1. Musculoskeletal System
Chapter 8 1

2. CPT®
CPT® copyright 2010 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.

3. Objectives Understand the components of the musculoskeletal system
œDefine key terms
œUnderstand the most common pathologies affecting these organs
œUnderstand orthopedic surgeries and how they relate to pathologies
œRecognize common eponyms and acronyms
œIdentify when other sections of CPTR or ICD-9-CM should be accessed
œKnow when HCPCS Level II codes or modifiers are appropriate
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4. Anatomy Skeleton Axial Appendicular Skull Chest Spine
Upper and lower limbs
Shoulders
Pelvis
The skeletal system provides the framework of the body. It consists of 206 bones, joints, and cartilage providing protection and support to body organs. There is considerable variation in bone structure among both the races and the sexes and even between individuals of the same sex and race. The sex of a skeleton can be determined; the bone structure of the pelvis often gives the most clues.
The two main parts of the skeleton are the axial and appendicular skeletons. The axial skeleton is comprised of the bones of the head (cranium or skull), neck (cervical vertebrae), and trunk (ribs, sternum, vertebrae and sacrum). The appendicular skeleton consists of the bones of the limbs, including those forming the pectoral (shoulder) and pelvic girdles. All bones are covered on the outside by a thin layer of periosteum. A cavity in a bone is an antrum or air cell, also called a sinus in some cases. A hole through a bone is a foramen.
There is usually a superficial thin layer of compact bone around a central mass of spongy bone, except where the latter is replaced by a medullary (or marrow) cavity. In this bone marrow blood cells and platelets are formed. Compact bone provides strength for weight bearing. The amount of compact bone is greatest near the middle of the shaft (or body) of the bone. Living bones have some elasticity or flexibility. Bones are further classified by their shape: long bones (humerus); short bones are cube shaped and found only in the ankle and wrist (carpus); flat bones (skull); irregular bones (face); and sesamoid bones which develop in certain tendons (patella).
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5. Anatomy Skeleton Muscles Ligaments – attach bones to other bones
Body’s framework
Bones store calcium and produce blood cells
Muscles
Assist with heat production
Posture
Ligaments – attach bones to other bones
Tendons – attach muscles to bones
Cartilage – Acts as a cushion between bones in a joint
Bone tissue is living tissue, it is metabolically active, serving critical functions and it is a hard form of connective tissue. Bones have a blood supply, venous drainage and a sensory nerve supply.
It also contains calcium and phosphorus. Functions of bone include: protection for vital structures; support for the body and its vital cavities; mechanical basis for movement; storage of minerals like calcium and phosphorus; and production and storage of new blood cells. There are two types of bones, compact and spongy.
Whenever two bones come together, whether movement is allowed or not, a joint is formed; also sometimes called an articulation. Actually, a joint can be a bone and cartilage or even the same bone (skull). Joints are subject not only to structural injuries and dislocations but also to inflammatory conditions (like arthritis) of various kinds. Sutures in the skull are a type of joint, this type of joint is found only in the skull and are immovable.
The muscular system consists of muscles that act to move and position parts of the body. Most muscles are attached directly or indirectly through tendons to bones, cartilage, ligaments or fascia or some combination of these structures.
Ligaments are bands or sheets of strong fibrous cords extending from one bone to another; they cross joints attaching bones together.
A tendon is a non-distensible, strong cord-like structure. Tendons are composed of dense fibrous connective tissues that attach muscles to bones. When measuring muscle length, tendons are included.
Cartilage is a connective tissue characterized by its non-vascularity and firm consistency. There are three types of cartilage: hyaline, elastic and fibrocartilage. Hyaline cartilage is found in only a few places in the body: the larynx (or voicebox); ends of long bones at joints; nose and the articulation between the breastbone and ribs. The fetal skeleton contains a large amount of hyaline cartilage.
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6. Muscles Types of Muscles Naming Conventions Striated Smooth Cardiac
Size
Shape
Location
Action
Number of attachments
Direction of fibers
There are three types of muscle: skeletal (or striated); smooth; and cardiac. Skeletal muscles move bones and other structures. Smooth muscle forms part of the walls of most vessels and hollow organs. It also moves substances through viscera such as the intestine and ureter (movement is called peristalsis) and controls movement through blood vessels. There is no muscle in capillaries. Smooth muscle is involuntary muscle and it is innervated by the autonomic nervous system. It can undergo partial contraction for long periods. This can be important in regulating the size of the lumen of structures like the intestines or blood vessels. Cardiac muscle forms most of the walls of the heart and adjacent parts of the great vessels such as the aorta, pulmonary vein and superior vena cava. Cardiac muscle contractions are not under voluntary control, it is regulated by a pacemaker which is composed of special cardiac muscle fibers that are influenced by the autonomic nervous system. It is both striated and involuntary muscle.
