1. By Alex Munoz, CPC, NCICS

2.  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

3.  Most common:  Fracture and dislocation treatments  “General” subheading  Arthroscopic procedures  Casting and strapping

4.  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

5.  *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

6.  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.

8.  Use of force (distracting or traction force) applied to internal device (e.g., wire, pin, screw, or clamp) inserted into bone

9.  Application of force by means of adhesion to skin

10.  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

11.  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

12. Bone displaced from normal joint position Treatment: Return bone to normal joint location Vertebral dislocation Vertebral dislocation / Subglenoid dislocation

13.  Begins “Incision”  Depth: Difference between Integumentary and Musculoskeletal incision codes  Musculoskeletal used when underlying bone or muscle is involved

14.  Traumatic penetrating wounds  Divided on wound location (body site)  Includes  Enlargement  Debridement  Foreign body(ies) removal  Ligation  Repair of tissue and muscle

15.  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

16.  Located in Excision subheading (20200-20251)  Biopsies for bone and muscle  Divided by:  Type of biopsy (bone/muscle)  Depth  Some by method

17. Cont….. 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

18.  Within “General” subheading  Codes for:  Injections  Aspirations  Insertions  Applications  Removals  Adjustments

19.  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

20. Cont……  Removal: foreign bodies lodged in muscle or tendon sheath  Integumentary removal codes for removal from skin

21. Cont….  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

22.  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”

23.  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

24. Cont…  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

25.  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

26. Cont….  Fascia lata grafts: From lower 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

27.  Monitoring muscle fluid pressure (interstitial)  Pressure increases when blood supply decreases due to increased accumulation of fluids

28. Cont…..  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

29. Cont…  Electrical or ultrasound stimulation  Used to speed bone healing  Placement of stimulators externally or internally  Often used in treatment of fractures

30.  Divided by repair location:  Cervical (C1-C7)  C1 = Atlas  C2 = Axis  Thoracic (T1-T12)  Lumbar (L1-L5)  Sacral (SI)  Coccyx (tailbone)

31.  Open incision and drainage of deep abscess of spine  Divided by location  Cervical, thoracic, or cervicothoracic  Lumbar, sacral, or lumbosacral

32.  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

33.  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  Report in addition to definitive procedure without the -51 modifier

34.  After first subheading, General, divided by anatomic location  Anatomic subheadings divided based by type procedure  Example subheading “Head” divided by procedure (21010-21499):  Incision  Excision  Head Prosthesis  Introduction or Removal  Repair, Revision, and/or Reconstruction  Other Procedures  Fracture and/or Dislocation  Manipulation

35.  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

36. Cont…. Initial cast  Not coded when part of a surgical procedure  Removal is bundled into surgical procedure  Supplies are reported separately

37.  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 -59 on the diagnostic scope

38. Cont….  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

39.  Buck, C. (2010). Step by Step. Elsevier.