AAPC Chapter 8: Musculoskeletal System

In the CPT® codebook, 25000 and 25001 are for incisions in the tendon sheath on the wrist. Code 25000 is for the extensor tendon and 25001 is for the flexor tendon sheath. What is the difference between extension and flexion?

Extension causes straightening of the wrist; flexion causes bending of the wrist. RATIONALE: When muscles are named for their action, words like flexor and extensor are often included in the name. Flexion is bending of a limb or body part and Extension is straightening of a limb or body part.

Hallux rigidus is a condition affecting what part of the body?

Foot Rationale: Hallux rigidus is an arthritic condition of the big toe or first metatarsophalangeal joint causing rigidity and inability to bend the toe. Look in the ICD-10-CM Alphabetic Index for Hallux/rigidus (acquired) referring you to code M20.2-. In the Tabular List the foot is in the code description. One of the treatments for it is a cheilectomy, an operation to remove a bony growth to release the joint. Look in the CPT® Index for Cheilectomy which directs you to 28289.

This type of connective tissue attaches a muscle to a bone:

Tendon RATIONALE: Tendons attach muscles to bone, and ligaments attach bones to other bones.

A 31 year-old secretary returns to the office with continued complaints of numbness involving three radial digits of the upper left extremity. Upon examination, she has a positive Tinel's test of the median nerve in the left wrist. Anti-inflammatory medication has not relieved her pain. Previous electrodiagnostic studies show sensory mononeuropathy. She has clinical findings of carpal tunnel syndrome. She has failed physical therapy and presents for injection of the left carpal canal. The left carpal area is prepped sterilely. A 1.5 inch 25-gauge needle is inserted radial to the palmaris longus or ulnar to the carpi radialis tendon at an oblique angle of approximately 30 degrees. The needle is advanced a short distance about 1 or 2 cm observing for any complaints of paresthesia or pain in a median nerve distribution. The mixture of 1 cc of 1% lidocaine and 40 mg of Kenalog-10 is injected slowly along the median nerve. The injection area is cleansed and a bandage is applied to the site. What codes are reported?

20526, J3301 x 4 Rationale: For the CPT® code, look in the CPT® Index for Injection/Carpal Tunnel/Therapeutic, 20526. Verify in the numeric section. Look in your HCPCS Level II codebook in the Table of Drugs and Biologicals for Kenalog, and you are referred to See Triamcinolone Acetonide, which refers you to J3300 and J3301. Check the tabular listing to verify. Kenalog-10 is not listed; however, Kenalog is listed under J3301. Code J3301 is reported for 10 mg, and 4 units are reported to cover the 40 mg given.

The patient has developed plantar fasciitis, a painful condition in his heel and the sole of his foot. He has tried using shoe inserts and over-the-counter pain relievers, but is still having pain. His physician performs an injection of the tendon sheath on the bottom of his foot. What procedure code is reported?

20550 RATIONALE: An injection of a single tendon sheath, or ligament, aponeurosis (for example: plantar fascia) is coded with a 20550. Look in the CPT® Index for Tendon Sheath/Injection.

CASE 7 Procedure performed in office. PREOPERATIVE DIAGNOSIS: Right-sided thoracic pain. POSTOPERATIVE DIAGNOSIS: Right-sided thoracic pain. OPERATION: Trigger point injection into the right-sided thoracic spine musculature, into the rhomboid major, rhomboid minor, and levator scapular muscles. PROCEDURE: The patient was seated on the bed. He has metastatic right lung cancer. The risks of the procedure, including bleeding, infection, nerve damage, and no guarantee of symptom relief were explained. The patient agreed to the procedure and the informed consent was signed. I palpated for areas of maximal tenderness. Five points were marked over the right-sided thoracic paraspinal musculature. I then cleaned off his back with chlorhexidine x2. Then I used a 25 gauge 1.5-inch needle on a 10 cc controlled syringe with 40 mg/ml Depo-Medrol. After negative aspiration, 1 cc was injected into each point. A total of four points were injected. A total of 4 cc (160mg) was used. The patient tolerated the procedure well. Band-Aids were not placed. The patient was not bleeding. We are refilling the patient's pain medication. He is seeing an oncologist and gets Percocet 7.5/500. He takes four a day, providing him with pain relief. We will dispense to him today a three-week supply. We are going to dispense #84. He is to return to the office in two weeks, at that time we will get a urine specimen for follow-up. Emphasized to the patient, once again, that he had to bring his pills to every appointment according to the opioid contract. What are the CPT® and ICD-10-CM codes reported?

20553, J1030x4; M54.6, C78.01

A 22 year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was opened with a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner wire was located within the distal phalanx. It was removed and the skin was closed with sutures. What CPT® code is reported?

20680-F4 Rationale: In the CPT® Index look for Removal/Fixation Device. You are referred to 20670-20680. Review the codes to choose the appropriate service. 20680 is the correct code because a deep incision was made all the way to the bone to locate the wire for removal. Modifier F4 is reported to indicate the left little finger.

