1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 19 MUSCULOSKELETAL SYSTEM

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Musculoskeletal System Subsection divided: Anatomic site (Forearm and Wrist), then service (e.g., excision) Used extensively by orthopedic surgeons –Many codes commonly used by variety of physicians Extensive notes (Cont’d…)

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Musculoskeletal System (…Cont’d) Most common: –Fracture and dislocation treatments –“General” subheading –Arthroscopic procedures –Casts and strapping

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Fractures Questions to ask: –Site of fracture or dislocation –Type of treatment (open, closed) –Manipulation performed and documented –Was traction used; if so, what type –Was percutaneous fixation used –Was internal fixation applied (make sure this is not included in code description) –Was an external fixation system applied –Did documentation support skin closure –What type of anesthesia was used

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Fracture Treatment Open: Surgically opened to view or remotely opened to place nail across fracture –____________ with _____________ (ORIF) ______ treatment, fracture site is not exposed by surgical incision ___________, neither open or closed. Fixation devices (such as pins) are placed across the fracture site under imaging Treatment terms not to be confused with type of fracture –_____ fracture: Bone penetrates skin –______ fracture: Bone does not penetrate skin Open reduction internal fixation Closed Percutaneous Open Closed

6. Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Type of treatment depends on type and severity of fracture “Complicated” in a code descriptor may indicate excessive hemorrhage, infection, prolonged physician work, or difficulty in reaching the site or depth of the site. Fracture Treatment Figure: 19.1

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Application of force to align bone Traction Figure: 19.4

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Skeletal Traction Use of force (distracting or traction force) applied to internal device (e.g., wire, pin, screw, or clamp) inserted into bone Figure: 19.5

9. Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Skin Traction Figure: 19.6 Application of force by means of adhesion to skin

10. Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Manipulation Use of force to return a fractured bone to normal alignment Fracture repair codes are often divided based on whether __________ was or was not used AKA: ________ Manipulation means a fracture has been reduced manipulation Reduction

11. Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Fracture Term Fractures are described by a physician in terms of the direction of the fracture line (horizontal, vertical, oblique, spiral), and the direction and degree of angulation (the most distal fragment) When the fracture results in more than two fragments, it is __________ comminuted

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Dislocation From Dorland's Illustrated Medical Dictionary, ed 32, Philadelphia, 2012, Saunders. Vertebral dislocation/ Subglenoid dislocation Bone displaced from normal joint position Treatment: Return bone to normal joint location Figure: 19.7

13. Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Subheading “General” (20005-20999) Begins “Incision” Depth: Difference between Integumentary and Musculoskeletal incision codes Musculoskeletal used when underlying ____ or ______ is involved bone muscle

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. General Subheading, Wound Exploration (20100-20103) Traumatic penetrating wounds Divided on wound location (body site) Includes –Enlargement –Debridement –Foreign body(ies) removal –Ligation –Repair of tissue and muscle

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. General Subheading, Wound Exploration (20100-20103) (…Cont’d) These procedures describe surgical exploration to an already open wound These codes are “separate procedure” codes They can be coded and reported in the following circumstances: 1.If only procedure performed 2.If totally ________ to another procedure performed at the same session unrelated

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Biopsy Located in Excision subheading (20200-_____) Biopsies for ____ and ______ Divided by: –Type of biopsy (bone/muscle) –Depth –Some by ______ (Cont’d…) 20251 bone muscle method

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. (…Cont’d) Can be ___________ needle or excisional –Coded separately If lesion is excised and biopsied, only the excision can be billed If biopsy taken on one day and based on the results an excision was performed, modifier -58 may be appropriate on excision code Biopsy percutaneous

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction or Removal (20500-20697) Within “General” subheading Codes for: –Injections –Aspirations –Insertions –Applications –Removals –Adjustments (Cont’d…)

19. Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction or Removal (20500-20697) (…Cont’d) Therapeutic Sinus Tract Injection Procedures: –Not nasal sinus –Abscess or cyst with a passage (sinus tract) to skin –Antibiotic injected with use of __________ guidance (Cont’d…) radiographic

20. Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction or Removal (20500-20697) (…Cont’d) Removal: foreign bodies lodged in muscle or tendon sheath Integumentary removal codes for removal from skin (Cont’d…)

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction or Removal (20500-20697) (…Cont’d) Injection: Into tendon sheath, ligament, or ganglion cyst, trigger joint ____________: Injection “and/or” aspiration of a joint –Both an aspiration and injection are reported with one code Arthrocentesis

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Arthrocentesis (20600-20610) _____ anesthesia is integral to these codes and should not be reported Report the drug separately with a “J” code HCPCS modifiers used to report specific digits: “FA to __” or “TA to __” Local F9 T9

