MS Procedural CodingMS Procedural Coding
MHAMHA
June 11, 2009June 11, 2009
Irene Mueller, EdD, RHIAIrene Mueller, EdD, RHIA
Objectives Objectives
• 2nd hour – Coding Common MS Tx– ICD-9-CM – CPT coding
• Resources
MS Procedure CodingMS Procedure Coding
• Procedures– ICD-9-CM– CPT
Bone BxBone Bx• ICD-9-CM
– 77.40-49 Bone Bx OR 41.31 Aspiration bone marrow• CPT
– Bone biopsy - 20220– Bone marrow aspiration performed alone
• 38220– Bone marrow biopsy is performed
• 38221 (bone marrow biopsy)• cannot report with CPT code 20220 (bone biopsy)
– 38220 and 38221 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 38220 performed at same site through same incision• Only CPT 38221 is reported
MyelographyMyelography
• ICD-9-CM– 87.21
• CPT– Myelography
• Brain 70010 • Spine
– Cervical 72240 – Lumbosacral 72265– Thoracic 72255 – Total 72270
ArthrocentesisArthrocentesis• ICD
– 81.91 Arthrocentesis • includes: Joint aspiration • excludes:
– for arthrography (88.32)– bx of joint structure (80.30-80.39) – for injection of drug (81.92)
• CPT– Arthrocentesis
• Intermediate Joint 20605 • Large Joint 20610 • Small Joint 20600
Fracture ReductionFracture 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
CPT Fracture MgtCPT 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
Internal FixationInternal Fixation
• ICD-9-CM – 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 21470-LT
External FixationExternal Fixation
• ICD-9-CM– Reduction w/ External
fixator device • add’l code 78.10-78.19• 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
CPT External fixation 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, 20692-51
• Ex: Closed tx of tibial fx w/manipulation, application of cast, partial skin debridement of fx site– 27752, 11040
Open Fx DebridementOpen Fx Debridement
• ICD-9-CM– 79.6X Debridement of open fracture– Used instead of 86.22, Excisional
debridement of wound, infection, or burn
• CPT– 11010, 11011 and 11012
• Differ by extent of debridement• Must meet open fx definition
Amputation ProceduresAmputation 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
DislocationsDislocations
• ICD-9-CM– Associated
w/reduction of 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
Casts and StrappingCasts and Strapping
• ICD-9-CM and CPT– 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.
Sprain/Strain SurgerySprain/Strain Surgery
• 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
• CPT– Codes often include graft
harvesting • Ligament, Repair
– Knee Joint 27405 - 27409 • Knee, Reconstruction
– Ligament 27427 - 27429 • Knee, Repair
– Ligament 27405 - 27409 – Collateral 27405 – Collateral and Cruciate 27409 – Cruciate 27407 – 27409
– Arthroscopic 29888 - 29889 (not in Index here)
Bunion SurgeryBunion 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
CPT Bunionectomy CodesCPT Bunionectomy Codes
• Hallux valgus repair codes– 28290-28299– 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
Bunion Surgery ExamplesBunion 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, 28306 -59, 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)
Bursitis ProceduresBursitis Procedures
• ICD-9-CM– 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.
ArthroscopyArthroscopy
• ICD– Converted to open, code only open w/ V64.43– 80.20-80.29
• CPT – Dx – visualization and synovial Bx ONLY
• 29870 (separate procedure)
– Surgical – anything else done• Includes dx • # of compartments important for some codes
Decompression of Medial Nerve Decompression of Medial Nerve (CTS)(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
Arthroplasty (Joint Replacement)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
Arthroplasty (Joint Replacement)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
– 27137 acetabular component only, with or without autograft or allograft
– 27138 femoral component only, with or without allograft
Prosthesis replacementProsthesis 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
Joint Replacement RevisionJoint Replacement Revision• Adjust or remove and replace• ICD-9-CM coding
– Includes removal of component(s)
• 81.53 hip component NOS• 00.70-00.73 (hip components) add’l code• 81.54 knee component NOS• 00.80- 00.84 (knee components) add’l code• 84.57 removal of joint spacer (cement) add’l code• 81.59, 81.97 joint revision NEC (upper/lower extremities)• 00.74 – 00.76 add’l code (if known)• V43.6 Joint replacement status, if significant for pt care
Joint Replacement RevisionJoint Replacement Revision
• CPT Coding– 27134 Revision of total hip arthroplasty; both
components, with or without autograft or allograft
– 27137 acetabular component only, with or without autograft or allograft
– 27138 femoral component only, with or without allograft
• Many other joint arthroplasties in CPT
Bone Ca SurgeryBone 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.