CASE 6 PREOPERATIVE DIAGNOSIS: Painful hardware, left foot. POSTOPERATIVE DIAGNOSIS: Painful hardware, left foot. PROCEDURE PERFORMED: Removal of hardware, left foot ANESTHESIA: Sedation and local DRAIN: None. ESTIMATED BLOOD LOSS: Minimal. INDICATIONS FOR PROCEDURE: The patient had his status post metatarsal fracture, treated with internal fiixation. Patient has suffered pain due to hardware for the past six months. Patient's pain has been unresponsive to conservative treatment. We discussed the above-mentioned surgery, along with the potential risks and complications, and the patient understood and wished to proceed. DESCRIPTION OF PROCEDURE: With the patient supine on the operating table after the successful induction of anesthesia, the left foot was prepped and draped in the usual sterile fashion. In the area of the screw heads, 0.5% Marcaine was injected, both on the lateral side of the foot and the dorsal midfoot, administering about 5 ml in each area. Small 0.5 cm incisions through the skin were made and blunt dissection was carried down to the screw heads. The screws were removed with the screwdrivers. The incisions were irrigated and closed with simple 4-0 nylon sutures. A sterile compression dressing was applied. The patient was taken to the recovery room in satisfactory condition. MATERIAL SENT TO LABORATORY: None. COMPLICATIONS: None. CONDITION ON DISCHARGE: Satisfactory. DISCHARGE DIAGNOSIS: Painful hardware, left foot. DISCHARGE PLAN: Discharge instructions were discussed with the patient. A copy of the instructions was given to the patient and a copy retained for the medical record. The following items were discussed: diet, activity, wound care medications if applicable, when to call the physician, and follow-up care. What are the CPT® and ICD-10-CM codes reported?

20680-LT T84.84XA, G89.18

CASE 3 PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist. POSTOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist.(The postoperative diagnosis is used for coding.) PROCEDURE: Application of a uniplane fixation and closed reduction of left distal radial fracture under fluoroscopy.(This is the working procedure until the report is read.) ANESTHESIA: General endotracheal.(General anesthesia used.) DESCRIPTION OF THE PROCEDURE: After induction of adequate general anesthesia, the patient's left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius.(The external fixation component of the procedure is further described.) We connected these two pins with clamps, and then under C-arm control, we reduced the fracture.(This supports the closed reduction under fluoroscopy.) All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution(The comminuted aspect of the diagnosis is confirmed.) and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible, and tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications. What are the CPT® and ICD-10-CM codes reported?

20690-LT, 25605-51-LT S52.532A

A 44 year-old male with biplanar deformity, acquired limb length discrepancies and tibial nonunion has undergone deformity correction. He now requires exchange of an external fixation strut 45 days postoperatively. One of the struts for his multiplane external fixation device is removed and then replaced with an adjustable strut. The intraoperative mounting parameters, deformity parameters and initial strut settings are entered into the computer prior to Jim's discharge and a daily schedule is generated for him to perform the gradual deformity correction necessary. What CPT® code(s) is/are reported?

20697 Rationale: The exchange of an external strut guided by stereotactic computer-assisted adjustment is coded with 20697. There is a parenthetical note under code 20697 that it is not used in combination with 20692 or 20696. In the CPT ® Index look for External Fixation/Application/Stereotactic Computer Assisted directing you to 20696-20697.

CASE 2 PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture. POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.) NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.) FINDINGS PREOPERATIVELY: She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. She initially had very good results, but then developed back pain once again. The repeat MRI two weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalloping of the superior end plate, consistent with a compression fracture at L2.(The diagnosis is confirmed in the body of the report.) After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. At surgery, L2 had some scalloping of the superior end plate. Most of the softness was in the back part of the vertebral body. PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia(The type of anesthesia utilized is documented within the report. General anesthesia was used.) in a supine position. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. Using biplane image intensifiers, the skin incision sites were marked. 0.5% Marcaine with epinephrine was injected. Initially on the left side. A Kyphon trocar was passed down to the superior lateral edge of the pedicle, through the pedicle, and into the vertebral body in the usual fashion.(This describes the approach to the defect. It is percutaneous using trocars.) The drill was placed into the vertebral body followed by the Kyphon bone tamp. In a similar fashion, the same thing was done on the other side. Balloons were inflated uneventfully. The balloons were then deflated and removed, and the cement (when it was in the doughy state) was injected into the two sides in the usual fashion.(This describes how the area is enlarged and the cement is placed in a kyphoplasty procedure.) This was done carefully and sequentially to make sure there were no cement extrusions, which after inspection, there were none. There was a good fill to the vertebral body edges, up towards the superior end plate, and across the midline. The bone filling devices were removed, and the trocars were removed, Pressure was applied after which the skin was sutured with 4-0 nylon. Sand-Aids were applied and she was taken to recovery in stable condition. COMPLICATIONS: There were no complications. BLOOD LOSS: Minimal blood loss. COUNTS: Sponge and needle counts were correct. What are the CPT® and ICD-10-CM codes reported?

22514 M48.56XA

This 45 year-old male presents to the operating room with a painful mass of the right upper arm. Upon deep dissection a large mass in the soft tissue of the patient's shoulder was noted. The mass appeared to be benign in nature. With deep blunt dissection and electrocautery, the mass was removed and sent to pathology. What CPT® code is reported?

23075-RT Rationale: Look in the CPT® Index for Excision/Tumor/Shoulder and you are referred to 23071-23078. Code 23075 reports the excision of a soft tissue mass (tumor), subcutaneous. The mass was removed with deep, blunt dissection; however, there is no mention of the depth and you cannot assume that the mass was subfascial because of the word deep. The measurement of the mass is not documented resulting in the default to the smallest measurement of less than 3 cm for code 23075. It is a rule of thumb that if a coder cannot ask the physician to document the size of a mass, lesion or repair in order to give the physician credit, the smallest measurement is reported. Modifier RT is appended to indicate the procedure is performed on the right side.

This 45 year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried through the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL (inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What CPT® code is reported?

