OP Orthopaedics Lamon Willis.

OP Orthopaedics Lamon Willis

Aspirations/Injections

Aspirations & Injections
20526 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”) 20551 Injection(s); single tendon origin/insertion 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s)

Cross Section of Wrist Joint
Carpal tunnel syndrome (CTS) is divided into: Early Intermediate Advanced, and Acute stages. Patients with early CTS without thinner atrophy and mild symptoms respond well to steroid injection & splinting.

What is a trigger point? A tender and painful area of a muscle. Hyperirritable spots in muscle associated with palpable nodules in taut bands of muscle fibers. They may also manifest as tension headaches, tinnitus, temporomandibular joint pain (TMJ), decreased range of motion in the legs, and low back pain. Palpation of the trigger will illicit pain directly over the affected area and/or cause radiation of pain.

Trigger Point Injection Info Outpatient injection given into the trigger point May be dry needling, an anesthetic, and also a steroid Does not require imaging guidance Needle does not go very deep

These injections can be provided in various muscles throughout the body

Joint injection are coded by joint size as follow: 20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) without ultrasound guidance 20604 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting 20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) without ultrasound guidance

20606 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder hip, knee joint, subacromial bursa) 20611 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa); with ultrasound guidance, with permanent recording and reporting

Arthrocentesis of a joint would occur to remove fluid which has built up due to an injury or illness that has caused swelling and discoloration of the area

The synovial fluid analysis provides details to the physician related to current and future treatment

Dupuytren’s Contracture

The Relevant Anatomy Dupuytren’s contracture is a progressive disease of the palmar fascia which results in shortening, thickening and fibrosis of the fascia and aponeurosis of the palm. The palmar fascia is continuous with the antebrachial fascia, the deep fascia of the forearm, and the layer of fascia that covers the dorsum of the hand.

The Relevant Anatomy The palmar fascia is thicker in the center of the palm and fingers where it forms the palmar aponeurosis and digital sheaths. The palmar aponeurosis covers the soft tissues of the palm and long flexor tendons. As the longitudinal bands of the palmar aponeurosis undergo fibrosis, the metacarpophalangeal and proximal interphalangeal joints get pulled into flexion.

The Relevant Anatomy The fourth metacarpal is most commonly affected, followed by the fifth, third, and second. Recently, Dupuytren’s disease has become a more widely adopted term than Dupuytren’s contracture to name this condition, as the fingers are not always held in a fixed flexion deformity.

The Relevant Anatomy

Mechanism of the Injury/Illness
The exact origin of Dupuytren disease is unknown; however, researchers have identified a number of risk factors: Genetic Human leukocyte antigen (HLA) type Family linkage Zf9 genetic binding protein Mitochondrial mutation

Environmental Trauma and exposure to continuous vibrations Alcohol consumption Smoking Age These all provide oxidative stresses on the body, which is an imbalance between the production of reactive oxygen and body’s ability to detoxify and repair damaged tissue.

Associated Diseases Diabetes Epilepsy HIV Cancer When there are multiple disease processes working in the body, these simply compound the impact of the problem of this disease.

Clinical Presentation
Dupuytren contracture occurs slowly and typically progresses over the course of several years, but can also develop more rapidly over weeks or months. It typically affects older men of European decent. This condition most commonly begins with thickening of the skin on the palm, resulting in a puckering or dimpled appearance. As the condition progresses, bands of fibrotic tissue form in the palmar area and may travel distal toward the fingers.

Clinical Presentation
This tightening and shortening eventually leads to the affected fingers being pulled into flexion. Dupuytren’s contracture typically occurs bilaterally, with one hand being more severely affected than the other.

Diagnostic Procedures
Several features of Dupuytren’s disease can be noted upon examination: sites of nodules and bands or contracted cords, skin pitting, degree of skin involvement, measurement of the angle between the metacarpophalangeal and proximal interphalangeal joints, presence of any surgical scarring and sensation in the palm and digits.

ICD-10 Dx code M72.0: Palmar fascial fibromatosis [Dupuytren]

The degree of flexion contracture in the affected digit or digits can be measured with a goniometer. A Staging System has been created and used by some to measure the flexion contracture of an affected digit to determine the severity of Dupuytren’s disease; stage 1 indicates the least severe flexion contracture deformity while stage 4 indicates the most severe flexion contracture deformity.

Stage Contracture Comment healthy N feel nodules / cords N/1 0-5 degrees beginning contracture 1 6-45 deg. 2 46-90 deg. 3 deg. 4 > 135 deg.

Stage 1 Stage 2 Stage 3 Stage 4

Management / Interventions
Most common: Surgical Enzyme Injection Less common and unproven or clinically ineffective: Splinting Hyperbaric Oxygen Radiation Ultrasound Therapy Vitamin E Physical Therapy Interferon

Simple Fasciotomy Performed percutaneously or through small incisions, The surgeon dividing the contracted tissue cord to release the flexion contracture. The contracted cord is simply cut, but is not surgically removed from the digit. Fasciectomy Removal of the diseased palmar fascia, including the contracted tissue cord and nodule. Partial or total depending on the severity of the disease.

A partial fasciectomy involves removal of the diseased palmar fascia. A total fasciectomy is more invasive, involving the removal of the entire palmar fascia; both areas affected by disease and areas not affected by disease.

Dermofasciectomy is the most invasive surgical procedure for Dupuytren’s disease. Removal of the diseased palmar fascia, the contracted tissue cord and nodule included, and all overlying affected skin and subcutaneous fat. A full-thickness skin graft is required to cover the surgical site. In cases of chronic advanced proximal interphalangeal joint contracture, external fixators may be indicated in addition to the dermofasciectomy procedure to keep the contracture from recurring.

Fasciotomy - Percutaneous CPT-4 code Fasciotomy, palmar (eg, Dupuytren’s Contracture); percutaneous is for the percutaneous procedure called needle fasciotomy or needle aponeurotomy. Modifier -50 should be reported if the procedure is performed bilaterally. This code is reported once per hand, and not based upon the fingers involved.

