Musculoskeletal system
Arthrocentesis
Arthrocentesis is injection and/or aspiration of a joint and is a commonly used treatment for joint conditions (Figures 8-1 and 8-2). A needle is inserted into the joint to anesthetize it. Drugs such as Depo-Medrol (synthetic glucocorticoid) or cortisone can then be injected into the joint, or fluid can be withdrawn. Bundled into the arthrocentesis are the dual services of injection and aspiration. For example, 20610 is reported when a physician withdraws fluid from the knee joint and then injects Depo-Medrol into the knee joint. The drug injected would be reported separately with a HCPCS code. HCPCS J code (drug code) descriptions identify the drug by the generic name, not the brand name. When reporting the drug with a HCPCS code, it is necessary to translate the brand name into the generic name; this is when the cross-reference feature of the Table of Drugs will be useful. For example, if the medical record indicates a Depo-Medrol injection, the Table of Drugs entry for Depo-Medrol (brand name) refers you to the generic name of the drug, methylprednisolone acetate (J1020-J1040). A current medical drug reference is also often necessary to translate brand names into the generic names to locate the drug in the HCPCS manual.
If image guidance was used during an arthrocentesis reported with 20600-20610, report the radiographic service separately with 77002, 77012, 77021, or 76942.
Injections into the tendon sheath or ligament, tendon origin or insertion, or muscle are reported with 20550-20553 and are reported one time per service visit when the same tendon sheath, tendon origin/insertion, or muscle is injected, no matter how many injections were placed in that specific sheath, origin/insertion, or muscle. If, however, a tendon sheath and a tendon insertion were injected, both injections are reported.
One sheath, origin/insert, or muscle injected, report one injection code.
Multiple sheaths, origins/insertions, or muscle sites injected, report multiple injection codes.
Use modifier -59 (distinct service) when reporting multiple injections during the same service visit to make it clear that documentation indicates that separate services were provided. The drug injected would be reported separately with a CPT or HCPCS code. If image guidance was used during an injection reported with 20550-20553, report the radiographic service separately with 77002, 77021, or 76942.
Fractures
Closed fractures are those in which the bone does not protrude outside the skin and usually include terms such as comminuted, compound, depressed, elevated, fissured greenstick, impacted, linear, simple, or spiral.
Open fractures are those in which the bone does protrude outside the skin and include terms such as compound, infected, missile, puncture, or with foreign body. If the documentation indicates both open and closed fracture terminology, assign an open fracture code. The type of treatment does not necessarily correlate to type of fracture; for example, an open reduction of a closed fracture—meaning that the closed fracture can be repaired by means of an open procedure. The terminology describing the type of fracture and the type of treatment must be carefully abstracted from the documentation to correctly report the fracture type.
ICD-10-CM: Fractures are reported with S codes based on the area of injury, such as injuries to the head, S00-S09 or fractures of the face bones, S02.
ICD-9-CM: Fractures are reported with codes from the range 800-829 based on the location, such as:
The codes within these categories are usually divided based on the location of the fracture and/or the type (open/closed).
ICD-10-CM: Vertebral column fractures are reported with S12, S22, S32. Spinal cord injury is reported separately in addition to the fracture code. If the injury was only of the spinal cord, the injury would be reported with one of these codes: S14, S24, and S34. Cervical fractures are reported with S12.1–A for a closed fracture, and S12.1–B for an open fracture. Multiple cervical fractures are reported individually for each vertebral fracture.
ICD-9-CM: Vertebral column fractures are reported with 805. The fracture codes report fractures either with or without mention of spinal cord injury. Cervical fractures are reported with 805.0 for a closed fracture and 805.1 for an open fracture. There are fifth digits 0-8 available for assignment to indicate the level as C1-C7, unspecified, or multiple cervical vertebrae involvement. Multiple cervical vertebrae fracture without mention of spinal cord injury is reported with one code for the multiple sites, 805.08.
Fractures of the rib(s), sternum, larynx, and trachea
ICD-10-CM: Fractures of the upper limbs (S42, S52, S62) are divided by the specific location, as are the fractures of the lower limbs (S72, S82, S92). All fractures reported with ICD-10-CM codes require a seventh character to indicate the episode of care, such as “A” for the initial encounter, “D” for subsequent encounter, or “S” for sequelae. Not all codes have the same seventh characters available for assignment. Turn to the Tabular of the ICD-10-CM to S82 and review all of the seventh characters available for assignment. Also, see instructions in the Official Guidelines for Coding and Reporting, Section I.A.4. and 5., for more specific instructions on episode of care.