23076-RT Rationale: The 4 cm mass was removed from the soft tissue of the shoulder. To access the mass, the provider had to go through the proximal aspect of the teres minor muscle. The mass was located distal to the inferior glenohumeral ligament (IGHL). Masses that are removed from joint areas as opposed to masses removed close to the skin require special knowledge and become more of an orthopedic concern due to joint involvement. Therefore, it is reported from codes within the musculoskeletal section. Code 23076 is used because dissection was carried through the proximal aspect of the teres minor. In the CPT® Index, look for Excision/Tumor/Shoulder directing you to 23071-23078.

A 49 year-old female had two previous rotator cuff procedures and now has difficulty with shoulder function, deltoid muscle function and axillary nerve function. An arthrogram is scheduled. After preparation, the shoulder is anesthetized with 1% lidocaine, 8 cc without epinephrine. The needle was placed into the shoulder area posteriorly under image intensification. It appeared as if the dye was in the shoulder joint. A good return of flow was obtained. The shoulder was then mobilized and there was no evidence of any cuff tear from the posterior arthrogram. What CPT® codes are reported?

23350, 73040-26 Rationale: Contrast material is being injected into the shoulder joint for a radiographic look of the joint and internal structures (arthrogram). Look in the CPT® Index for Arthrography/Shoulder/Injection referring you to 23350. In the Musculoskeletal section, there is a parenthetical note under code 23350 that indicates to use code 73040 for radiographic arthrography. Modifier 26 is required to indicate the radiologic professional service.

CASE 1 Operative Report PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introduced into the joint.) INDICATIONS: The patient is a 66 year-old female who sustained a traumatic severe comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were discussed. She stated that she understood and desired to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where she was prepped and draped in the usual sterile fashion in beach chair position after administering general anesthesia. Standard deltopectoral approach was used.(The approach is documented within the body of the operative report.) The cephalic vein was taken laterally with the deltoid. Dissection was carried out down to the fracture site and the fracture was identified. The fragments were mobilized and the humeral head fragments were removed. Once this was done, the stem was prepared up to a size 10.(This further explains the comminuted fracture.) A trial reduction was carried out with the DePuy trial stem and implant head.(Placement of the prosthesis is described.) This gave good range of motion with good stability. Sutures down to and through the shaft were placed in key positions for closure of the tuberosities. The shaft was prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and then reduced. A bone graft was placed around the area where the tuberosities were being brought down.(Bone grafts are common in prosthetic placement. A matrix is provided where new bone can grow and further stabilize the prosthesis. These are not reported separately.) The tuberosities were tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with vicryl over a drain and staples in the epidermis. A sterile dressing and sling were applied. The patient was taken to recovery in stable condition. There were no immediate complications. What are the CPT® and ICD-10-CM codes reported?

23616-LT S42.202A

A 66 year-old sustained a left proximal humerus fracture. Standard deltopectoral approach was used and dissection was carried down to the fracture site. The fracture site was identified and fragments were mobilized and the humeral head fragments removed. Once this was done, the stem was prepared up to a size 10. A trial reduction was carried out with the DePuy trial stem and implant head. Sutures were placed in key positions for closure of the tuberosities down to the shaft including sutures through the shaft. The shaft was then prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and reduced. A bone graft was placed around the area where the tuberosities were being brought down. The tuberosities were then tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with Vicryl over a drain and also staples in the epidermis. A sterile dressing and sling was applied. The patient was taken to recovery in stable condition. No immediate complications. What CPT® code is reported?

23616-LT Rationale: In the CPT® Index, look for Fracture/Humerus/Open Treatment. You are referred to 23615-23616. Review the codes to choose appropriate service. 23616 is the correct code because the surgeon made an incision to expose the fracture site. The fracture repair included a prosthetic replacement (implant head) and the repair of the tuberosities. Modifier LT is appended to indicate that the procedure was performed on the left side.

CASE 4 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Dislocation of right elbow. POSTOPERATIVE DIAGNOSIS: Dislocation of right elbow with medial epicondyle fracture.(The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Closed reduction of elbow dislocation with a closed reduction of medial epicondyle fracture.(This is the working procedure until the report is read.) ANESTHESIA: General.(General anesthesia used.) INDICATIONS: This is a 12 year-old male who had an injury, sustaining a dislocation of his right elbow and medial epicondyle fracture.(The diagnosis is confirmed in the body of the report.) The risks and benefits of surgical treatment were discussed with the family, who stated they understood and wanted to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where general anesthesia was induced. Once he was under adequate anesthesia, the reduction maneuver was performed.(There is no indication the skin was cut, which reflects a closed method of reduction.) The elbow was reduced and was stable. Through full range of motion there was noted to be a slight crepitus on the medial elbow and some mobility was felt in the medial epicondyle. Examination under C-arm imagery(C-arm imagery indicates fluoroscopy was used.) revealed a concentric reduction of the elbow, but with mildly unstable medial epicondyle fracture. When the elbow was held in the appropriate position, the medial epicondyle was well reduced in an acceptable position.(Manipulation of the medial epicondyle supports closed reduction of the fracture.) It was elected to treat this non-surgically. A long arm splint was applied.(This is showing the fracture was reduced and set.) The patient was awakened from anesthesia and taken to recovery in stable condition with no immediate complications. What are the CPT® and ICD-10-CM codes reported?