When muscles contract, their fibers shorten. This contraction causes movement of a body part. Muscle cells are long and slender and are called fibers rather than cells. Muscle power increases as the total number of muscle cells increases. When a muscle contracts and shortens, one of its attachments usually remains fixed and the other one moves. This fixed portion is usually proximal and called the origin; the insertion is usually distal and the part that moves. Some muscles can act in both directions under different circumstances.
Muscles are generally named basde on characteristics such as size, shape orientation of fibers, location, the number of origins and muscle action. For example, size – vastus is huge, maximus is large, longus is long and minimus is small. Examples of muscles named for shape: deltoid is triangular; trapezius is trapezoid and teres is round. Examples of muscles named for location include: gluteus is buttock, brachii is arm and lateralis is lateral. Muscles named for their action include: an abductor – moves the limb away from the midline of the body; an adductor moves the limb toward the midline; and a flexor muscle causes flexion. The origin of a muscle was defined previously; examples of muscles named for the number of origins is the biceps, such as the biceps brachii. Muscles can be named for the direction of orientation of the fibers; oblique is diagonal, circularis is circular.
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7. Axilla Armpit area Anatomic Landmarks Posterior axillary fold
Anterior axillary fold
The axilla or armpit is a dome-shaped area between the arm and the lateral chest wall. The shape and size of the axilla varies depending on the position of the arm. The axilla provides a passageway for vessels and nerves going to and from the upper limb. It has an apex, base and four walls, three of which are composed of muscles. When the arm is abducted (or moved away from the midline of the body) the boundaries of the axilla can be seen. Anteriorly is the pectoralis major muscle, the latissimus dorsi muscle posteriorly, the serratus muscle anteromedially and the humerus laterally. The axilla is a passageway for vessels and nerves going to and from the upper limb. Part of the brachial plexus passes through the axilla; the brachial plexus is made up of spinal nerves C5,6,7 & 8. The brachial plexus is a major network of nerves supplying the upper limb
Many lymph nodes are located in the axilla; these lymph nodes receive lymph drainage from various parts of the body including the thoracic wall and most of the breast as well as from the upper limb. With an infected laceration to the lower arm, lymph nodes may be felt as small nodules in the axilla.
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8. Fracture Eponyms Colles’ Fracture Smith’s Fracture Jones’ Fracture
Salter-Harris Fracture
Dupuytren’s Fracture
Monteggia’s Fracture
Fractures have been given specific names including:
Colle’s Fracture – fracture of the distal radius with displacement and/or angulation of the distal bone.
Smith’s Fracture – is a reversed Colles fracture; it is fracture of the distal radius with displacement of the fragment toward the palmar aspect.
Jone’s Fracture – is a transverse stress fracture of the proximal shaft of the fifth metatarsal.
Salter-Harris Fracture – is a fracture that involves the epiphyseal (or growth) plate of a bone. Commonly occurs in children and is divided into nine different types. It occurs in 15% of childhood long bone fractures.
Dupuytren’s Fracture – is a fracture of the part of the fibula (one of the lower leg bones), with dislocation of the ankle.
Monteggia’s Fracture – is fracture of the proximal ulna with dislocation of the head of the radius.
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9. Treatments Manipulation Reduction Fixation Cast application Internal
External
Cast application
Amazingly, broken bones heal. Even after bone growth has been completed, bones are continuously being reshaped; this is called bone remodeling. It is accomplished by the combined actions of osteoblasts (or bone-forming cells) and osteoclasts (bone destroying cells). Osteoblasts, are on the underside of the periosteum and are continuously depositing bone on the external bone surface. Osteoclasts break down bone tissue, this process is called bone resorption. The dynamic nature of bones with continual growth and resorption is a critical factor in fracture healing. Pain from a fracture comes from tissue swelling and damage to other structures in the area as well as pain from the periosteum. Once a fracture has been diagnosed, initial treatment for most limb fractures is a splint. The joints above and below the injury are immobilized to prevent movement at the fracture site. When swelling and edema have gone down after a few days, surgery or casting may be applied depending on the injury.