Fasciotomy - Open CPT-4 code Fasciotomy, palmar (eg, Dupuytren’s Contracture); open, partial is for the invasive incisional service.

Dermofasciectomy CPT-4 codes Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure)

Dermofasciectomy

Fasciotomy – Enzyme Injection In 2009 Clostridium histolyticum collagenase injection (J0775) became a promising new nonsurgical treatment for Dupuytren’s disease. The injection of this enzyme targets excessive collagen deposition and rupturing the fibrous tissue cords that cause the contractures.

Fasciotomy – Enzyme Injection: 1st Part CPT-4 code Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture)

Manipulation – 2nd Part Post Injection 26341 Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord In this procedure the wrist is held in flexion while gentle but firm traction is placed across the contracted finger until rupture of the fascial cord is felt and the digit fully extends. This process can be repeated two more times at 10-minute intervals if full extension is not initially achieved. Once the digit is fully extended, the tendon function is evaluated.

Manipulation – 2nd Part Post Injection Clinical Example A 60-year old male with Dupuytren’s contracture who underwent enzyme injection into a palmar cord the previous day presents for manipulation of the contracted finger. Post procedure the patient’s hand was placed in a molded brace for continued post procedure resolution.

Head, Neck & Spine

Head, Neck & Spine CPT codes are for procedures performed on the head. Procedures cover a variety of items: Tumor removal Osteotomy, ostectomy, contouring, and Bone grafts and reconstructive surgeries NOTE: Many procedure performed on the cervical, thoracic, and lumbar spine are performed in an inpatient setting.

Head, Neck & Spine CPT codes involve soft tissues of the neck and thorax The list is short but sufficient with description of tumor removals, excision of rib(s), sternum, various open and closed procedures, some of which are performed in an inpatient setting Note: Spinal procedures are under a separate subheading Spine (vertebral column) in codes

Head, Neck & Spine CPT codes 21920-21936 are for the back and flank
These procedures are only for soft tissue tumor resection and removal

Head, Neck & Spine CPT codes involve the spine or vertebral column The spine is broadly arranged into several regions: Term # of Vertebrae Body Area Abbreviation Cervical 7 Neck C1-C7 Thoracic 12 Chest T1-T12 Lumbar 5 Lower Back L1-L5 Sacrum 5 (fused) Pelvis S1-S5 Coccyx 3 Tailbone None

Head, Neck & Spine The majority of procedure codes for spine surgery are designated by the approach used to perform the procedure. The two most common approaches are: Anterior Posterior Whatever approach is used should be well documented in the operative note.

Head, Neck & Spine There is an important difference to take note of between vertebra/vertebrae and the vertebral interspace. CPT defines the vertebral interspace as: “The non-bony compartment between two adjacent vertebral bodies, which contains the intervertebral disk, and includes the nucleus pulpous, annulus fibrosus, and two cartilaginous endplates.” The vertebra or vertebral segment is the bone itself.

Head, Neck & Spine For example:
“L1” is a vertebra, whereas L1-L2 describes an interspace. The span from L1 to L5 includes five vertebrae and four interspaces. NOTE: Decompression of the spinal cord is described with codes from the nervous system (60000 series) portion of CPT. For removal of a disc without decompression; utilize codes from the CPT series.

Common Spine Surgeries
The most frequently reported spinal procedures for orthopaedics include: Decrompression/Laminectomy/Laminotomy/Hemi- laminectomy: CPT codes Laminotomy and laminectomy are spinal decompression surgeries performed on the lamina. Laminotomy is the partial removal of the lamina. Laminectomy is the complete removal of the lamina. It is important to know that the terms are often used interchangeably.

Arthrodesis: CPT codes Arthrodesis in the spine is performed to fuse two vertebral bodies together. Arthrodesis is reported based on approach and technique. The different types of fusion include: Posterolateral fusion – procedure is done through the back Posterior lumbar interbody fusion (PLIF/TLIF) – the procedure is done from the back and includes removing the disc between two vertebrae and inserting bone into the space created between the two vertebral bodies

Anterior lumbar interbody fusion (ALIF) – the procedure is done from the front and includes removing the disc between two vertebrae and inserting bone into the space created between the two vertebral bodies Anterior/posterior spinal fusion – the procedure is done from the front and the back

Instrumentation; including rods, plates, screws, etc.: CPT codes The codes for spinal instrumentation are selected based on the whether the instrumentation is anterior or posterior and the number of vertebral segments. If the surgeon removes instrumentation to necessitate a spinal procedure (such as a repeat fusion), you cannot charge for the instrumentation removal.

On rare occasions, however, the surgeon may have to remove spinal instrumentation because the instrumentation breaks, the patient’s body rejects it, or the patient requires an adjustment in the instrumentation type. In these cases, you can separately code the instrumentation removal (22850, 22852, 22855). If the surgeon reinserts instrumentation following the procedure (such as a repeat fusion), you should report (Reinsertion of spinal fixation device).

Bone Grafting: CPT codes Bone grafts are reported with many spine surgeries unless the code descriptions includes the bone graft. Bone grafts can be allografts (grafts between individuals of the same species or autografts (grafts taken from the patient).

Placement of Biomechanical Device, such as synthetic cage(s): CPT codes , 22859 These are all add-on codes 22853 is “per interspace” 22854 and are “each contiguous defect”

Vertebroplasty vs. Kyphoplasty
Things to look for: Is a balloon used to create a cavity? Report kyphoplasty. How many vertebral bodies are involved? What type of imaging guidance is used?

