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

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

[email protected]

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