Manipulation is a treatment for broken bones whereby the broken ends of bone are approximated for healing.
Reduction is the correction through manipulation or surgery of a fracture to a normal anatomical position.
Fixation of broken bones can be internal and external. External fixation is holding together of a broken bone by means of a plaster or fiberglass cast encircling the injured part while healing occurs. Internal fixation is use of devices such as pins, screws, wires or plates applied directly to the bony fragments to hold them in proper alignment for healing.
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10. ICD-9-CM Coding Fifth Digit Specification 0—Site unspecified
1— Shoulder region (Acromioclavicular joint, Clavicle, Glenohumeral joint(s), Scapula, Sternoclavicular joint(s))
2— Upper arm (Elbow joint, Humerus)
3—Forearm (Radius, Ulna, Wrist joint)
4— Hand (Carpals, Metacarpals, Phalanges (fingers))
5— Pelvic region and thigh (Buttock, Femur, Hip joint)
6— Lower leg (Fibula, Knee joint, Patella, Tibia)
7— Ankle and foot (Ankle joint, Digits (toes), Metatarsals, Phalanges, foot, Tarsals, Other joints in foot)
8— Other specified sites (Head, Neck, Ribs, Skull, Trunk, Vertebral column)
9—Multiple sites
ICD-9-CM diagnosis codes are found in Chapter 13 of the Tabular List, Diseases of the Musculoskeletal System and Connective Tissue ( ). At the beginning of this section are instructions regarding fifth-digit subclassification for listings in this Chapter. They are listed by region beginning superiorly with the shoulder and moving down the body. Specific bones found in the individual regions are listed.
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11. Arthropathies and Related Disorders
Systemic lupus erythematosus
Arthropathy
Rheumatoid arthritis
Osteoarthritis
Internal derangements of the knee
MCL and ACL
Bucket handle tear
Lupus (or Systemic lupus erythematosus) is also abbreviated as SLE. It is an autoimmune disorder that can impact various body organs and systems. Simply put, an autoimmune disease means a person is producing antibodies attacking their own tissues. These antibodies can attack the lungs, kidneys or in this case, joints. It is most common in women ages years old. Often times, the first symptoms a woman has with SLE is arthritis pain. Arthritis is inflammation of a joint.
An arthropathy is any disease or pathology affecting a joint. Joints can be affected by various conditions; another code must be listed first to specify the underlying disease. An example is Rheumatoid arthritis, another autoimmune disease. It is the most debilitating type of arthritis and can also manifest with systemic problems such as fatigue and fever. The disease can progress to destruction of the joint with disfiguration and fusion of the joint.
Osteoarthritis is degeneration of the joint space. It is the most common type of arthritis, joints are “worn-out” and this afflicts many elderly people. Loss of supporting and cushioning factors in the joints leads to “bone-on-bone” joints that are painful and don’t work well. Replacement surgery for these weight bearing joints includes hip, knee and shoulder replacements.
Supporting structures of joints can become injured, traumatized and torn. Common the knee injuries include MCL (or medial collateral ligament) and ACL (or anterior cruciate ligament). Codes are listed for both chronic and acute conditions.
A bucket handle tear is a tear of the lateral meniscus of the knee. The meniscus is a crescent shaped fibrocartillagenous structure of the knee. The meniscus is directly on the articular surface of the joint.
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12. Dorsopathies 4th digit – type of disorder 5th digit – area of spine
Diseases
Spondylosis
Displacement of vertebral disc
Degenerative disc disease
Spinal stenosis
Symptoms
A dorsopathy is a disorder affecting the spinal column. The spine is divided into regions beginning superiorly, the cervical (there are 7), thoracic (there are 12) and lumbar (there are 5). These disorders are classified according to what part of the spine is affected. Fourth and fifth digits are required to specify type of disorder and area affected.
Spondylosis is degeneration of deficient development of the articulating part of a vertebra. It is an osteoarthritis resulting in inflammation of the spine. Ankylosing spondylitis is arthritis of the spine and resembles rheumatoid arthritis and is more common in men.
Degenerative disc disease is deterioration of the disc between vertebrae. Individual vertebrae are separated by the discs that provide strong attachments between the vertebral bodies also, permitting movement between adjacent vertebrae. They act as shock absorbers. With age and use, they wear out. Discs can also be displaced or ruptured.
Spinal stenosis is narrowing of the spinal canal which can put pressure on spinal nerves. This can result in pain and numbness in the back, buttock and leg regions.
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13. Rhumatism, Excluding Back
Enthesopathies
Capsulitis
Tendonitis
Tenosynovitis
Bursitis
Synovitis
Compartment Syndrome