CPT Spine ProceduresCPT 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
CPT Spine OsteotomyCPT Spine Osteotomy
• Anterior/Posterior approach
• Osteotomy code includes– Corpectomy, discectomy, laminectomy
Spinal FusionSpinal Fusion• 3 basic approaches
– Anterior, posterior, lateral transverse
• ICD-9-CM coding– Anterior (81.02-81.36)
• 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+
360360° Spinal Fusion° 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• 81.08, 81.38
Refusion of SpineRefusion 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, 81.39 = Refusion– Various sites, various approaches
Kyphoplasty for Kyphoplasty for Compression fxsCompression fxs
• Kyphoplasty – reestablish vertebral height– Uses inflatable balloon to gain height– Injection of Polymethylmethacrylate to stabilize– ICD-9-CM - 81.66– 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)
Vertebroplasty for Vertebroplasty for Compression fxsCompression 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
Spinal Disc ProsthesesSpinal Disc Prostheses
• ICD-9-CM Coding– Type of prosthesis – total/partial– Spinal segment
• Cervical – 84.61, 84.62• Thoracic – 84.63 (total/partial – same code)• Lumbarsacral – 84.64, 84.65• No location – 84.60
– Revision/replacement – 84.66-84.69• Synchronous insertion of new prosthesis
CPT Spine procedure ExamplesCPT Spine procedure Examples
• Arthodesis of T1-T3; autograft from ribs Dual rods inserted w/multiple hooks/wires– 22610, 22614, 22614 – 3 fusions– 22842 - rods– 20936 – autograft
• Surgical repair of L1-2 and L3-L4 by 2 surgeons (distinct parts of procedure)– 22612-62 (reported by each surgeon)– 22614-62 (reported by each surgeon)
Answers to Dx Coding ExercisesAnswers to Dx Coding Exercises
• Primary osteoarthritis of hip– 715.95 (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? 996.40
Answers to Dx Coding ExercisesAnswers 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
HomeworkHomework
• View ORlive http://www.or-live.com/– Previous webcasts– Browse by specialty– Orthopaedics– April 7, 2009
Spotlight on Beth Israel Orthopedics, New York City Need Adobe Flash Player
– Code the 4 operations– Dx? Procedures – ICD and CPT
Resources (Books)Resources (Books)
• Brown, F. ICD-9-CM Coding Handbook with Answers, 2006. AHA Press.
• Frazier, M. S. & Drzymkowski, J. W. Essentials of Human Diseases and Conditions, 4th ed., Saunders, 2009
• Green, M. A. 3-2-1 Code It! 2nd ed. 2010. 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
Resources (Videos)Resources (Videos)
• ORlive http://www.or-live.com/
• Laminectomy Back Surgery Video. Spine-Health.
– http://www.spine-health.com/video/laminectomy-back-surgery-video
• Microdiscectomy: Lumbar Microdecompression Spine Surgery Video. Spine-Health. – http://www.spine-health.com/video/microdiscectomy-lumbar-micr
odecompression-spine-surgery-video
Resources (Videos)Resources (Videos)
• Minimally Invasive Discectomy. ORLive. – http://www.or-live.com/distributors/NLM/rnh.cfm?id=310
• Pediatric Spinal fusion to correct scoliosis. ORLive. (via NLM link)– www.or-live.com/distributors/NLM/rnh.cfm?id=321
• Spine Fusion Surgery Video. Spine-Health. – http://www.spine-health.com/video/spine-fusion-surgery-video
Resources (Websites)Resources (Websites)
• Acute vs. Chronic Pain. Cleveland Clinic. – http://my.clevelandclinic.org/services/Pain_Management/
hic_Acute_vs_Chronic_Pain.aspx
• A Guided Tour of the Visible Human – http://www.madsci.org/~lynn/VH/tour.html
• Bone scan. Mayo Clinic.– http://www.mayoclinic.com/health/bone-scan/MY00306
• Bunionectomy. Clinical Policy Bulletin: Aetna. – http://www.aetna.com/cpb/medical/data/600_699/0629.html
• Bursitis and Tendinitis; Questions and Answers. National Institute of Arthritis and MS and Skin Diseases. April 2007.– http://www.niams.nih.gov/Health_Info/Bursitis/default.asp
Resources (Websites)Resources (Websites)
• Drugs of Abuse, Chapter 1 The Controlled Substance Act. Drug Enforcement Administration, US DoJ. – http://www.usdoj.gov/dea/pubs/abuse/1-csa.htm
• Feinberg, S. D. MD. Medications and Chronic Pain, 2007 Supplement. American Chronic Pain Association.
– http://www.theacpa.org/documents/ACPA%20Meds%202007%20Final.pdf
• Hallux Valgus (Bunion Deformity). Institute for Foot and
Ankle Reconstruction. Mercy Hospital, Baltimore, MD. – http://footandankle.mdmercy.com/conditions/bigtoe/hallux_valgus.html
Resources (Websites)Resources (Websites)
• Myelography. American Society of Radiologic Technologists.– https://www.asrt.org/content/ThePublic/AboutRadiologicProcedures/Myelography.aspx
• Osteosarcoma Overview. American Cancer Society. – http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?rnav=criov&dt=52
• Planes of Section. A Guided Tour of the Visible Human – http://www.madsci.org/~lynn/VH/planes.html
• Rheumatoid Arthritis: Treatment options. Arthritis Foundation. – http://www.arthritis.org/disease-center.php?disease_id=31&df=treatments
• Staging: Questions and Answers– http://www.cancer.gov/cancertopics/factsheet/Detection/staging
• WebMD. – http://www.webmd.com/default.htm
Resources (X-plain modules)Resources (X-plain modules)
• Carpal Tunnel Release – Open. X-plain module. Patient Education Institute, Nat’l Library of Medicine– http://www.nlm.nih.gov/medlineplus/tutorials/
carpaltunnelsyndromeopensurgery/htm/index.htm• Myelogram. X-plain module. Patient Education Institute,
Nat’l Library of Medicine– http://www.nlm.nih.gov/medlineplus/tutorials/myelogram/htm/ind
ex.htm