24565-RT, 24605-51-RT S42.441A, S53.104A

The patient is a 17 year-old male who was struck on the elbow by another player's stick while playing hockey. He is found to have a fracture of the olecranon process. The patient was brought to the OR, anesthetized and intubated. The right upper extremity was prepped with Betadine scrub and draped free in the usual sterile orthopedic manner. The arm was then elevated and exsanguinated and the tourniquet inflated to 250 mm/Hg. A five-inch incision was made with the scalpel on the extensor side of the elbow, beginning distally and proceeding in an oblique fashion up the proximal forearm. Dissection was carried through subcutaneous tissue and fascia, and bleeding was controlled with electrocautery. We then subperiosteally exposed the proximal ulna and olecranon to visualize the fracture site. The fracture could be seen at the base of the olecranon process. We irrigated the site thoroughly and reduced the fracture fragments without difficulty. Extending the elbow, we inserted two smooth K-wires across the fracture site. Through a drill hole in the proximal ulnar shaft, we threaded an 18-gauge wire through it and wrapped it around the K-wires in a figure-of-eight manner to further stabilize the fixation. Wires were then twisted and placed into soft tissues. The K-wires in the olecranon were advanced slightly after being bent and cut. Sterile dressing was applied and the patient was placed in a splint. What CPT® code is reported?

24685-RT Rationale: This is a fracture of the olecranon process which is located at the upper end of the ulna. An incision was made to expose the fracture site, making it an open treatment. Look in the CPT® Index for Fracture/Ulna/Olecranon/Open Treatment 24685. Modifier RT is appended to indicate the procedure was performed on the right side.

A 49 year-old female presented with chronic deQuervain's disease and has been unresponsive to physical therapy, bracing or cortisone injection. She has opted for more definitive treatment. After induction of anesthesia, the patient's left arm was prepared and draped in the normal sterile fashion. Local anesthetic was injected using a combination 2% lidocaine and 0.25% Marcaine. A transverse incision was made over the central area of the first dorsal compartment. The subcutaneous tissues were gently spread to protect the neural and venous structures. The retractors were placed. The fascial sheath of the first dorsal compartment was then incised and opened carefully. The underlying thumb abductor and extensor tendons were identified. The tissues were dissected and the extensor retinaculum of the first extensor compartment was incised. The fibrotic tissue was incised and the tendons gently released. The tendons were freely moving. Subcutaneous tissues were closed with a 3-0 Vicryl and the skin with 3-0 Prolene subcuticular closure. Steri-strips, Xeroform and dry sterile dressings were applied. What CPT® code is reported?

25000-LT Rationale: The report states that the extensor retinaculum of the first extensor compartment was incised. Look in the CPT® Index for Incision/Wrist/Tendon Sheath 25000-25001. Code 25000 shows deQuervain's disease in the description. Code 25001 refers to the flexor tendon sheath and this involved the extensor tendon making 25000 correct. Note this was an incision, not excision of the tendon of the extensor tendon sheath. Modifier LT is appended to indicate the procedure is performed on the left side.

A 72 year-old female sustained a left radius fracture, resulting in volar angulation, radial shortening and loss of radioulnar inclination. A general anesthetic was administered. A standard dorsal central approach to the wrist was made. The capsule was opened in a T fashion and the malunion site was identified. A series of osteotomes was utilized to open the fracture site and the normal distal radial architecture was restored. The pie-plate was placed on the distal radius utilizing a combination of 2.0 and 1.8 screws and threaded pins for the distal segment and 2.7 screws proximally. Fragments were secured, and Norian SRS was packed into the defect and allowed to harden. With this completed, the wounds were copiously irrigated with normal saline. Soft tissue was closed over the plate and distal radius, and secured with 2-0 Vicryl. What CPT® code is reported?

25400-LT Rationale: This is not the repair of a fracture; it is repair of a malunion. In the CPT® Index look for Repair/Radius/Malunion or Nonunion, 25400, 25405, 25415, 25420. Code 25400 reports repair of a malunion of the radius. There is no mention of an autograft; therefore, 25405 is incorrect. Norian SRS is a biocompatible bone gap filler, not a graft. Modifier LT is appended to indicate the procedure is performed on the left side.

CASE 5 PREOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left shoulder impingement/subacromial bursitis. POSTOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left shoulder impingement/subacromial bursitis.(The postoperative diagnosis is used for coding.) PROCEDURES: Right long finger trigger release. Injection of the left shoulder with Xylocaine, Marcaine and Celestone via anterior subacromial approach. ANESTHESIA: General.(General anesthesia used.) COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Minimal. REPLACEMENT: Crystalloids. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where he was given general anesthesia. The right upper extremity was prepped and draped in the usual sterile fashion. While draping, the left shoulder was prepped with Betadine; and through an anterior subacromial approach, the left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine.(Documentation confirms the left shoulder injection.) The patient tolerated the procedure well. Meanwhile, the right hand had been prepped and draped. It was exsanguinated with an Esmarch bandage, and the tourniquet inflated to 250 mm. I made an incision over the A1 pulley(The A1 pulley is a flexor tendon pulley.) in the distal transverse palmar crease, about an inch in length. This was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. Care was taken to avoid injury to the neurovascular bundle.(The release of the nerve is described, which is a trigger finger release.) The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. A clean dressing was applied. The patient was awakened and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?

26055-F7; 20610-51-LT M65.331; M75.52

An 85 year-old has developed a lump in her right groin. An incision over the lesion was made and tissue was dissected through the skin and subcutaneous tissue going deep through the femoral fascia. Sharp dissection of the mass was performed, freeing it from surrounding structures. The 3 cm mass was isolated and excised. The incision was closed, the area was cleaned and dried, and a dressing applied. What CPT® code is reported?

