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

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

3. MS Procedure Coding
Procedures
ICD-9-CM
CPT

4. Bone Bx ICD-9-CM CPT 77.40-49 Bone Bx OR 41.31 Aspiration bone marrow
Bone biopsy
Bone marrow aspiration performed alone
38220
Bone marrow biopsy is performed
38221 (bone marrow biopsy)
cannot report with CPT code (bone biopsy)
38220 and 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 performed at same site through same incision
Only CPT is reported

5. Myelography ICD-9-CM CPT Brain 70010 Spine 87.21 Myelography
Cervical 72240 
Lumbosacral 72265
Thoracic 72255 
Total 72270 

6. Arthrocentesis CPT ICD 81.91 Arthrocentesis Arthrocentesis
 includes: Joint aspiration  
excludes: 
for arthrography (88.32)
bx of joint structure ( )
for injection of drug (81.92)
CPT
Arthrocentesis
Intermediate Joint 20605 
Large Joint 20610 
Small Joint 20600 

7. 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

8. 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

9. 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 LT

10. External Fixation ICD-9-CM No reduction
Reduction w/ External fixator device
add’l code
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

11. 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,
Ex: Closed tx of tibial fx w/manipulation, application of cast, partial skin debridement of fx site
27752, 11040

12. 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, and 11012
Differ by extent of debridement
Must meet open fx definition

13. 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

14. 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

15. 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.

16. Sprain/Strain Surgery
CPT
Codes often include graft harvesting
Ligament, Repair 
Knee Joint   
Knee, Reconstruction
Ligament   
Knee, Repair 
Ligament   
Collateral 27405 
Collateral and Cruciate 27409 
Cruciate 27407 – 27409
Arthroscopic    (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 

17. 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 

18. CPT Bunionectomy Codes
Hallux valgus repair codes
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 

19. 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, , 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)

20. 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.

21. Arthroscopy ICD CPT Converted to open, code only open w/ V64.43
CPT
Dx – visualization and synovial Bx ONLY
29870 (separate procedure)
Surgical – anything else done
Includes dx
# of compartments important for some codes

22. 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 

23. 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

24. 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
 acetabular component only, with or without autograft or allograft
 femoral component only, with or without allograft

25. 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

26. Joint Replacement Revision
Adjust or remove and replace
ICD-9-CM coding
Includes removal of component(s)
81.53 hip component NOS
(hip components) add’l code
81.54 knee component NOS
(knee components) add’l code
84.57 removal of joint spacer (cement) add’l code
81.59, joint revision NEC (upper/lower extremities)
00.74 – add’l code (if known)
V43.6 Joint replacement status, if significant for pt care

27. Joint Replacement Revision
CPT Coding
27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft
 acetabular component only, with or without autograft or allograft
 femoral component only, with or without allograft
Many other joint arthroplasties in CPT

28. 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.

29. 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

30. CPT Spine Osteotomy Anterior/Posterior approach
Osteotomy code includes
Corpectomy, discectomy, laminectomy

31. Spinal Fusion 3 basic approaches
Anterior, posterior, lateral transverse
ICD-9-CM coding
Anterior ( )
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+

32. 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

33. 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, = Refusion
Various sites, various approaches

34. Kyphoplasty for Compression fxs
Kyphoplasty – reestablish vertebral height
Uses inflatable balloon to gain height
Injection of Polymethylmethacrylate to stabilize
ICD-9-CM
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) 

35. 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  

36. Spinal Disc Prostheses
ICD-9-CM Coding
Type of prosthesis – total/partial
Spinal segment
Cervical – 84.61, 84.62
Thoracic – (total/partial – same code)
Lumbarsacral – 84.64, 84.65
No location – 84.60
Revision/replacement –
Synchronous insertion of new prosthesis

37. CPT Spine procedure Examples
Arthodesis of T1-T3; autograft from ribs Dual rods inserted w/multiple hooks/wires
22610, 22614, – 3 fusions
rods
20936 – autograft
Surgical repair of L1-2 and L3-L4 by 2 surgeons (distinct parts of procedure)
(reported by each surgeon)
(reported by each surgeon)

38. Answers to Dx Coding Exercises
Primary osteoarthritis of hip
(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?

39. 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

40. Homework View ORlive http://www.or-live.com/ Previous webcasts
Browse by specialty
Orthopaedics
April 7, Spotlight on Beth Israel Orthopedics, New York City Need Adobe Flash Player
Code the 4 operations
Dx? Procedures – ICD and CPT

41. Questions ? ? ?
Thank You !

42. Resources (Books)
Brown, F. ICD-9-CM Coding Handbook with Answers, AHA Press.
Frazier, M. S. & Drzymkowski, J. W. Essentials of Human Diseases and Conditions, 4th ed., Saunders, 2009
Green, M. A Code It! 2nd ed 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

43. Resources (Videos) ORlive http://www.or-live.com/
Laminectomy Back Surgery Video. Spine-Health.
Microdiscectomy: Lumbar Microdecompression Spine Surgery Video. Spine-Health.

44. Resources (Videos) Minimally Invasive Discectomy. ORLive.
Pediatric Spinal fusion to correct scoliosis. ORLive. (via NLM link)
Spine Fusion Surgery Video. Spine-Health.

45. Resources (Websites) Acute vs. Chronic Pain. Cleveland Clinic.
A Guided Tour of the Visible Human
Bone scan. Mayo Clinic.
Bunionectomy. Clinical Policy Bulletin: Aetna.
Bursitis and Tendinitis; Questions and Answers. National Institute of Arthritis and MS and Skin Diseases. April 2007.

46. Resources (Websites)
Drugs of Abuse, Chapter 1 The Controlled Substance Act. Drug Enforcement Administration, US DoJ.
Feinberg, S. D. MD. Medications and Chronic Pain, 2007 Supplement. American Chronic Pain Association.
Hallux Valgus (Bunion Deformity). Institute for Foot and Ankle Reconstruction. Mercy Hospital, Baltimore, MD.

47. Resources (Websites)
Myelography. American Society of Radiologic Technologists.
Osteosarcoma Overview. American Cancer Society.
Planes of Section. A Guided Tour of the Visible Human
Rheumatoid Arthritis: Treatment options. Arthritis Foundation.
Staging: Questions and Answers
WebMD.

48. Resources (X-plain modules)
Carpal Tunnel Release – Open. X-plain module. Patient Education Institute, Nat’l Library of Medicine
Myelogram. X-plain module. Patient Education Institute, Nat’l Library of Medicine