Bunion
Enthesopathies are diseases occurring at the site of insertion of muscle tendons and ligaments into bones or joint capsules. Capsulitis is inflammation and pain of the tissues surrounding the joint. Tendonitis is inflammation of a tendon. Tenosynovitis is a more involved inflammation affecting the tendon and the tendon sheath lining.
Bursitis is a “catch-all” term describing inflammation of the bursa, small fluid filled sacs in the joints. Synovitis is inflammation of the synovial membrane of a joint; this term is often used synonymously with arthritis. All of these disorders are coded by location.
Compartment syndrome is pressure or compression of vital structures such as nerves and blood vessels in spaces with no “give.” This can lead to numbness, decreased function and damage of these structures. These conditions can be caused by trauma or can be non-traumatic. Edema and swelling put pressure on structures affecting blood flow and nerve function.
A bunion is a localized swelling caused by inflammation of the bursa with resulting fibrosis. Hallux valgus is a deviation of the tip of the great toe toward the outer or lateral side of the foot.
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14. Osteopathies, Chondropathies, and Acquired Musculoskeletal Deformities
Osteomyelitis
Osteochondroses
Osteoporosis
Curvature of the spine
Osteomyelitis is inflammation of the bone marrow cavities with thinning of the osseous bone. This is a very serious infection, can be extremely difficult to eradicate. Patients at risk for these infections include those with bone fractures, orthopedic surgery and those with diabetes. These infections can be acute but often become chronic as they are difficult to eliminate.
Osteochondroses are disorders of ossification centers in children, characterized by degeneration or aseptic necrosis followed by reossification. These conditions are not a result of infection; they involve the epiphyses which is a part of a long bone developed from a center of ossification distinct from the shaft.
Osteoporosis is reduction in the quantity of bone or bone density; it occurs in postmenopausal women and elderly men. Inactivity can also result in osteoporosis. Osteoporotic bones fracture more easily.
Curvature of the spine difficulties include kyphosis, lordosis and scoliosis. Kyphosis is an anterior curvature of the vertebral column generally in the thoracic area. Lordosis is curvature of the lumbar spine. Scoliosis is lateral curvature of the vertebral column; there can be a primary curve with a secondary compensatory curve.
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15. Injury and Poisoning Sprains and Strains Fractures Comminuted Impacted
Simple
Greenstick
Pathologic
Compression
Torus or Incomplete
A sprain is an injury to a ligament when the joint is carried through a range of motion greater than normal, also referred to as a strain.
A sprain is an injury to a ligament when the joint is carried through a range of motion greater than normal, but there is no dislocation or fracture.
A break in a bone is called a fracture. Fractures can be simple, the overlying skin is intact and local damage is minimal; compound is a broken bone that has also ruptured the skin causing tissue damage. A greenstick fracture is an incomplete break in the bone and occurs primarily in children due to the pliable nature of their bones. A spiral fracture extends in a circular or spiral direction and results from torsion or twisting. A comminuted fracture occurs when there are more than two bone fragments; an impacted or compression fracture occurs when two parts of the broken bone have been jammed into each other. An evulsion fracture is tearing off of a bony prominence. A pathologic fracture is the result of a disease process such as a tumor. Torus or incomplete fractures occur in children, one side of the bone buckles. Diagnosis codes for fractures are listed by anatomical site and whether the fracture is open or closed.
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16. Injury and Poisoning Compartment Syndrome Rotator Cuff Tear
Nursemaid’s Elbow
Compartment syndrome was discussed earlier and is usually the result of an injury. There is increased pressure in a confined space impacting vital structures such as blood vessels and nerves.
The rotator cuff of the shoulder is the upper half of the capsule of the shoulder joint reinforced by the tendons of insertion ; it holds the head of the humerus in place. When the cuff is torn, surgery may be necessary and can be either open or arthroscopic (or endoscopic).
Nursemaid’s elbow involves the elbow, it is a partial dislocation of the head of the radius. It is also called Malgaigne luxation.
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17. Musculoskeletal System
Table of Contents
Listing of headings and subheadings
Anatomic Illustrations
Useful when coding from this subsection
Knowledge of anatomy and terminology will be key
The musculoskeletal system in CPT® lists procedures involving muscles, bones, joints ligaments, tendons and cartilage. It is the longest section in CPT®. This section contains very useful anatomical illustrations at the beginning. This is a good time to review anatomy and have a medical dictionary handy.