Terminology changes Kyphoplasty now referred to as “percutaneous vertebral augmentation” Codes are found at Codes are for one “1” vertebral body for the body areas listed: Thoracic Lumbar Codes are unilateral or bilateral Imaging is included

Vertebroplasty codes are These are percutaneous codes The codes are for one (1) vertebral body for the body areas listed: Cervicothoracic Lumbosacral Codes are unilateral or bilateral Imaging is included

Vertebroplasty Vertebroplasty is often utilized because:
More extensive repair experience Good pain relief record Relatively quick procedure Performed as an outpatient procedure Less costly than kyphoplasty

Spinal Injections

Spinal Injections Spinal injections may be either diagnostic or therapeutic (pain management), depending on the type/location of the injection, and the substance being injected. Codes 62280–62282 describe subarachnoid or epidural injections, by location: 62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid

Spinal Injections 62281 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic 62282 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Spinal Injections Codes describe spinal injections with and without indwelling catheters, with and without image guidance, and some with indwelling catheter placement. 62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

Spinal Injections 62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Spinal Injections 62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

Spinal Injections 62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Spinal Injections 62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

Spinal Injections 62325 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Spinal Injections 62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

Spinal Injections 62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Spinal Injections A final set of spinal injection codes describes transforaminal epidural injections by location: 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Spinal Injections 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Spinal Surgery The X-STOP is an interspinous process decompression system for use in the cervical and lumbar area, touted as an alternative to fusion. Use of this device is reported with codes : 22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level

Spinal Surgery 22868 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure) 22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level

Spinal Surgery 22870 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) Medicare will cover X-STOP with specific diagnosis and other requirements. Check with your individual payer for guidelines. Other payers may regard these devices as experimental, and they will not be covered.

Spinal Surgery Artificial disc placement has become more common. The procedures include: 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical

Spinal Surgery 22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure) 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

Spinal Surgery 22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar 22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

Fractures

Fractures Fracture repair codes are arranged by anatomical site, and are further classified as with or without manipulation, and percutaneous or open treatment. When a broken bone is misaligned, manipulation is necessary to move it back into place. Percutaneous repair occurs through a puncture in the skin, usually with hardware placement. An open repair requires that the physician create a surgical opening to view and repair the fracture directly.

Fractures Nonunion or malunion occurs in two to five percent of fractures. For most body areas, there are specific codes to describe treatment of such fractures in the repair/ reconstruction—rather than the fracture treatment—portion of CPT. Bone grafts are normally included with fracture nonunion/malunion treatments.

Musculoskeletal, Blood Vessel, and Nerve Repairs

Musculoskeletal Repairs
Musculoskeletal repairs may involve tissues other than bone, including: Cartilage Ligaments Muscles Tendons Flexor-palmar Extensor-dorsum CPT codes for these repairs generally are listed by site or are indexed under the heading of arthroscopy.

Blood Vessel Repairs For repair of blood vessels (artery or vein), look to codes 35201–35286 in the cardiovascular portion of CPT, depending on the type of repair or graft used. You should report 35201–35226 for direct vessel repair; 35231–35256 for vein graft, and 35261– for non-direct repairs using other than vein graft.

Nerve Repairs (Neurorhaphy)
For primary nerve repairs, look to codes 64831– , as appropriate to nerve location. Add on codes and describe secondary or delayed suture and extensive mobilization or transposition of the nerve, respectively. You should report these procedures, when performed, in addition to the appropriate nerve repair code.

Nerve Repairs (Neurorhaphy)
For primary nerve repairs, look to codes 64831– , as appropriate to nerve location. Add on codes and describe secondary or delayed suture and extensive mobilization or transposition of the nerve, respectively. You should report these procedures, when performed, in addition to the appropriate nerve repair code. Codes 64885–64911 describe nerve grafts, by location and length

Neuroplasty Codes for neuroplasty are specific to nerve or location.
Note the availability of “other than specified” codes (e.g., 64708) for those procedures not targeted to a nerve identified specifically in CPT. 64702 Neuroplasty; digital, 1 or both, same digit 64704 Neuroplasty; nerve of hand or foot 64708 Neuroplasty; major peripheral nerve, arm or leg, open; other than specified

Neuroplasty 64712 Neuroplasty; major peripheral nerve, arm or leg, open; sciatic nerve 64713 Neuroplasty; major peripheral nerve, arm or leg, open; brachial plexus 64714 Neuroplasty; major peripheral nerve, arm or leg, open; lumbar plexus

Neuroplasty Additional codes describe neuroplasty and/or transposition. For instance, for surgical treatment of carpal tunnel syndrome (G56.0X): 64716 Neuroplasty and/or transposition; cranial nerve (specify) 64718 Neuroplasty and/or transposition; ulnar nerve at elbow 64719 Neuroplasty and/or transposition; ulnar nerve at wrist 64721 l Neuroplasty and/or transposition; median nerve at carpal tunnel

Coding for Hallux Valgus, Hammertoe, and Bunionectomy

Agenda Mechanism of Illness/Injury Clinical Presentation
Diagnostic Procedures Management/Interventions

Hallux Valgus/Bunionectomy

Mechanism of Illness/Injury
A bony bump at the base of the big toe Causes that toe to deviate toward the others It throws foot bones out of alignment and producing the characteristic bump at the joint's base Painful due to pressure or arthritis, and may also lead to corns.

Etiology Essential extrinsic factor = shoe Female/male = 2:1 to 15:1 Intrinsic cause Heredity: + FH ~63%

Treatment and Procedures
Pain relievers Wearing roomy shoes and avoiding high heels Stretching exercises

Anatomy

Pathophysiology

Pathophysiology IMA (normal <9) [8-9] HVA (normal <15) [15-20]
DMAA (normal <10) [10-15]

Hallux Valgus Classifications
Mild Moderate Severe Hallux Valgus Angle <20 20-40 >40 Intermetatarsal Angle <11 11-16 >16 Sesamoid Subluxation <50% 50-75% >75%

Pads to cushion the bunion Custom shoe inserts or orthotics

Cortisone injection

Bunionectomy The key to coding and billing the bunionectomy is to focus on the inherent procedure as opposed to one’s personal preference in regard to variations to the procedures, the use of specific fixation devices/material or even additional services. For fixation of a first metatarsal osteotomy, there is no variation in reimbursement if you are using a K-wire, screw, plate or other fixation devices.