27048 Rationale: In the CPT® Index look for Excision/Tumor/Pelvis. You are referred to 27043, 27045, 27047, 27048, 27049 and 27059. Review the codes to choose the appropriate service. 27048 is the correct code to report the removal of the 3 cm mass below the fascia.

A 16 year-old female was hit by a car while crossing a two-lane highway. She was taken to the hospital by ambulance. She was found to have an open wound of the left lower thigh, just above the knee and a displaced fracture of the left femoral neck. She was taken to the operating room within four hours of her injury. She was given general endotracheal anesthesia and was prepped and draped in sterile fashion. Debridement including excision of devitalized skin and muscle was performed on the lateral thigh. The area was approximately 15 sq cm. After debridement and thorough copious irrigation, the wound was closed with layer sutures and a dressing was applied and then covered with adhesive plastic. The patient was then prepped and draped for the fracture and turned on her right side. We all rescrubbed. An 8 inch incision was made over the left hip and the head of the femur was exposed. Multiple fragments from the neck and the greater tuberosity were removed. The decision was made to replace the femoral head. The femur was removed from the acetabulum and the femoral head was removed. The femoral canal was reamed and a prosthesis was placed. It was then replaced in the acetabulum with a good fit, and the capsule was closed. The wound was closed. The patient was sent to recovery in good condition.

27236-LT, 11043-59-LT Rationale: The main procedure is repair of a right femoral neck fracture. Look in the CPT® Index for Fracture/Femur/Neck/Open referring you to 27236. Modifier LT is appended to show the left side. Next look in the CPT® Index for Debridement/Skin/Subcutaneous Tissue referring you to 11042-11047. The correct code is 11043 for debridement of subcutaneous tissue including muscle for less than 20 sq cm. Do not report 11010-11012, because this was not debridement of an open fracture site. Codes 27236 and 27244 are only reported for hip arthroplasty, not for femoral neck fractures. Modifier 59 is appended to 11043 to show that this is a different site and not included in 27236.

A 50 year-old male had surgery on his upper leg one day ago to remove an intramuscular tumor and presents with serous drainage from the wound. He was taken back to the operating room for evaluation of a hematoma. His wound was explored down to the rectus femoris muscle, and there was a hematoma which was very carefully evacuated. The wound was irrigated with antibacterial solution, and the wound was closed in multiple layers. What CPT® and ICD-10-CM codes are reported?

27301-78, M96.840 Rationale: In the CPT® Index look for Hematoma/Leg, Upper. You are referred to 27301. Verify the code for accuracy. Modifier 78 is appended to 27301 to indicate that an unplanned procedure related to the initial procedure was performed during the postoperative period. Use modifier 78 for a return to the OR for a complication in the global period of another procedure. In the ICD-10-CM Alphabetic Index look for Complication/surgical procedure (on)/hematoma/post procedural - see Complication, postprocedural, hematoma. Look for Complication/post procedural/hematoma (of)/musculoskeletal structure/following musculoskeletal surgery M96.840. His wound was explored down to the level of the rectus femoris muscle; the excision of the mass was intramuscular. The code selection is specific to the location of the hematoma as well as the body system for which the procedure was performed. Review the code in the Tabular List for accuracy.

A 68 year-old female with long-standing degenerative arthritis in her right knee presented. Risks and benefits were discussed. She was agreeable to surgery. After adequate anesthesia, the patient was prepped and draped in usual sterile fashion with DuraPrep1 and Betadine scrub. The leg was exsanguinated and tourniquet inflated. An anterior incision was made and carried through the skin and bursa, cauterizing all bleeders. The bursa was elevated medially and a medial parapatellar incision was made. The proximal tibia was cleaned. The knee had an 18-degree flexion contracture. The cruciate ligaments were debrided along with the menisci. The proximal tibial cutting guide was placed and the proximal tibial cut made. The femoral canal was entered and a 6 degree cut was made for the anterior jig. The distal cut was made at 6 degrees. The femur measured a size 2. The 2 cutting block was placed and the anterior, posterior and chamfer cuts were made. The notch cut was made and the trial component was placed with a size 2 tibia and 12 mm spacer and was found to fit beautifully and it tracked well. The patella was cut and measured to be a 32. The holes were drilled and the proximal tibial cuts were made. All the excess meniscal tissue and hypertrophic synovium were debrided. The wound was thoroughly irrigated and the bone dried. The cement was mixed; the size 2 tibia with a 12 mm tibial tray, size 2 femur and a size 32 patella were all cemented in place removing all excess cement. After the cement was hard, the tourniquet was released. The knee was placed through a range of motion and was found to track beautifully. The knee was thoroughly irrigated. The retinaculum was closed with interrupted figure-of-eight 1 Vicryl. The bursa was closed with 1 and 0. The subcutaneous layers were closed with 0 and 2-0 and the skin with staples. Sterile dressing was applied. The patient was taken to the recovery room in stable condition. What CPT® code is reported?

27447-RT Rationale: The procedure performed was an arthroplasty of the knee found in the CPT® Index by looking for Arthroplasty/Knee referring you to 27437-27447. This was a total knee arthroplasty with patella resurfacing reported with 27447. Modifier RT is appended to indicate the procedure is performed on the right side.

The patient fell and fractured his left femoral shaft in three places. The fracture is treated with an ORIF of the left femur with an intramedullary nail and interlocking screws (peritrochanterically). The orthopedist also places the leg in a plaster splint prior to leaving the OR. What CPT® code(s) is/are reported?