18. Musculoskeletal System
Formatted by anatomic site
General
Head, Neck (soft tissues) and Thorax
Back and Flank
Spine (vertebral column)
Abdomen
Shoulder, Humerus and Elbow
Forearm and Wrist
Hand and Fingers
Pelvis and Hip Joint
Femur and Ankle Joint
Foot and Toes
Application of Casts and Strapping
Endoscopy/Arthroscopy
The beginning of this section also contains several instructions with useful definitions. As this list demonstrates, the listings are grouped anatomically beginning superiorly with the head, neck and thorax. Wound exploration is listed first. This relates to a traumatic event such as a gunshot or stab wound

19. Musculoskeletal System
“General” subheading
Many different anatomic sites
Other subheadings
Divided by anatomic site, procedure type, condition and description
Incision, excision, introduction or Removal, Repair, Revision and/or Reconstruction, Fracture and/or dislocation, Arthrodesis, Amputation
The “General” subheading is just that, general. It can be used to report various anatomic sites.
As mentioned, the other subheadings are listed by anatomic site. The listings are also by the specific procedure and the condition. Orthopedic treatments are often performed in “stages.” Plates and screws may be placed for approximation and stabilization. They often will be removed at a later point when healing is at a point that this can be done.

20. Guidelines Types of fracture treatment
Closed means the fracture site not surgically exposed
Three methods
Without manipulation
With manipulation
With or without traction
The Guidelines at the beginning of this section define closed, open and percutaneous treatments. A closed treatment utilizes methods to treat fractures without an incision. The broken ends of the fractured bones are brought into approximation either with or without manipulation to promote healing. Traction may or may not be necessary to stabilize the fractured bone in place to heal.

21. Guidelines Types of Fracture Treatment (cont)
Open – used when fractured bone is surgically exposed
Internal fixation may be used
Percutaneous skeletal fixation
Not open or closed
Pin placed across the fracture site
Open treatment requires an incision, either at the fracture site or remotely. Internal fixation involves placement of “hardware” such as screws or nails.
Percutaneous skeletal fixation is fracture treatment neither open nor closed. The fracture fragments a not visualized, fixation is placed across the fracture site usually with X-ray imaging.
Not that the type of fracture (closed, compound, open) does not have any coding correlation with the type of treatment provided.

22. Guidelines Traction Skeletal Skin
The application of a pulling force to hold a bone in alignment
Skeletal
Use of internal devices
Skin
Strapping or tape
Traction is the act of drawing or pulling by force; this may be necessary to correctly align broken bone ends for healing. This may be accomplished by use of a wire, pin, screw or clamp attached to a bone and is referred to as skeletal traction. Skin traction is application of a force to a limb using strapping or felt applied directly to the skin only.
External fixation is use of skeletal pins plus and attaching mechanism to treat or align a deformity.

23. General Not specific to anatomic site Incision of soft tissue abscess
Associated with deep tissue
Wound Exploration
Traumatic wounds
Include surgical exploration/enlargement, debridement, removal of foreign bodies, ligation/coagulation minor blood vessels
The General subheading begins with one code, Incision and drainage of soft tissue abscess, subfascial; this is a deep procedure, below the fascia. Fascia is below the skin and fat layers, it is very tough. A hernia is a defect or weakness in the fascia. The gristly white tissue on a steak that is very chewy is fascia.
There is a paragraph of instructions with the section on Wound Exploration – Trauma. These wounds include gunshot and stab wounds. Wounds of this nature may be small to begin with, but it may be necessary to explore them and make them larger in the process.