Reimbursement is always based upon the inherent procedure performed and the standard of care. The fixation unit and the extra work involved would not be payable as that is more of a doctor preference. Utilizing other types of materials to reinforce tendons or capsules may or may not be covered if this is not a common practice in performing the given bunionectomy procedure.

Certain insurance carriers may have specific guidelines for the use of these materials. Some “newer” devices/materials which bind metatarsals together to decrease angles are generally not covered by insurance companies.

The CPT codes for Bunionectomy include as integral parts of the operation: capsulotomy, arthrotomy, synovial biopsy, synovectomy, tendon release, tenotomy, tenolysis, excision of medial eminence, excision of associated osteophytes,

The CPT codes for Bunionectomy include as integral parts of the operation: placement of internal fixation, scar revision, articular shaving, and removal of bursal tissue when done at the first MTP joint.

Common Codes 28111 – Ostectomy, complete excision; first metatarsal head Physician incises first MTP joint Inserts a retractor to remove the joint capsule and any proliferative synovial tissue Detaches the abductor hallucis tendon from base of phalanx and cuts the metatarsal head and base

Common Codes 28288 – Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head There is no mention in the code descriptor as to which specific metatarsal this applies to. However, this code most commonly applies to the lesser metatarsals.

Ostectomy 1st Metatarsal Head
CPT This code is for the complete resection of the first metatarsal head.

Proximal Osteotomy (Scarf)

Proximal Osteotomy (Ludloff)

Stability of Osteotomies

Proximal Phalangeal Osteotomy
28298/28299 Akin, Akin/Austin Procedure CPT This code is for the complete resection of the first metatarsal head.

Medial Cuneiform Osteotomy
Riedl & Coughlin CPT This code is for the complete resection of the first metatarsal head.

Common Codes CPT Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint Similar in nature to CPT 28288, this code is specifically for the first metatarsal joint. This is the best code to use when one is performing a cheilectomy procedure to increase motion at the joint in order to address hallux limitus/rigidus. NOTE: “Cheilectomy” refers to excision of the lip of the first MTP joint. CPT This code is for the complete resection of the first metatarsal head.

Common Codes CPT 28289 (continued)
This procedure code also includes any capsular release the surgeon deems necessary, as well as dissection and removal of additional prominences on the base of the proximal phalanx that are jamming the joint. Bony irregularities may be removed using a chisel, and edges smoothed with a rasp. When adequate flexion is reached the tendon is returned to its correct position and the skin is closed with sutures.

Common Codes CPT Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method (formerly known as Silver, Keller, McBride, and Mayo type procedure) This code describes a simple exostectomy bunionectomy procedure. This would involve resecting the medial eminence. This code also covers releasing or excising the sesamoid.

Common Codes Keller procedure is a simple resection of the base of the proximal phalanx with removal of the medial eminence. It provides excellent pain relief for Hallux rigidus (MTP arthritis) and decompression for medial breakdown. Resulting diminished toe function however, has led many physicians to seek other procedures in active individuals.

Common Codes 28292

Common Codes 28292 Simple resect 1/3 of proximal phalanx
Decompress joint and relax tight lateral structure Allow correction deformity High recurrence rate Little improve IMA Metatarsalgia Difficult salvage of failure procedure

Common Codes McBride procedure, now modified and referred to as the distal soft tissue release, corrects all soft-tissue deformity at the MTP joint by releasing the tight lateral capsule, ligament complex and adductor tendon, and reefing the loose medial capsule with resection of the medial eminence. The lateral sesamoid is no longer removed. McBride procedure is seldom being performed.

Common Codes 28292 – Modified Bunionectomy (modified McBride)

Common Code McBride

Common Codes 28292 Mayo procedure historically involves resection of the first metatarsal head and is now rarely done for bunions.

Common Codes CPT Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant The use of flexible silicone type implants for arthritis in the first MTP joint is controversial. They may be subject to acute inflammatory reaction, local bone resorption, synovitis, proximal lymphatic involvement, wear and fracture. Cemented implants are also being used but significant long term follow-up is not yet available.

Common Codes CPT code Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (e.g., Joplin type procedure) was deleted for 2018. Unlisted code Unlisted procedure, foot or toes would be used in place of that code. If tendon transplant is a major part of the procedure this code should be used.

Common Codes 28296 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method This procedure was formerly called the Mitchell or Chevron, or concentric type procedure. Mitchell procedure is a complex, biplane, double step cut osteotomy through the neck of the first metatarsal, and is indicated for moderate hallux valgus with a subluxed MTP joint.

Common Codes Distal chevron or concentric osteotomy involves a resection of the medial eminence, combined with a transverse osteotomy in the coronal plane of the metatarsal neck to lateralize the head. Proximal osteotomies in the base of the first metatarsal (CPT code 28306), often required for severe metatarsus primus varus ( > 15 degrees), are done through a separate incision at a more proximal anatomic area and require a -59 modifier.

Common Codes 28297 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method Formerly referred to as the “Lapidus-type” procedure This involves a metatarsocuneiform fusion plus a distal soft tissue bunion repair when there is arthritis or suspected instability at the first metatarso-cuneiform joint.

Common Codes 28298 Hallux Valgus (bunion) correction, with or without sesamoidectomy; by phalanx osteotomy Formerly known as “Akin” procedure involves the removal of a medially based bony wedge from the base of the of the proximal phalanx to reorient its axis. It is the procedure of choice for Hallux valgus interphalangeus, but offers too little correction to correct a major bunion deformity by itself.

Common Codes 28299 Hallux valgus (bunion) correction, with or without sesamoidectomy; by other methods (e.g., double osteotomy) With severe hallux valgus or a congruent joint, a double osteotomy of the first metatarsal or metatarsal and proximal phalanx might be required.