ICD-9-CM: Rib, sternum, larynx, and trachea fractures are assigned to 807 based on the status of open/closed and specific location. There are fifth digits available (0-9) to indicate the number of ribs involved, such as 5 for fifth rib and 6 for sixth rib.
From the Trenches
“Coders must investigate codes, modifiers, HCPCS codes, and more before a final decision can be made. It is never boring!”
Fractures of the upper limbs (810-819) are divided by the specific location, as are the fractures of the lower limbs (820-829). There are also fifth digits available for many of the codes for ICD-9-CM.
External cause codes are only reported at the time of initial episode of care and only if the facility policy indicates that external cause codes will be assigned. If, as per facility policy, external cause codes are assigned, and since fractures usually are a result of an accident of some type, an external cause code would be assigned to indicate the way in which the accident happened (circumstances of the accident).
Fixation
Fixation can be internal or external and is used to hold a bone in place. Internal fixation is the placement of wires, pins, screws, plates, or rods onto or into the bone to repair bones. External fixation is the application of a device that holds the bone in place from the outside. Fasteners are driven into the bone percutaneously, and the external fixation device is attached to the fasteners. Percutaneous fixation (skeletal fixation) is a type of external fixation that serves as attachments for traction devices.
Both application and removal of the device are reported with one code. If a physician other than the physician who applied the device removes the device, the removal is reported separately. When reporting a fracture repair with the application of a fixation device, the device is usually reported separately; however, use caution when reporting the repair and application, because some fracture codes include application of devices in the code description (so then you would not report the services separately). Routine adjustment of the device is included in the application code unless the adjustment requires anesthesia.
CASE 8-2 8-2A Operative Report, Application of Halo
CASE 8-2
Dr. Almaz applies a cranial halo to stabilize a C1-C2 fracture, as illustrated in Figures 8-3 and 8-4. This is the initial treatment of the injury. Assign an external cause code/E code to indicate how the accident happened.
8-2A Operative report, application of halo
LOCATION: Outpatient, Hospital
PREOPERATIVE DIAGNOSIS: Fracture of C1 (first cervical vertebra) and C2 (second cervical vertebra)
POSTOPERATIVE DIAGNOSIS: Fracture of C1 and C2
PROCEDURE PERFORMED: Application of halo
PROCEDURE: The patient’s head was prepped and draped. The halo was applied to the head. Lidocaine was used in the area where the pins enter. We then placed the pins and fitted the patient with the rest of the vest. The patient is comfortable. She can get mobilized with the halo. She is 89 years old. You wonder whether she will ever heal after this fall. We will keep her in the halo for 3 to 4 months and see if she heals properly.
Excision
Throughout the Musculoskeletal System subsection, there are excision codes. These codes are used to report excisions from the deeper levels. Recall that excision codes are also located in the Integumentary System subsection. It is the origin of the excision that differentiates the codes. For example, if a superficial benign lesion was removed from the skin of the leg, the service is reported with a code from 11400-11406 (Integumentary System). If the excision was of a lesion located on the muscle of the leg, the service is reported with 27619 or 27634 (Musculoskeletal System), depending on the size of the tumor (<5 cm, >5cm). Watch for terms that indicate the origin of the neoplasm, such as melanoma (skin) or sarcoma (connective tissue) to direct you to the correct code selection.
CASE 8-5 8-5A Operative Report, Carbuncle Removal
CASE 8-5
Not all deep tissue excisions are reported with Musculoskeletal System codes. For example, the services in the next two cases are reported with Hemic and Lymphatic Systems codes. Note the two diagnoses highlighted in this report. This is another good example of why a coder must read the report and not code from the Postoperative Diagnosis section of the report.
8-5A Operative report, carbuncle removal
LOCATION: Outpatient, Hospital
PRIMARY CARE PHYSICIAN: Ronald Green, MD
PREOPERATIVE DIAGNOSIS: Two separate carbuncles, left axilla
POSTOPERATIVE DIAGNOSIS: Two separate carbuncles, left axilla
PROCEDURE PERFORMED: Removal of two separate carbuncles, left axilla. Tissue was submitted for aerobic and anaerobic cultures as well as permanent section.
INDICATION: This patient for the last 6 months has had a couple of carbuncles in her left axilla. They have been observed, and she has been placed on antibiotics. Attempts at drainage have been made, however, without results. Finally, the patient wants to have these tumors removed.