24. General Excision Category Biopsy Typically includes Muscle or Bone
Local anesthesia
Incision
Removal of tissue, sutures
Excision refers to the biopsy and excision of muscle and bone. It is important to know the depth of the wound and this will require good documentation by the provider. Codes are divided into superficial and deep excisions. A needle biopsy is usually superficial, deep biopsies are performed on deeper structures such as major bones (eg, humerus or femur).

25. General Introduction or Removal Category
Aspiration, Insertion, Application
Removal foreign body muscle/tendon sheath
Injections into tendon, ligament, ganglion cyst
Aspiration/injection into joint
Insertion pins/wires
Grafts/Implants
Introduction or removal codes report the removal of a foreign body or old hardware such as pins or screws. These codes require knowing the depth of tissue that must be incised to reach the foreign body.
Injections involve insertion of a needle into an area for aspiration or for introduction of a medication.
A graft is tissue transplanted to an area; it is often called an implant.
Arthrocentesis is puncture of a joint with a needle for fluid removal and/or injection. An example of this is injection of steroids into a joint for treatment of pain. This code does not include the drug itself, the drug supply code should be listed separately.

26. General Grafts Bone Cartilage Fascia Lata Tendon Tissue
Taken from thigh area
Tendon
Tissue
Fat, dermis, fatty tissue from tendon compartment
Grafts can be of various tissues such as bone cartilage, tendon or fascia lata and is usually through a separate incision. Following grafts, often a splint or cast is placed to prevent movement or injury while it heals.
The fascia lata is deep fascia of the thigh; it is substantial, it encloses the large thigh muscles and becomes the iliotibial tract. Autografts are tissue transferred by grafting into a new position in the body of the same individual; Allografts are transplants between genetically non-identical individuals of the same species.

27. General Other Procedures Bone Grafts Free osteocutaneous flaps
Based on where graft is obtained
Free osteocutaneous flaps
Based on part of the body flap is taken
Monitoring of interstitial fluid pressure
Bone grafts are often taken from the patient’s own iliac crest (pelvic bone), ribs or the fibula (bone in lower leg). Grafts are also called implants. Codes for obtaining autogenous bone, cartilage, tendon or other tissues through separate incisions should be reported separately unless the code descriptor references the harvesting of the graft or implant. There is an instruction at the beginning of this section instructing to not append modifier 62 to bone graft codes.
Free osteocutaneous flaps can include bone and skin with microvascular anastomoses. This is usually reconstructive surgery. Use of the operating microscope is reported separately. These types of flaps are used to treat high energy extremity wounds (trauma) with loss of bone and soft tissue.
An interstitial pressure monitoring device may be inserted into a muscle compartment to prevent muscle compartment syndrome from developing.

28. Anatomical Subheadings
Based on anatomic site
Divided based on procedure
Incision
Excision
fracture
Read notes carefully
These anatomical subheadings begin with the head. As in other sections of CPT®, procedures are divided by the procedure performed beginning with Incision. Codes related to procedures on the head include structures of the skull, facial bones and temporomandibular joint (or TMJ). Documentation quality and quantity are essential to accurate reporting.
The Repair, Revision, and/or Reconstruction listings is a very large section.

29. Spine Cervical C1-C7 Thoracic T1-T12 Lumbar L1-L5 C1 Atlas C2 Axis
Spine (or Vertebral Column) begins with instructions and examples. Surgery on the spine often includes surgery on nerves. The spine is divided into three sections. Beginning superiorly, the cervical area includes seven vertebra which are referred to as: C1 for the first cervical vertebra. Atlas is the first cervical vertebra, it articulates with the occipital bone of the skull. C2 is called “axis” and is the second cervical vertebra. All of the cervical vertebra collectively are referred to as C1-C7.
Thoracic vertebra come next and includes 12 vertebra. They are referred to as T1 for the first thoracic vertebra and so forth.
Next comes the Lumbar spine – vertebra L1-L5.
At times operative reports can specify areas involving portions of more than one group of vertebra. For example, if a procedure was performed on “C6-T3,” vertebra involved includes C6, C7, T1, T2, and T3 or five vertebra.
The space between vertebra contains an intervertebral disc, the nucleus pulposus, annulus fibrosus and two cartilagenous endplates.

