ORLive.
– http://www.or-live.com/distributors/NLM/rnh.cfm?id=310
• Pediatric Spinal fusion to correct scoliosis.
ORLive. (via NLM link)
– www.or-live.com/distributors/NLM/rnh.cfm?id=321
• Spine Fusion Surgery Video. Spine-Health.
– http://www.spine-health.com/video/spine-fusion-surgery-video
Resources (Websites)
• Acute vs. Chronic Pain. Cleveland Clinic.
–
http://my.clevelandclinic.org/services/Pain_Management/hic_Acute_vs_Chronic_Pain.
aspx
• A Guided Tour of the Visible Human
– http://www.madsci.org/~lynn/VH/tour.html
• Bone scan. Mayo Clinic.
– http://www.mayoclinic.com/health/bone-scan/MY00306
• Bunionectomy. Clinical Policy Bulletin: Aetna.
– http://www.aetna.com/cpb/medical/data/600_699/0629.html
• Bursitis and Tendinitis; Questions and Answers. National
Institute of Arthritis and MS and Skin Diseases. April
2007.
– http://www.niams.nih.gov/Health_Info/Bursitis/default.asp
Resources (Websites)
• Drugs of Abuse, Chapter 1 The Controlled Substance
Act. Drug Enforcement Administration, US DoJ.
– http://www.usdoj.gov/dea/pubs/abuse/1-csa.htm
• Feinberg, S. D. MD. Medications and Chronic Pain, 2007
Supplement. American Chronic Pain Association.
– http://www.theacpa.org/documents/ACPA%20Meds%202007%20Final.pdf
• Hallux Valgus (Bunion Deformity). Institute for Foot and
Ankle Reconstruction. Mercy Hospital, Baltimore, MD.
– http://footandankle.mdmercy.com/conditions/bigtoe/hallux_valgus.html
Resources (Websites)
• Myelography. American Society of Radiologic Technologists.
–
https://www.asrt.org/content/ThePublic/AboutRadiologicProcedures/Myelography.aspx
• Osteosarcoma Overview. American Cancer Society.
–
http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?rnav=criov&dt=52
• Planes of Section. A Guided Tour of the Visible Human
–
http://www.madsci.org/~lynn/VH/planes.html
• Rheumatoid Arthritis: Treatment options. Arthritis Foundation.
– http://www.arthritis.org/disease-center.php?disease_id=31&df=treatments
• Staging: Questions and Answers
– http://www.cancer.gov/cancertopics/factsheet/Detection/staging
•
WebMD.
– http://www.webmd.com/default.htm
Resources (X-plain modules)
• Carpal Tunnel Release – Open. X-plain module. Patient
Education Institute, Nat’l Library of Medicine
– http://www.nlm.nih.gov/medlineplus/tutorials/carpaltun
nelsyndromeopensurgery/htm/index.htm
• Myelogram. X-plain module. Patient Education Institute,
Nat’l Library of Medicine
– http://www.nlm.nih.gov/medlineplus/tutorials/myelogram/htm/inde
x.htm