PROCEDURE IN DETAIL: After good MAC, the patient was prepped and draped in the usual sterile fashion. The left arm was adducted to expose the axilla. The two areas were infiltrated separately with 1% lidocaine after the incisions were made over both affected areas, and dissection was carried down to encompass subdermal and deeper tissue. An inflamed lymph node was also identified, and this was taken with the more superficial tissue. After this, the wounds were irrigated and closed with 4-0 subcuticular stitch. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was returned to the recovery room in good condition.
Pathology Report Later Indicated: Lymph node was negative for neoplastic behavior.
From the Trenches
“Some of the benefits to working in medical coding are advancement, friends, education continues on a daily basis, and it rewards a job well done.”
Repair, revision, and reconstruction
Most of the anatomic subheadings (e.g., Shoulder or Humerus [Upper Arm] Elbow) in the Musculoskeletal System subsection include a Repair, Revision, and Reconstruction category. The procedures are osteoplasty, osteotomies, arthroplasty, tendon transplants or transfers, and various other repairs, revisions, and reconstructive procedures with numerous grafting procedures for bones, tendons, and muscles. Be certain to identify the correct location and extent of the procedure before assigning a code. A good medical dictionary is an important tool as you report muscle repairs, as only by understanding all of the medical terminology in each report can you be certain to report the service accurately.
CASE 8-12 8-12A Operative Report, Rotator Cuff Repair
CASE 8-12
This report states that the reconstruction procedure was a repair with acromioplasty. An acromioplasty is the surgical removal of a portion of the acromion (the highest point on the shoulder) to relieve compression of the rotator cuff when the joint moves. The acromioplasty is bundled into the repair procedure and is not reported separately.
8-12A Operative report, rotator cuff repair
LOCATION: Outpatient, Hospital
PREOPERATIVE DIAGNOSIS: Left, nontraumatic, rotator cuff tear
POSTOPERATIVE DIAGNOSIS: Left, nontraumatic, rotator cuff tear
PROCEDURE PERFORMED: Repair of left rotator cuff repair with Neer acromioplasty
ANESTHESIA: General with endotracheal intubation
FINDINGS: The patient was found to have a complete tear of the rotator cuff. This extended from approximately the level of the long head of the biceps around posteriorly about 2 cm (centimeter).
We created an incision over the left acromion in a shoulder-strap fashion and dissected down through the subcutaneous tissue until we identified the acromion. We reflected the deltoid sharply off the anterior and anterolateral aspect of the acromion. We were then able to view the subacromial space, and we immediately noted a large tear in the rotator cuff. We were careful not to split the deltoid more than about 1 cm.
We then thought there was a rather prominent inferior corner to the anterolateral edge of the acromion. We elected to proceed with a Neer acromioplasty. We then removed the inferior corner of the anterolateral aspect of the acromion using an oscillating saw. We smoothed the undersurface of the acromion with a rasp. After thoroughly irrigating the area with saline, we were able to achieve a very nice view of the rotator cuff tear. We found that the rotator cuff had essentially split into two layers, and they were both avulsed from the humeral head from the long head of the biceps around the articular surface about 2 cm. We freshened the edges of the rotator cuff and then created a bony trough along the margin of the articular surface, starting from the long head of the biceps posteriorly about 2 cm. We then used two sutures of no. 1 Nurolon. We passed each suture through the proximal humerus and out through the bony trough. We then entered the rotator cuff and then again through the bony trough such that when we tied the sutures, the rotator cuff was pulled nicely into the bony trough. We thoroughly irrigated this area before we tied the sutures and then abducted the shoulder as the sutures were tied. Again, the rotator cuff was pulled nicely into the trough without undue tension. We then freshened the margins of the acromion and repaired the deltoid back to the acromion with no. 1 Panacryl suture. We closed the subcutaneous tissue using 2-0 Vicryl, and the skin was closed using 4-0 nylon suture. A sterile Xeroform dressing was applied. Then we placed the patient’s left arm into a sling with an abduction pillow to keep the arm abducted slightly. She was then taken from the operating room in good condition and breathing spontaneously. The final sponge and needle counts were correct. She was given 1 g of Kefzol intravenously preoperatively and will be continued on 1 g of Kefzol q.8h. for 2 days.
Pathology Report Later Indicated: Benign tissue and bone morsels
SERVICE CODE(S): _________________________________________
ICD-10-CM DX CODE(S): ___________________________________
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