27506 Rationale: Documentation shows the patient had a fracture of his left femoral shaft. The fracture was repaired with open reduction and internal fixation (ORIF) using an intramedullary nail and interlocking screws. Selection of codes depends on the fracture site and the method of treatment (closed, open, or percutaneous). The range of codes can be found in the CPT® Index by looking for Fracture/Femur/Peritrochanteric/Intramedullary Implant Shaft. Check the numeric section to select the correct code. Code 27245 is not correct, because this was not a peritrochanteric fracture; it is a femoral shaft fracture. The approach is from the peritrochanteric region. The application of the first cast or splint is included in 27506. See the guidelines for Application of Casts and Strapping in the CPT® codebook.

Joe was in a motorcycle accident, and fractured his right femur. The surgeon placed an intramedullary locking implant (nail) through a buttock incision. What procedure code is reported?

27506-RT RATIONALE: The surgery is an open treatment of a closed femoral shaft fracture with internal fixation (intramedullary implant), and is reported 27506-RT. Look in the CPT® Index for Fracture/Femur/Peritrochanteric/Intramedullary Implant Shaft. Report modifier RT to indicate right femur.

CASE 9 PREOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. POSTOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. OPERATION PERFORMED: Open Left Achilles' tendon repair. ANESTHESIA: General anesthesia INDICATIONS: The patient is a 25 year-old male who was playing basketball when he was hit by another player and felt a pop in the back of his ankle approximately two months ago. Examination reveals a positive Thompson test, but no plantar flexion on squeezing the calf. There is a palpable defect in the Achilles' tendon. There is swelling in this region and neurovascular examination is intact. Given these clinical findings, the patient is taken to the operating room for the aforementioned procedure. DESCRIPTION OF PROCEDURE: Following induction of general anesthesia the patient was placed prone on the operating table and all bony prominences were well-padded. The patient received a 1g dose of Ancef. Under tourniquet control of 250 mmHg, a longitudinal incision was made followed by opening up the paratenon of the Achilles' tendon. An obvious rupture was noted. The hematoma was evacuated and the ends were then debrided with a Metzenbaum scissors. A No. 2 FiberWire® was placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles' tendon. A No. 2 Orthocord was then used and placed in a running fashion along the proximal and distal portions of the Achilles' tendon. A total of four sutures were used. These were then tied together to re-approximate the tendon with no significant tension on the repair. A secure repair was noted. The ends of the repair were further augmented with a 2-0 Vicryl suture. The wound was thoroughly irrigated with antibiotic irrigation solution. The fascial plane was closed with a 2-0 Vicryl suture, followed by closing the skin with a 2-0 in subcuticular fashion. Approximately 10 cc of 0.5% Marcaine was injected for postoperative pain control. A routine dressing was applied to the extremity, and it was placed into a short leg cast with the foot slightly plantar-flexed. The anterior aspect of the cast was then univalved. The tourniquet was deflated for a total tourniquet time of 42 minutes. The patient was awakened in the operating room breathing spontaneously and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?

27650-LT S86.012A, W50.0XXA, Y93.67, Y99.8

CASE 10 PREOPERATIVE DIAGNOSIS: Right ankle triplane fracture POSTOPERATIVE DIAGNOSIS: Right ankle triplane fracture PROCEDURE: Open reduction and internal fixation (ORIF), right ankle triplane fracture ANESTHESIA: General endotracheal COMPLICATIONS: None SPECIMEN: None IMPLANT USED: Synthes 4.0 mm cannulated screws INDICATIONS FOR PROCEDURE: The patient is a pleasant 15 year-old male who fell and sustained a right ankle triplane fracture. This was confirmed on both X-ray and CT scan. The indications for ORIF were explained to the patient, as well as the possible risks and complications, which include infection, bleeding, stiffness, hardware pain, the need for hardware removal, and there is no guarantee of a functional ambulatory result. The patient and family understood and wished to proceed. PROCEDURE IN DETAIL: The patient was brought back to the operating room and placed on an operating table, given a general anesthetic without any complications, and given preoperative antibiotics per usual routine. He had the right lower extremity prepped and draped in the usual sterile fashion with alcohol prep followed by routine Betadine prep. Under X-ray guidance, a pointed reduction clamp was placed from the anterolateral corner of the distal tibia to the medial side, and I reduced the triplane fracture. It was confirmed on both AP and lateral X-ray images the gap was reduced. The patient then had guidewires taken from the Synthes 4.0 mm cannulated screw set. One was placed medially along the epiphysis on the anterior half of the epiphysis and parallel to the joint to catch the lateral aspect of the epiphysis. One screw was placed above the physis from anterior to posterior to capture that spike. Once the wires were in the appropriate position, the length was measured and partially threaded 4.0 mm cancellous screws were selected so all threads were across the fracture site. The appropriate length screws were placed, confirmed by an X-ray to be in good position. The fracture was anatomically reduced, and the ankle joint was anatomic. The patient had wounds copiously irrigated. Closure was done with interrupted horizontal mattress 3-0 nylon suture. The patient had a sterile compressive dressing applied, was placed into a three-sided posterior mold splint, was extubated, and brought to the recovery room in stable condition. There were no complications. There were no specimens. Sponge and needle counts were equal at the end of the case. What are the CPT® and ICD-10-CM codes reported?