Common Codes 28750 Arthrodesis, great toe; metatarsophalangeal joint
This is an important option that is considered in severe hallux valgus and when there are associated arthritic changes at the first MTP joint.

Hammertoe

Occurs from muscle and ligament imbalance around the toe joint, causes the middle joint of the toe to bend and become stuck in this position Most common complaint is rubbing and irritation on the top of the bent toe Toes that may curl rather than buckle are also considered hammertoes

The causes for Hammertoe are threefold: Genetic – Flatfoot or high arch Injury – High heels, pointed toe, ill-fitting Arthritis – Constant inflammation Women are more likely to get pain associated with hammertoes Serious problem in people with diabetes or poor circulation.

Two Types of Hammertoe Flexible
If the toe can still be moved at the joint, it’s a flexible hammertoe. This is an earlier, milder form of the problem which may be treated by several different options.

Two Types of Hammertoe Rigid
If the tendons in the toe become rigid, they press the joint out of alignment. At this stage, the toe can't be moved. It usually means that surgery is needed.

Types of Corrective Surgery
Soft tissue correction Soft tissue corrective surgery redirects the tendons and joint capsule of your toe which will correct the position. Digital arthroplasty This involves correcting the soft tissue and removing a piece of bone in order to straighten the toe. Arthrodesis The technique involves fusing two bones together in order to straighten the toe.

Types of Corrective Surgery
Often a combination of procedures using techniques from the different types of toe surgeries mentioned is performed. Many times hammertoe surgery requires a metal wire or other implant to be inserted into the toe that will hold it into place while it heals. The end result will be a straightened toe.

Materials and Products
Pins, K-wires, and screws of various kinds are often employed in various aspects of these procedures. Since 2007, the Smart Toe implant has been utilized widely by many Orthopaedic surgeons. Proper use of this product appears to provide faster fusion of repaired toes, has less pain during recovery period, and fewer complications following surgery.

Example – Smart Toe Information
A) Distal Phalange B) Medial & Proximal Fused C) Smart Toe Implant D) Proximal Phalange A) Distal Phalange B) Interphalangeal Articulation C) Proximal Phalange

Example – Smart Toe Information
A) Before insertion, the implant is cooled by the surgical team. B) After insertion, body heat expands and contracts the implant. Angled Smart Toe implant provides a natural angle to the surgically corrected toe.

Common Codes 28285 Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy) 28286 Correction, cock-up fifth toe, with plastic skin closure (e.g., Ruiz-Mora type procedure) The Ruiz-Mora procedure has been advocated for treatment of congenital overlapping fifth toes, fifth hammertoe, and clavus deformities. The toe is shortened by removing the proximal phalanx and leaving a space between the base of the metatarsal and distal phalanx.

Questions Q: Is it appropriate to report a hammertoe correction along with a corresponding metatarsophalangeal joint capsulotomy during the same surgical encounter when both procedures are medically necessary to completely correct the presenting deformities? A: Yes. It is not unusual to have to perform both of these procedures during the same surgical session to completely correct a complex ray deformity. Yes. It is not unusual to have to perform both of these procedures during the same surgical session to completely correct a complex ray deformity. A hammertoe can be defined by a digital contracture at the distal interphalangeal joint and/or proximal interphalangeal joint. A contracted metatarsophalangeal joint is a dorsiflexory positioning of the proximal phalanx on the metatarsal head. These are two distinct deformities that can and do exist in isolation, but if both conditions are present, no single CPT code describes the correction of both deformities. The coding would be hammertoe correction and corresponding open metatarsophalangeal joint capsulotomy with or without tenorrhaphy These procedures are performed independent of one another. Note: A percutaneous release of the joint contracture does not meet the description of code The coder should append Modifier 59, Distinct Procedural Service, to the 28270 code to separately identify these procedures.

Questions A: A hammertoe can be defined by a digital contracture at the distal interphalangeal joint and/or proximal interphalangeal joint. A contracted metatarsophalangeal joint is a dorsiflexory positioning of the proximal phalanx on the metatarsal head. These are two distinct deformities that can and do exist in isolation, but if both conditions are present, no single CPT code describes the correction of both deformities.

Questions Q: Is it appropriate to append modifier 50, Bilateral procedure, to procedure code 28285, Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy, if the procedure is performed on the same toes of both the right and left foot?

Questions Yes. The use of this modifier is only applicable to services or procedures performed on identical anatomic sites, aspects, or organs (e.g., arms, legs, eyes) during the same operative session. The intent is for the modifier to be appended to the appropriate unilateral code as a one line entry on the claim form to indicate that the procedure was performed bilaterally.

Techniques and Images Persistent dorsiflexion contracture at the metatarsophalangeal joint and plantar flexion contracture at the proximal interphalangeal joint of the fifth toe (Figures 1A and 1B) is frequently associated with a painful hyperkeratosis Figures 1A and 1B

Techniques and Images Some techniques involve the excision of an elliptical portion of the plantar skin is excised, a possible cause of vascular impairment of the fifth toe and hypertrophic scarring. Figures 2A and 3B

Techniques and Images Some minimally invasive procedures often produce insufficient correction of the deformity. The Augustine and Jacobs technique consists of a plantar closing wedge osteotomy of the 5th toe at the base of its proximal phalanx associated with an exostosectomy of the head of the proximal phalanx and at the base of the middle phalanx. Figures 2A and 3B

Techniques and Images Lastly, a complete tenotomy of the deep and superficial flexor tendons and of the tendon of the extensor digitorum longus is undertaken. In this way, correction of the deformity is achieved without interfering with the joint surface and producing only minimal shortening of the 5th toe, and no vascular or skin compromise.