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. External Fixation (20690, 20692) Figure: 19.13A Application of a device that holds bone in place These codes include the removal of the fixator If it is necessary to adjust or revise an external fixator see 20693. Code 20694 describes removal under anesthesia and includes imaging (Cont’d…)

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. External Fixation (20690, 20692) (…Cont’d) _______—pins or wires in one plane (flat, smooth surface) _________ —requires complex adjustments and correction in alignment. Bedside adjustments are not separately billed Code fracture treatment and external fixation –Unless treatment and fixation are both included in code description Multiplane Uniplane

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Grafts (or Implants) (20900-20938) Used to report harvesting through separate incision of: –Bone –Cartilage –Fascia lata –Tissue Involve “morselized” or “structural” bone taken from a donor (allograph) or from the patient (autograph) –Morselized—small pieces of bone –Structural—a segment of bone machined into the space Report only one bone graft code per operative session (Cont’d…)

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Grafts (or Implants) (20900-20938) (…Cont’d) _________ grafts: From mid-upper thigh where fascia is thickest Some codes include obtaining ______ material –Then not coded separately –Composite grafts involve combinations of autogenous material and allograft or alloplast Fascia lata grafting

27. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Other Procedures (20950-20999) Monitoring muscle fluid _______ (interstitial) –Pressure increases due to increased accumulation of fluids, causing blood supply to be compromised (Cont’d…) pressure

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Other Procedures (20950-20999) (…Cont’d) Bone grafts are identified by site they are taken from (donor site) ____ osteocutaneous flaps: bone grafts –Taken along with skin and tissue overlying bone (Cont’d…) Free

29. Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Other Procedures (20950-20999) (…Cont’d) Electrical or ultrasound stimulation –Used to speed bone healing Placement of _________ externally or internally Often used in treatment of fractures stimulators

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Divided by repair location: –Cervical (_____) __ = Atlas __ = Axis –Thoracic (______) –Lumbar (_____) –Sacral (__) –______ (tailbone) Spine (Vertebral Column) (22010-22899) Modified from Buck CJ: 2014 ICD-10- CM Standard Edition DRAFT (Softbound), St. Louis, 2014, Saunders. C1-C7 C1 C2 T1-T12 L1-L5 SI Coccyx

31. Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Incision (22010, 22015) Open incision and drainage of deep abscess of spine Divided by _______ –Cervical, thoracic, or cervicothoracic –Lumbar, sacral, or lumbosacral location

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Arthrodesis (22532-22819) Fixation of joint (arthro = joint, desis = fusion) –Fixation with pins, wires, rods, etc., to immobilize the joint Often performed with other procedure –Such as fracture repair –Use -51 on arthrodesis code –Unless service reported with add-on code Coded by approach, site, and number of interspaces or segments

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Types of Spinal Instrumentation –_________ : Devices at each end of repair area plus at least one other attachment –____________ : Devices at each end only Extensive notes Report in addition to definitive procedure without the -51 modifier Spinal Instrumentation (22840-22865) Figure: 19.15 Segmental Nonsegmental

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Subsequent Subheadings After first subheading, General, divided by anatomic location –Anatomic subheadings divided based by type of procedure (Cont’d…)

35. Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Subheadings (…Cont’d) Example subheading “Head” divided by procedure (21010-21499): –Incision –Excision –Manipulation –Head Prosthesis –Introduction or Removal –Repair, Revision, and/or Reconstruction –Fracture and/or Dislocation –Other Procedures

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Casts and Strapping (29000-29799) Replacement procedure or initial placement stabilizes without additional restorative treatment Initial fracture treatment includes _________ and _______ of first cast –Subsequent cast applications are coded _________ (Cont’d…) placement removal separately

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Casts and Strapping (29000-29799) (…Cont’d) Initial cast Not coded when part of a _______ procedure Removal is bundled into surgical procedure _______ are reported separately surgical Supplies

38. Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endoscopy/Arthroscopy (29800-29999) Surgical arthroscopy always includes ________ arthroscopy Codes divided by joint –Subdivided on procedure Diagnostic arthroscopy codes only reported for cases where no surgical scope is performed (exception is diagnostic scope that determines need to do open surgery, same day) –Use modifier -51 on the diagnostic scope (Cont’d…) diagnostic

39. Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endoscopy/Arthroscopy (29800-29999) (…Cont’d) Note: Parenthetical information following codes indicates which code to use if procedure was an ____ procedure Most arthroscopies include the following procedures: –Local infiltration of medication –Suture removal by operating surgeon –Surgical approach –Wound culture –Intraoperative photos and video imaging –Isolation of neurovascular structures –Stimulation of the nerves for identification –Placement of drains and suction devices –Wound closure open

40. Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 19 MUSCULOSKELETAL SYSTEM