1. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 19 MUSCULOSKELETAL SYSTEM

2. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Musculoskeletal System Subsection divided: Anatomic site (Forearm and Wrist), then service (e.g., excision)Subsection divided: Anatomic site (Forearm and Wrist), then service (e.g., excision) Used extensively by orthopedic surgeonsUsed extensively by orthopedic surgeons –Many codes commonly used by variety of physicians Extensive notesExtensive notes (Cont’d…) (Cont’d…)

3. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Musculoskeletal System (…Cont’d) Most common:Most common: –Fracture and dislocation treatments –“General” subheading –Arthroscopic procedures –Casting and strapping

4. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Fractures Questions to ask: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. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Fracture Treatment Open: Surgically opened to view or remotely opened to place nail across fractureOpen: 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 incisionClosed 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 imagingPercutaneous, 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 fractureTreatment terms not to be confused with type of fracture –Open fracture: Bone penetrates skin –Closed fracture: Bone does not penetrate skin

6. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Type of treatment depends on type and severity of fractureType 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.“Complicated” in a code descriptor may indicate excessive hemorrhage, infection, prolonged physician work, or difficulty in reaching the site or depth of the site. Fracture Treatment Figure: 19.1

7. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Application of force to align boneApplication of force to align bone Traction Figure: 19.4

8. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Skeletal Traction Use of force (distracting or traction force) applied to internal device (e.g., wire, pin, screw, or clamp) inserted into boneUse of force (distracting or traction force) applied to internal device (e.g., wire, pin, screw, or clamp) inserted into bone

9. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Skin Traction Figure: 19.6 Application of force by means of adhesion to skinApplication of force by means of adhesion to skin

10. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Manipulation Use of force to return a fractured bone to normal alignmentUse of force to return a fractured bone to normal alignment Fracture repair codes are often divided based on whether manipulation was or was not usedFracture repair codes are often divided based on whether manipulation was or was not used AKA: ReductionAKA: Reduction Manipulation means a fracture has been reducedManipulation means a fracture has been reduced

11. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Fracture Term 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)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 comminutedWhen the fracture results in more than two fragments, it is comminuted

12. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Dislocation From Dorland's Illustrated Medical Dictionary, ed 31, Philadelphia, 2007, Saunders. Vertebral dislocation Subglenoid dislocation Vertebral dislocation/ Subglenoid dislocation Bone displaced from normal joint positionBone displaced from normal joint position Treatment: Return bone to normal joint locationTreatment: Return bone to normal joint location Figure: 19.7

13. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Subheading “General” (20005-20999) Begins “Incision”Begins “Incision” Depth: Difference between Integumentary and Musculoskeletal incision codesDepth: Difference between Integumentary and Musculoskeletal incision codes Musculoskeletal used when underlying bone or muscle is involvedMusculoskeletal used when underlying bone or muscle is involved

14. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 General Subheading, Wound Exploration (20100-20103) Traumatic penetrating woundsTraumatic penetrating wounds Divided on wound location (body site)Divided on wound location (body site) IncludesIncludes –Enlargement –Debridement –Foreign body(ies) removal –Ligation –Repair of tissue and muscle

15. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 General Subheading, Wound Exploration (20100-20103) (…Cont’d) These procedures describe surgical exploration to an already open woundThese procedures describe surgical exploration to an already open wound These codes are “separate procedure” codesThese codes are “separate procedure” codes They can be coded and reported in the following circumstances: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. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Biopsy Located in Excision subheading (20200-20251)Located in Excision subheading (20200-20251) Biopsies for bone and muscleBiopsies for bone and muscle Divided by:Divided by: –Type of biopsy (bone/muscle) –Depth –Some by method (Cont’d…)

17. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 (…Cont’d) Can be percutaneous needle or excisionalCan be percutaneous needle or excisional –Coded separately If lesion is excised and biopsied, only the excision can be billedIf 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 on excision codeIf biopsy taken on one day and based on the results an excision was performed, modifier -58 may be appropriate on excision code Biopsy

18. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Introduction or Removal (20500-20697) Within “General” subheadingWithin “General” subheading Codes for:Codes for: –Injections –Aspirations –Insertions –Applications –Removals –Adjustments (Cont’d…)

19. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Introduction or Removal (20500-20697) (…Cont’d) Therapeutic Sinus Tract Injection Procedures: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 (Cont’d…)

20. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Introduction or Removal (20500-20697) (…Cont’d) Removal: foreign bodies lodged in muscle or tendon sheathRemoval: foreign bodies lodged in muscle or tendon sheath Integumentary removal codes for removal from skinIntegumentary removal codes for removal from skin(Cont’d…)

21. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Introduction or Removal (20500-20697) (…Cont’d) Injection: Into tendon sheath, ligament, or ganglion cyst, trigger jointInjection: Into tendon sheath, ligament, or ganglion cyst, trigger joint Arthrocentesis: Injection “and/or” aspiration of a jointArthrocentesis: Injection “and/or” aspiration of a joint –Both an aspiration and injection are reported with one code

22. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Arthrocentesis (20600-20610) Local anesthesia is integral to these codes and should not be reportedLocal anesthesia is integral to these codes and should not be reported Report the drug separately with a “J” codeReport the drug separately with a “J” code HCPCS modifiers used to report specific digits: “FA to F9” or “TA to T9”HCPCS modifiers used to report specific digits: “FA to F9” or “TA to T9”

23. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 External Fixation (20690, 20692) Figure: 19.13A Application of a device that holds bone in placeApplication of a device that holds bone in place These codes include the removal of the fixatorThese 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 imagingIf it is necessary to adjust or revise an external fixator see 20693. Code 20694 describes removal under anesthesia and includes imaging(Cont’d…)

24. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 External Fixation (20690, 20692) (…Cont’d) Uniplane—pins or wires in one plane (flat, smooth surface)Uniplane—pins or wires in one plane (flat, smooth surface) Multiplane—requires complex adjustments and correction in alignment. Bedside adjustments are not separately billedMultiplane—requires complex adjustments and correction in alignment. Bedside adjustments are not separately billed Code fracture treatment and external fixationCode fracture treatment and external fixation –Unless treatment and fixation are both included in code description

25. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Grafts (or Implants) (20900-20938) Used to report harvesting through separate incision of: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)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 sessionReport only one bone graft code per operative session(Cont’d…)

26. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 Grafts (or Implants) (20900-20938) (…Cont’d) Fascia lata grafts: From mid-upper thigh where fascia is thickestFascia lata grafts: From mid-upper thigh where fascia is thickest Some codes include obtaining grafting materialSome codes include obtaining grafting material –Then not coded separately –Composite grafts involve combinations of autogenous material and allograft or alloplast

27. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Other Procedures (20950- 20999) Monitoring muscle fluid pressure (interstitial)Monitoring muscle fluid pressure (interstitial) –Pressure increases when blood supply decreases due to increased accumulation of fluids –Pressure increases when blood supply decreases due to increased accumulation of fluids (Cont’d…)

28. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Other Procedures (20950- 20999) (…Cont’d) Bone grafts are identified by site they are taken from (donor site)Bone grafts are identified by site they are taken from (donor site) Free osteocutaneous flaps: bone graftsFree osteocutaneous flaps: bone grafts –Taken along with skin and tissue overlying bone –Taken along with skin and tissue overlying bone (Cont’d…)

29. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Other Procedures (20950- 20999) (…Cont’d) Electrical or ultrasound stimulationElectrical or ultrasound stimulation –Used to speed bone healing Placement of stimulators externally or internallyPlacement of stimulators externally or internally Often used in treatment of fracturesOften used in treatment of fractures

30. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Divided by repair location:Divided by repair location: –Cervical (C1-C7) C1 = AtlasC1 = Atlas C2 = AxisC2 = Axis –Thoracic (T1-T12) –Lumbar (L1-L5) –Sacral (SI) –Coccyx (tailbone) Spine (Vertebral Column) (22010-22899) From Buck CJ:2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.

31. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Incision (22010, 22015) Open incision and drainage of deep abscess of spineOpen incision and drainage of deep abscess of spine Divided by locationDivided by location –Cervical, thoracic, or cervicothoracic –Lumbar, sacral, or lumbosacral

32. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 Arthrodesis (22532-22819) Fixation of joint (arthro = joint, desis = fusion)Fixation of joint (arthro = joint, desis = fusion) –Fixation with pins, wires, rods, etc., to immobilize the joint Often performed with other procedureOften 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 segmentsCoded by approach, site, and number of interspaces or segments

33. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Types of Spinal InstrumentationTypes of Spinal Instrumentation –Segmental: Devices at each end of repair area plus at least one other attachment –Nonsegmental: Devices at each end only Extensive notesExtensive notes Report in addition to definitive procedure without the -51 modifierReport in addition to definitive procedure without the -51 modifier Spinal Instrumentation (22840-22865) Figure: 19.15

34. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 Subsequent Subheadings After first subheading, General, divided by anatomic locationAfter first subheading, General, divided by anatomic location –Anatomic subheadings divided based by type procedure (Cont’d…)

35. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 Subheadings (…Cont’d) Example subheading “Head” divided by procedure (21010-21499):Example subheading “Head” divided by procedure (21010-21499): –Incision –Excision –Manipulation –Head Prosthesis –Introduction or Removal –Repair, Revision, and/or Reconstruction –Fracture and/or Dislocation –Other Procedures

36. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 Casting and Strapping (29000-29799) Replacement procedure or initial placement stabilizes without additional restorative treatmentReplacement procedure or initial placement stabilizes without additional restorative treatment Initial fracture treatment includes placement and removal of first castInitial fracture treatment includes placement and removal of first cast –Subsequent cast applications are coded separately (Cont’d…)

37. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 Casting and Strapping (29000-29799) (…Cont’d) Initial cast Not coded when part of a surgical procedureNot coded when part of a surgical procedure Removal is bundled into surgical procedureRemoval is bundled into surgical procedure Supplies are reported separatelySupplies are reported separately

38. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 Endoscopy/Arthroscopy (29800-29999) Surgical arthroscopy always includes diagnostic arthroscopySurgical arthroscopy always includes diagnostic arthroscopy Codes divided by jointCodes 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)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 -51 on the diagnostic scope (Cont’d…)

39. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 Endoscopy/Arthroscopy (29800-29999) (…Cont’d) Note: Parenthetical information following codes indicates which code to use if procedure was an open procedureNote: Parenthetical information following codes indicates which code to use if procedure was an open procedure Most arthroscopies include the following procedures: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

40. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 Conclusion CHAPTER 19 MUSCULOSKELETAL SYSTEM