Techniques and Images Tenotomy of the tendon of extensor digitorum longus to the 5th toe A 2 mm incision is performed just above the extensor tendon and parallel to it at the level of the metatarsophalangeal joint. 28010 – Tenotomy, percutaneous, toe; single tendon Figures 3A and 3B

Techniques and Images Tenotomy of the tendon of extensor digitorum longus to the 5th toe The patient is then asked to extend the 5th toe, allowing to better locate the tendon, which is fully tenotomised (Figures 3A and 3B). Figures 2A and 3B

Techniques and Images Dorsal metatarsophalangeal capsulotomy
In patients with severe rigidity, capsulotomy of the metatarsophalangeal joint is performed, releasing only the superior portion of the capsule and the extensor sling. Correction of the hyperextension is usually remarkable. Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure)

Techniques and Images Lateral condylectomy
If the hyper-flexion of the interphalangeal joints is difficult to correct, there often is an exostosis at the lateral condyle of the proximal phalanx of the 5th toes and at the base of the middle phalanx. If this is the case, a lateral condylectomy is indicated. A 2 mm incision is made over the dorso-lateral aspect of the 5th toe. The blade is introduced until it touches the underlying bone. Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head

Techniques and Images Lateral condylectomy
The periosteum is detached from the bone with a rasp, and the exostosis is removed with the short Shannon 44 burr (Figures 4A and 4B) at slow speed with gentle oscillating movements. Figures 4A and 4B

Techniques and Images Tenotomy of the flexor tendons
A 2 mm incision is performed just proximal to the plantar fold of the toe, just medial to the toe itself. The surgeon extends the 5th toe to tense the flexor tendon, which is severed with the tip of the scalpel. It should then be possible to appreciate the loss of resistance to extension in the proximal and distal interphalangeal joints. 28010 – Tenotomy, percutaneous, toe; single tendon

Techniques and Images Osteotomy of the proximal phalanx
A rasp is introduced through same incision used for the tenotomy of the flexor tendons, the periosteum is detached from the lateral aspect of the phalanx. A plantar closing wedge osteotomy is performed (Figure 5A and 5B) using the short Shannon 44 burr. Figures 5A and 5B

Techniques and Images Osteotomy of the proximal phalanx
Complete correction of deformity is thereby achieved (Figures 6A and 6B). Osteotomy, shortening, angular or rotational correction; other phalanges, any toe Figures 6A and 6B

Techniques and Images Q: Why wouldn’t Reconstruction, angular deformity of toe, soft tissue procedures only (e.g., overlapping second toe, fifth toe, curly toes) be used INSTEAD OF Osteotomy, shortening, angular or rotational correction; other phalanges, any toe? 28313 – This procedure involves the correction of the toe deformity by releasing soft tissues and possibly involving tendon transfers. It does not include cutting or realigning the shafts of the bones. Figures 6A and 6B

Techniques and Images A: – This procedure involves the correction of the toe deformity by releasing soft tissues and possibly involving tendon transfers. It does not include cutting or realigning the shafts of the bones. 28313 – This procedure involves the correction of the toe deformity by releasing soft tissues and possibly involving tendon transfers. It does not include cutting or realigning the shafts of the bones. Figures 6A and 6B

Other Coding Tips Bones of the Toes
There are 14 bones called phalanges located in the toes of a foot. The 1st toe (also called great toe or hallux) has a proximal phalanx and a distal phalanx. The 2nd, 3rd, 4th, and 5th toes each have 3 phalanges: proximal phalanx, middle phalanx and distal phalanx. Some physicians refer to an entire toe as a "phalanx," so be careful when reading the operative reports to distinguish between an entire toe and 1 of the toe bones when "phalanx" is referenced.

For example, if a physician dictates that the "distal phalanx of the left 3rd phalanx was removed entirely," this means that the distal phalanx bone was removed from the left 3rd toe. Code such a procedure as CPT code T2 (Phalangectomy, toe, each toe — left foot, 3rd digit). Confirm that the OR report documentation supports the specific phalanx when it impacts the CPT code assignment.

For example, if a patient has a right hallux proximal phalanx osteotomy performed, assign code: 28310-T5 Osteotomy, shortening, angular or rotational correction; proximal phalanx, 1st toe (separate procedure), right foot, great toe.

Arthroscopy

Arthroscopy Arthroscopic procedures may be performed in most joints of the body. Codes are distributed throughout the CPT manual by anatomic area. Be aware that surgical scope or open surgical intervention always includes same-session diagnostic scope in the same anatomic area.

Arthroscopy 29805–29828—shoulder 29830–29838—elbow 29840–29848—wrist
29860–29863, —hip 29866–29889—knee 29891–29899—ankle 29900–29902—metacarpophalangeal 29904–29907—subtalar joint

Shoulder Anatomy - Bones
Clavicle Medial end articulates with the sternum = sternoclavicular joint Lateral end articulates with the acromion process of the scapula = acromioclavicular joint

Scapula Posterior to ribs, has no bony attachment to the axial skeleton Acromion process Coracoid process Coracoacromial ligament connects the coracoid process with the acromion process Coracoclavicular ligament unites the clavicle with the acromion process

Glenohumeral joint - attachment of the humerus to the scapula at the glenoid Glenoid fossa – depression on the lateral scapula, provides articulation for the head of the humerus with the scapula Labrum – collar-like structure that surrounds the glenoid fossa

Shoulder Anatomy – Muscles & Tendons
Trapezius – thin sheet of muscle covering the upper back, helps form the contour of the neck Deltoid – so-named as it resembles the Greek letter, Delta, stretches from the clavicle and the scapula to the deltoid tuberosity of the humerus

Rotator cuff – composed of the tendons for four muscles: Subscapularis Supraspinatus Infraspinatus Teres minor

Coracobrachialis – originates at the tip of the coracoid process and inserts on the medial surface, mid-humerus Biceps brachii - anterior of the arm Triceps brachii – posterior of the arm NOTE: Most commonly dislocated joint in the body

Shoulder Pathology Shoulder instability – weakening of the glenohumeral joint by subluxation or discloation Bankart lesion - A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it. An initial Bankart lesion (sprain/strain) will code to S43.0XXA. A recurrent Bankart lesion will code to M24.41X.