27827-RT S82.391A, W19.XXXA

CASE 8 OPERATIVE REPORT Preoperative Diagnosis: Plantar fasciitis, left Postoperative Diagnosis: Same as preoperative diagnosis. Procedures: Plantar fasciotomy, left heel. For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating the patient understands the procedure and its possible complications. This 61 year-old male was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion. Attention was directed to the left heel where, utilizing a 61 blade, a stab incision was made, taking care to identify and retract all vital structures. The incision was deepened to the medial band insertion of the fascia. The fascia was then incised and avulsed from the calcaneus. The surgical site was flushed with saline. Next, 1 cc of Depo-Medrol was injected in the operative site. The site was dressed with a light compressive dressing. Excellent capillary refill to all of the digits was observed without excessive bleeding noted. Hemostasis: none Estimated Blood Loss: minimal Injectables: Agent used for local anesthesia was 5.0 cc Marcaine 0.5% with epinephrine. Pathology: No specimen sent. Dressings: Applied Bacitracin ointment. Site was dressed with a light compressive dressing. Condition: Patient tolerated the procedure and anesthesia well. Vital signs were stable. Vascular status was intact to all digits. Patient recovered in the operating room. What are the CPT® and ICD-10-CM codes reported?

28008-LT M72.2

An elderly female presented with increasing pain in her left dorsal foot. The patient was brought to the operating room and placed under general anesthesia. A curvilinear incision was centered over the lesion itself. Soft tissue dissection was carried through to the ganglion. The ganglion was clearly identified as a gelatinous material. It was excised directly off the bone and sent to pathology. There was noted to be a large bony spur at the level of the head of the 1st metatarsal. Using a double action rongeur, the spur itself was removed and sequestrectomy was performed. A rasp was utilized to smooth the bone surface. The eburnated bony surface was then covered utilizing bone wax. The wound was irrigated and closed in layers. What CPT® codes are reported?

28122-LT, 28090-51-LT Rationale: Look in the CPT® Index for Excision/Metatarsal/Head, and you are referred to 28110-28114, 28122, 28140, 28288. Code 28122 reports a partial excision or sequestrectomy of metatarsal bone. Next in the CPT® Index look for Lesion/Foot/Excision referring you to 28080, 28090. Code 28090 reports the excision of the ganglion of the foot. Modifier 51 is appended to indicate multiple procedures performed during the same session. Modifier LT is appended to indicate the procedure is performed on the left side.

Julia tripped and fell down three stairs in her apartment. X-rays show a fracture of the metatarsal bone of her left great toe, and the physician treats the fracture with a special orthotic boot. What procedure code is reported?

28470-TA RATIONALE: This is a closed treatment because no surgery was performed. The orthotic boot would be coded separately by the DME supplier. Look in the CPT® Index for Fracture/Metatarsal/Closed Treatment. Modifier TA is appended to indicate the left foot, great toe.

Jeff is a 13-year-old boy who fractured his left radius and ulna while snowboarding. Three weeks after the physician placed a long arm cast on Jeff, he was skateboarding and crushed the cast (without further injury to the arm). The physician replaces the cast with a short-arm fiberglass cast. What procedure code is reported for the services provided after the skateboard accident?

29075-58 RATIONALE: The first cast or splint is included as part of the initial fracture treatment; because this was a replacement cast, it can be coded. Look in the CPT® Index for Cast/Elbow to Finger. Append modifier 58 to indicate this was a related procedure by the same physician during the postoperative period.

A 27 year-old triathlete is thrown from his bike on a steep downhill ride. He suffered a severely fractured vertebra at C5. An anterior approach is used to dissect out the bony fragments and strengthen the spine with titanium cages and arthrodesis. The surgeon places the patient supine on the OR table and proceeds with an anterior corpectomy at C5 with discectomy above and below. Titanium cages are placed in the resulting defect and morselized allograft bone is placed in and around the cages. Anterior Synthes plates are placed across C2-C3, C4-C5, and C5-C6. What CPT® codes should be reported?

63081, 22554-51, 22846, 22854, 20930 Rationale: Anterior approach is used to perform several procedures on the cervical spine. The corpectomy has the highest RVUs and is listed first. Code 63081 is the removal of one single cervical segment by anterior approach. In the CPT® Index look for Vertebral/Body/Excision/Decompression directing you to 63081-63103. Arthrodesis, anterior interbody technique is coded with 22554. In the CPT® Index, look for Arthrodesis/Cervical/below C2 referring you to several codes including 22551-22554. Plates are used for anterior instrumentation and placed over a total of five segments (C2, C3, C4, C5, and C6), 22846. In the CPT® Index, look for Instrumentation/Spinal/Insertion referring you to 22840-22848. Report only one unit of 22846, regardless of how many devices placed at one level. Modifier 51 is appended to 22554 to indicate multiple procedures. The application of the titanium cages is described by add-on code 22854. In the CPT® Index look for Application/Intervertebral Device. The morselized allograft is described by 20930. In the CPT® Index look for Allograft/Bone/Spine Surgery/Morselized.

A young female patient was taken to the operative suite and was placed under appropriate anesthesia. She has been suffering from pain and a potential rotator cuff tear of the right shoulder. The right arm was sterilely draped and prepped. Arthroscopic portals were created anteriorly-posteriorly. The joint line was carefully examined. The biceps insertion was noted to be normal. The middle and inferior glenohumeral ligaments were visualized and noted to be normal. The undersurface of the rotator cuff was clearly visualized and also noted to be normal. There was a large anterior spur formation. The burr was introduced through a lateral portal and the anterior lip of the acromion was resected. The undersurface of the clavicle was noted to be quite prominent and part of the impinging process. There was intense bursitis and a bursectomy was performed, allowing for acromial decompression and release. Spurs were removed from the distal clavicle. All instruments were removed, skin incisions were closed and a dressing was applied. The patient was placed in a sling and returned to the recovery room. What CPT® code(s) is/are reported?