30. Spinal Instrumentation
Segmental
Attachment at each end of repair area and at least one other attachment in the area being repaired
Non-segmental
Attachment of device at each end of the area being repaired
A vertebral segment describes the basic constituent part into which the spine may be divided. This includes a single complete vertebral bone with its articular processes and laminae. A laminae is a thin plate or flat layer on the individual vertebra.
Segmental refers to the individual segments as previously described. For example, if a procedure is described as segmental for levels T3-T7, five segments (T3, T4, T5, T6 and T7) are involved. Non-segmental indicates a device has been attached spanning a section of vertebra, not individual vertebra.

31. Application of Casts and Strapping
Use these codes when physician
Applies an initial cast/strapping/splint prior to definitive treatment by another physician
Applies a subsequent cast, strapping or splint
Treats a sprain and doesn’t expect to provide other type of treatment
Casts and splints serve to immobilize a body part. This can be done to allow swelling to decrease and to immobilize areas for healing. Casts are made of various materials including plaster, fiberglass or synthetic materials. Splints often involve bracing on one side with splints held in place by tape or bandages. These treatments can be temporary or definitive. Casts and splints can be used for fractures, strains or sprains. They are also commonly used following surgical repair.
Application of the first cast or a strapping device is part of the global surgical care for these procedures. This is true regardless of whether the cast is applied to treat a fracture or to immobilize an extremity following surgery.
The type of fracture does not dictate the type of treatment. If additional or replacement casts are required, this will need to be reported separately. When a cast or strapping are reapplied, the removal of the old cast or strap in included. When a physician applies a temporary cast, splint or strapping and another physician provides the definitive treatment of a fracture, each physician may report for the services they provided.

32. Endoscopy/Arthroscopy
Divided by body area
Elbow
Shoulder
Knee
Surgical endoscopy/arthroscopy includes a diagnostic endoscopy/arthroscopy
Multiple surgical procedures performed through scope may be reported
“Separate procedure” – included in more extensive procedure
An endoscopic or arthroscopic procedure is examination of a joint using a scope. Surgical arthroscopic procedures always include a diagnostic arthroscopy of the same joint. If a procedure begins as a diagnostic scope and an open procedure is required, it is okay to report both procedures and add modifiers 59 (distinct procedural service) and 51 (multiple procedures) to the diagnostic scope code.
Arthroscopic procedures of joints include procedures on the shoulder, wrist, spine, hip, knee, ankle, hand and foot.

33. HCPCS Level II Orthotic and Prosthetic Basic Orthopedic Supplies
Crutches
Canes
Walkers
Traction Devices
Wheelchairs
Other orthopedic supplies
As the CPT® is large and there are numerous procedures performed, a lot of supplies and support materials can be requires. Orthotics is the science concerned with the making and fitting of orthopedic appliances. Prosthetics is the art and science of making and adjusting artificial parts of the human body. A prosthetist is one skilled in constructing and fitting prostheses.
The HCPCS Level II codes are for orthotic and prosthetic procedures and supplies. There are many HCPCS level II codes used with musculoskeletal and orthopedic services. This includes crutches, walkers, canes, traction devices, wheelchairs and other orthopedic devices. These supplies are called durable medical equipment (or DME).
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34. Modifiers 50 – Bilateral 59 – Distinct Procedural Service
RT – right
LT – left
59 – Distinct Procedural Service
FA-F9 – Specifies Finger
TA-T9 – Specifies Toe
Modifiers are frequently used in orthopedic surgery to indicate the side of the body the surgery was performed. They may be necessary to report which finger or toe was repaired or to indicate that procedures were performed on both sides of the body.
When using modifiers, it may be helpful to check with payers to see what codes to list. This applies to modifier 50 (bilateral procedure) and it may be necessary to use modifiers LT (left side) and RT (right side). They may prefer a single code with modifier 50.
Modifier 54 is surgical care only and may apply when care is provided by multiple providers or the patient changes location.
59 (distinct procedural service) indicates that a service should not be bundled when it normally might be bundled.
62 (two surgeons) is listed when two surgeons work together to perform distinct portions of the same service. The same CPT® code must be used.
Fingers and toes can be specified individually. FA is left hand, thumb; F5 is right hand thumb. The other designations FA-F9 are used to list all of the fingers; TA-T9 list all the toes.
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35. The End