Shoulder Pathology SLAP tears – S46.111A, S46.919A, S43.431A, S43.439A, S43.491A Rotator cuff tear – S43.421A, S43.422A, Infraspinatus (muscle or tendon) – S43.80XA, S43.81XA, S43.82XA Supraspinatus (muscle or tendon) – S43.80XA, S43.81XA, S43.82XA Subscapularis (muscle) – S43.80XA, S43.81XA, S43.82XA

Shoulder Pathology Impingement Syndrome – M75.4X
Rotator cuff tendinopathy Degenerative – M66.211, M66212, M66.219, M66.811, M66.812, M66.819, M75.100, M75.101, M75.102 Nontraumatic rupture – M75.120, M75.121, M75.122 Biceps tendinopathy Degenerative – M75.20, M75.21, M75.22 Nontraumatic rupture – Multiple codes to choose from in the M66.XXX section of ICD-10-CM

Shoulder Procedures Superior labrum from anterior to posterior (SLAP)
The SLAP tear is identified and a small ball burr may be used to remove excess tissue and prepare the bony bed (glenoid) A small hole is drilled into the bone where the labrum has torn off An anchor with suture attached is placed it this hole The suture is used to tie the torn labrum snugly against the bone

Shoulder Procedures Arthroscopic Biceps Tenodesis
29828 Arthroscopy, shoulder, surgical; biceps tenodesis A procedure that cuts the biceps tendon (long head) from where it attaches to the upper rim of the glenoid (labrum), and reinserts it into another area.

Shoulder Procedures

Rotator Cuff Repair/Reconstruction
CPT code series to includes acute or chronic conditions within the CPT verbiage. The operative documentation should provide whether the patient has an acute versus chronic condition. If no indication is provided in the clinical documentation, don’t assume.

AMA guidelines state that three of the four muscles/tendons of the rotator cuff should be torn, with further clarification from the AMA stating that CPT is an extreme tear, typically requiring rearrangement of the normal anatomy with occasional grafting of biological or nonbiological material.

The AMA says that code determination is not necessarily based on the number of tendons. Remember, four tendons make up the rotator cuff: supraspinatus (top of humeral head), subscapularis (front of humeral head), infraspinatus (back of humeral head) and teres minor (also back of humeral head).

The American Academy of Orthopaedic Surgeons reiterates that you shouldn’t use CPT simply for a repair of a massive tear but for a reconstruction of a massive tear with significant retraction that involves extensive releases and mobilization, as well as fascial or synthetic material when applicable, in order to return the tendon to its original anatomical location. In other words, we aren’t simply suturing and repairing a tendon via anchors and tacks. In addition, three tendons need not be torn to support reporting CPT

Use CPT code series to to report mini open rotator cuff tear repairs, with code selection determined by acute versus chronic conditions. While CPT provides a parenthetical statement under CPT (Arthroscopy, shoulder, surgical; with rotator cuff repair) directing the CPT user to report for mini open rotator cuff repair, you still need to determine the final code selection based on the acute versus chronic condition. Recall that CPT code verbiage in to is specific to an acute versus chronic condition.

Mini open rotator cuff tear repairs typically don’t involve entry into the shoulder joint while the tear can still be visualized and repaired. When a surgeon performs an arthroscopic rotator cuff repair, report CPT regardless of whether the condition is acute versus chronic. The operative report should specify an acute versus chronic condition. The technique (open versus arthroscopic) will need to be apparent to include a detailed description of a repair versus reconstruction of the specific tendon(s) or cuff.

Distal Claviculectomy
Excision of the distal clavicle (approximately 1cm) involving more than a simple shaving of osteophytes at the AC joint is reported separately whether performed open or closed, according to the AAOS. The operative report must indicate the size of the distal clavicle excision to justify the separate reporting of this code.

Arthroscopic Labrum Repairs
Report CPT for surgical capsular repairs when performed arthroscopically. Simply because a labrum is torn and repaired, it doesn’t automatically warrant reporting if the torn labrum isn’t a SLAP (superior labrum from anterior to posterior) tear. CPT is specific for a SLAP repair; don’t use it for labral tears that aren’t SLAP tears. The surgeon will determine whether this is a true SLAP tear and also the “type” of SLAP.

Report both and per AAOS if the surgeon performs SLAP Type II or Type IV in addition to capsulorrhaphy for a different indication. To simplify, there should be two separate and distinct indications to report the capsular repair and the SLAP tear repair.

Medicare edits bundle CPT code into CPT at this time, but allows for a modifier if the surgeon performs SLAP separately and distinctly from the capsulorrhaphy. Use caution when considering the application of a modifier. Remember the terms “separate” and “distinct.” Simply because you can use a modifier doesn’t imply automatic application of a modifier with every scenario.

Don’t confuse the surgeon’s repair of the labrum by attaching it to the capsule as a separately identifiable capsulorrhaphy. The separate reporting of the capsulorrhaphy is indicated when there is a capsular defect unrelated to the labrum tear that in itself also warrants a repair.

Arthroscopic SLAP debridement is reported from the arthroscopic shoulder debridement codes pending other debridements performed during the operative session. These debridement codes may be considered inclusive into other surgical procedures performed during the same operative session. The operative report should specify the type of SLAP (I, II, III, IV, etc.), document the diagnosis for either or both the SLAP and capsulorrhaphy, and describe the procedure(s) in detail.

Decompression & Acromioplasty
Acromioplasty is an arthroscopic surgical procedure of the acromion. Generally, it implies removal of a small piece of the surface of the bone that is in contact with a tendon causing, by friction, damage to the tendon.

The Centers for Medicare & Medicaid Services (CMS) and the American Academy of Orthopaedic Surgeons (AAOS) have opposing views on shoulder anatomy. AAOS recognizes the glenohumeral joint, the acromioclavicular (AC) joint, and the subacromial bursa as separate anatomic areas. CMS, by contrast, considers the shoulder to be a single anatomic region.

