MHA June 11, 2009 Irene Mueller, EdD, RHIA MS Procedural Coding MHA June 11, 2009 Irene Mueller, EdD, RHIA

Objectives 2nd hour – Coding Common MS Tx Resources ICD-9-CM CPT coding Resources

MS Procedure Coding Procedures ICD-9-CM CPT

Bone Bx ICD-9-CM CPT 77.40-49 Bone Bx OR 41.31 Aspiration bone marrow 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 CPT Brain 70010 Spine 87.21 Myelography Cervical 72240  Lumbosacral 72265 Thoracic 72255  Total 72270 

Arthrocentesis CPT ICD 81.91 Arthrocentesis 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 CPT 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 No reduction Reduction w/ External fixator device add’l code 78.10-78.19 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 CPT 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 CPT Associated w/reduction of fx Not assoc. w/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 When performed in ED setting 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 CPT Codes often include graft harvesting Ligament, Repair  Knee Joint 27405 - 27409  Knee, Reconstruction Ligament 27427 - 27429  Knee, Repair  Ligament 27405 - 27409  Collateral 27405  Collateral and Cruciate 27409  Cruciate 27407 – 27409 Arthroscopic 29888 - 29889  (not in Index here) ICD-9-CM Repair Ligament (see also Arthroplasty) 81.96 collateral, knee NEC 81.46 cruciate, knee NEC 81.45 Reconstruction > Construction and repair Knee (joint) NEC 81.47  Collateral ligaments 81.46 Cruciate ligaments 81.45  Five-in-one 81.42  Triad 81.43 

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 CPT 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 CPT 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

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

Questions ? ? ? imueller@email.wcu.edu Thank You !

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. Spine-Health. http://www.spine-health.com/video/laminectomy-back-surgery-video Microdiscectomy: Lumbar Microdecompression Spine Surgery Video. Spine-Health. http://www.spine-health.com/video/microdiscectomy-lumbar-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/carpaltunnelsyndromeopensurgery/htm/index.htm Myelogram. X-plain module. Patient Education Institute, Nat’l Library of Medicine http://www.nlm.nih.gov/medlineplus/tutorials/myelogram/htm/index.htm