29822-RT, 29826-RT Rationale: In the CPT® Index, look for Arthroscopy/Surgical/Shoulder. You are referred to 29806-29828. The procedure performed was a decompression of the subacromial space with partial acromioplasty, 29826. The report states that the anterior lip of the acromion was resected and a bursectomy was performed. Also mentioned is the removal of spurs from the distal clavicle. The report does not state that a distal claviculectomy was performed; therefore, 29824 is not reported. The debridement of the distal clavicle is performed and reported with 29822. Modifier RT is appended to indicate the procedure is performed on the right side. Code 29826 is an add-on code and modifier 51 exempt.

The patient has a torn medial meniscus. An arthroscope was placed through the anterolateral portal for the diagnostic procedure. The patellofemoral joint showed grade 2 chondromalacia on the patellar side of the joint only, this was debrided with a 4.0-mm shaver. The medial compartment was also entered and a complex posterior horn tear of the medial meniscus was noted. It was probed to define its borders. A meniscectomy was carried out to a stable rim. What CPT® code(s) is/are reported?

29881 Rationale: In the CPT® Index look for Arthroscopy/Surgical/Knee. You are referred to 29866-29868, 29871-29889. Review the codes to choose appropriate service. 29881 is the correct code because the tear was in the medial meniscus. A meniscectomy as well as debridement with a shaver (or chondroplasty) were performed. 29877 is not reported as this is included in 29881. 29880 is not appropriate because a meniscectomy was not performed in both the medial and lateral compartments. The surgery started out as a diagnostic procedure, but changed when the physician decided to perform surgical procedures on the knee.

The physician performs arthroscopic meniscus repair with partial medial and lateral repairs. What procedure code is reported?

29883 RATIONALE: Code 29883 is for an arthroscopy, knee, surgical; with meniscus repair (medial AND lateral). Look in the CPT® Index for Arthroscopy/Surgical/Knee, which gives a range of codes for procedures on the knee that can be done with an arthroscope.

Which statement is TRUE regarding code selection for lumbago in ICD-10-CM?

Codes exist to indicate whether sciatica is present with the low back pain. Rationale: In ICD-10-CM, there are codes to indicate when sciatica is present with the low back pain, or low back pain is due to intervertebral disc disorder or displacement of intervertebral disc.

In ICD-10-CM, what classification system is used to report open fracture classifications?

Gustilo classification for open fractures Rationale: Open fracture designations are based on the Gustilo open fracture classification. 7th characters are added to indicate the type of encounter. This classification is grouped into three major category types to indicate the mechanism of the injury, soft tissue damage and the degree of skeletal involvement. One of the main categories, Type III, is further subdivided into IIIA, IIIB, and IIIC to report levels of extensive damage.

What ICD-10-CM code is used to report effusion of the right ankle joint?

M25.471 Rationale: Look in the ICD-10-CM Alphabetic Index for Effusion/joint/ankle and you are referred to M25.47-. In the Tabular List, code M25.47- requires the application of a 6th character to specify the location (foot or ankle) and laterality. Report M25.471 for effusion of the right ankle.

How would you code a new pathological fracture of the right femur due to postmenopausal osteoporosis?

M80.051A RATIONALE: Code M80.051A describes a pathological fracture of the right femur; In the ICD-10-CM Alphabetic Index look up Fracture/ pathological/due to/osteoporosis/postmenopausal — see Osteoporosis/postmenopausal/with pathologic fracture. You're directed to M80.00. In the Alphabetic Index there is no listing for femur. Review the subcategories for M80.0 in the Tabular List. Subcategory M80.05 is used to Identify current pathological fracture of femur. 6th character 1 is used for right femur and 7th character A is used for the initial encounter.

A patient presents to the ED with back pain and is diagnosed with a lumbar sprain. What ICD-10-CM code is reported?

S33.5XXA Rationale: In the ICD-10-CM Alphabetic Index, look for Sprain/lumbar (spine) and you are directed to S33.5-. In the Tabular List this code requires a 7th character to describe the episode of care. Because the patient is presenting to the ED, this supports the definition of initial encounter. For the 5th and 6th characters use the X placeholder to maintain the 7th character position of A. Back pain is not reported because a definitive diagnosis was documented, and pain is a symptom of lumbar sprain. (See ICD-10-CM guideline I.B.6.).

What is the correct ICD-10-CM code for a new patient seen for a left-sided Nursemaid's elbow?

S53.032A RATIONALE: Look up Nursemaid's elbow, S53.03-. Verification in Tabular List verifies code choice S53.032A, for left elbow, initial encounter.

What is the code for a traumatic fracture of the fifth metacarpal shaft on the right hand with delayed healing?

S62.326G RATIONALE: In ICD-10-CM Alphabetic Index look for Fracture/traumatic/metacarpal/fifth/shaft (displaced) directing you to S62.32-. In the Tabular List subcategory S62.32 requires a 6th character for laterality and a 7th character for type of encounter. S62.326G is the correct code. ICD-10-CM Guidelines I.19.c states "A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced".

What information is required to accurately code osteoarthritis in ICD-10-CM?

Whether the osteoarthritis is primary, secondary, post-traumatic, the site and laterality. Rationale: To accurately code osteoarthritis in ICD-10-CM, the documentation needs to include whether the arthritis is primary, secondary, post-traumatic, the site and laterality (right/left).