Subacromial Decompression with Partial Acromioplasty CPT requires both a subacromial decompression and a partial acromioplasty. If acromioplasty is not performed, report only a debridement. Keep in mind that is an add-on code requiring a primary procedure. When coding the acromioplasty, look for discussion about the morphology (specifically type I, II, or III) in the operative notes. This determines if the acromion is flat, curved, or hooked.

Was the creation of the 1 cm space in the AC joint due to a distal claviculectomy, acromioplasty, or both? If the bur was used to reshape the acromion by removing osteophytes or excess bone, this could be a form of debridement. If the acromioplasty is the only service performed, report a debridement (29822 or 29823). If acromioplasty is performed with distal claviculectomy, it’s possible the two procedures created the 1 cm space. In this situation, it may be appropriate to report or 29826, but not both.

Encourage providers to describe the acromioplasty with morphology and the distal claviculectomy of approximately 1 cm separately, rather than to indicate the creation of a 1 cm space at the AC joint.

Example: If a 1 cm space is created by removing 7 mm from the distal clavicle and 3 mm from the acromion, this is a debridement (29822) because the documentation does not meet the minimum requirements for the distal claviculectomy or the acromioplasty. If the 3 mm removed from the acromion is a true acromioplasty — achieved by converting the acromion to a type I morphology with a subacromial decompression — proper coding is and The 7 mm does not meet the requirements of the claviculectomy. Documentation must support both services.

Rotator Cuff Repair There are three possible codes for open rotator cuff surgery, depending on whether it’s an acute or chronic repair, or if it’s a reconstruction. CPT is the only code for arthroscopic rotator cuff repair.

Shoulder Debridement CPT code cover limited debridement of soft or hard tissue. Use it for limited labral debridement, cuff debridement, or the removal of osteophytes and degenerative cartilage. CPT code cover extensive debridement of soft or hard tissue. It includes for example, an abrasion chondroplasty of the humeral head or glenoid and associated osteophytes, or multiple soft tissue structures that are debrided, such as the labrum, subscapularis and supraspinatus.

Shoulder Debridement Operative documentation should describe all areas, sites, tendons and lesions debrided or excised. A sentence stating, “I performed an extensive debridement” does not justify reporting CPT code What was debrided? How much was debrided? Did the surgeon debride from two or three joint areas/regions? If so, could this debridement stand alone, or was it part of another procedure.

Shoulder Debridement Example
The surgeon may debride the rotator cuff in preparation for repairing the rotator cuff via the arthroscope. If this were the only debridement he performed, you’d consider this inclusive to the arthroscopic rotator cuff repair, since he performed the debridement in preparation for the repair.

Shoulder Debridement Example
However, if the surgeon thoroughly describes the debridement of multiple areas/sites, such as the labrum debridement, abrasion arthroplasty, biceps tendon debridement and partial synovectomy, which are not typically included in a rotator cuff, then you can feel comfortable reporting CPT

Knee Joint

Anatomy of the Knee - Bones
Femur – articulates with the acetabulum proximally and with the tibia and patella distally Patella – a sesamoid bone, serves as a fulcrum and as protection for the underlying structures Tibia the weight bearing, medial bone in the lower leg Fibula – thin, lateral bone in the lower leg, primarily for muscle attachment

Anatomy of the Knee - Ligaments
ACL – Anterior Cruciate Ligament PCL – Posterior Cruciate Ligament MCL – Medial Collateral Ligament LCL – Lateral Collateral Ligament

Anatomy of the Knee – Muscles & Tendons
Quadriceps Rectus femoris Vastus lateralis Vastus intermedius Vastus medialis Hamstrings Biceps femoris Semitendinosus Semimembranosus

Anatomy of the Knee - Meniscus
Medial meniscus is C-shaped Lateral meniscus is more circular in shape and covers a larger portion of the tibial plateau Thick at the edges and thin in the center Avascular, except for 10-30% at the periphery

Pathology of the Knee Sprains & strains of the knee
Lateral collateral ligament Medial collateral ligament Cruciate ligament Testing for ACL injury Lachman’s Anterior Drawer Pivot shift

Pathology of the Knee Degeneration/old disruption of the knee
Lateral collateral ligament Medial collateral ligament Anterior cruciate ligament Posterior cruciate ligament

Pathology of the Knee Tear of meniscal cartilage or meniscus of knee, current – ICD-10-CM choices include: “Bucket-handle” tear of medial meniscus Peripheral tear of medial meniscus Complex tear of medial meniscus Other tear of medial meniscus

Pathology of the Knee Derangement of medial meniscus - ICD-10-CM choices include: Old bucket handle tear Derangement of anterior horn Derangement of posterior horn Derangement of lateral meniscus

Pathology of the Knee Meniscal Tears Vertical longitudinal Oblique
Complete/incomplete longitudinal Bucket handle Displaced bucket handle Oblique Parrot beak Flap Displaced Flap

Pathology of the Knee Meniscal Tears
Radial – transverse tear that follows the radial fibers Horizontal Complex Double flap Degenerative Pathology of the Knee

Pathology of the Knee

Pathology of the Knee MRI classifications of meniscal change
Grade 0 normal with homogeneous signal intensity Grades I & II – high signal intensity within the meniscus, does not go to the surface Grade III – high signal intensity that does go to the surface of the meniscus Approximately one third of meniscal injuries occur in tandem with ACL tears

Arthroscopic Procedures

29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed 29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

Arthroscopic Meniscus Repair
Three basic options Inside-Out Suture – large bucket-handle and longitudinal tears Outside-In Suture – tears of the anterior and middle thirds of the meniscus and for radial tears All-Inside Repair – posterior horn tears Meniscal Arrow

Arthroscopic Ligament Repair
29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction 29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

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