Musculoskeletal
system
(20100 - 29999)
Anatomy
Procedures
• Manipulation = reduction : returning a fracture or dislocation to it’s normal
anatomical position by manually applied forces.
• Stabilization = fixation = immbolization.
• Sprain = twisting : involves the non contractile tissue (the ligament).
• Strain =stretching :involves the contractile tissue (mucle or tendon).
• Arthrocentesis :aspiration of fluid from a joint using needle puncture.
• Trigger points :points or areas where stimulation by touch,pain or pressure
induce a painfull response.
• Replantation :after a complete amputation.
• Repair :after partial amputation.
Fractures
Types of fracture
Fractures
• Def: traumatic or pathological breaking of bone or cartilage
• Types of fractures :
•
•
•
•
Comminuted Fracture—The bone is crushed or splintered into several pieces.
Impacted Fracture—One part of a bone is forcefully driven into another.
Simple Fracture—The bone is in only one place.
Greenstick Fracture—The bone is broken on one surface and bent on the other
(think of the way a "green" twig will break when bent too far); this fracture
occurs in children before the bones have hardened.
• Pathologic Fracture—Caused by disease, such as an infection or a tumor.
• Compression Fracture—The bone is compressed onto another bone; caused by
trauma or osteoporosis, and common in vertebrae.
Treatment of fractures
Closed treatment specifically means that the fracture site is not
surgically opened (exposed to the external environment and
directly visualized). This terminology is used to describe
procedures that treat fractures by three methods: (1) without
manipulation; (2) with manipulation; or (3) with or without
traction.
Open treatment is used when the fractured bone is either: (1)
surgically opened (exposed to the external environment) and the
fracture (bone ends) visualized and internal fixation may be used;
or (2) the fractured bone is opened remote from the fracture site in
order to insert an intramedullary nail across the fracture site (the
fracture site is not opened and visualized).
Percutaneous skeletal fixation describes fracture treatment which
is neither open nor closed. In this procedure, the fracture fragments
are not visualized, but fixation (eg, pins) is placed across the
fracture site, usually under X-ray imaging guidance
Guideline
The type of fracture (eg, open, compound, closed) does not have
any coding correlation with the type of treatment (eg, closed,
open,
or percutaneous) provided
A 22-year-old female sustained a dislocation of the right
elbow with a medial epicondyle fracture while on
vacation. The patient was placed under general
anesthesia, and the elbow was reduced and was stable.
The medial elbow was held in the appropriate position
and was reduced into an acceptable position and
elevated to treat non surgically. A long arm splint was
applied. The patient is referred to an orthopedist when
she returns to her home state in a few days.
What is/are the correct CPT@ code(s) reported?
A) 24575-54-RT, 24615-54-51-RT
B) 24576-54-RT, 24620-54-51-RT
C) 24577-54-RT, 24600-54-51-RT
D) 24565-54-RT, 24605-54-51-RT
• Answer is D
Excision
Excision of subcutaneous soft connective tissue tumors (including
simple or intermediate repair) involves the simple or marginal
resection of tumors confined to subcutaneous tissue below the skin
but above the deep fascia. These tumors are usually benign and are
resected without removing a significant amount of surrounding
normal tissue. Code selection is based on the location and size of
the tumor. Code selection is determined by measuring the greatest
diameter of the tumor plus that margin required for complete
excision of the tumor. The margins refer to the most narrow margin
required to adequately excise the tumor, based on the physician’s
judgment. The measurement of the tumor plus margin is made at
the time of the excision. Appreciable vessel exploration and/or
neuroplasty should be reported separately. Extensive undermining
or other techniques to close a defect created by skin excision may
require a complex repair which should be reported separately
Excision
Excision of fascial or subfascial soft tissue tumors (including
simple or intermediate repair) involves the resection of tumors
confined to the tissue within or below the deep fascia, but not
involving the bone. These tumors are usually benign, are often
intramuscular, and are resected without removing a significant
amount of surrounding normal tissue. Code selection is based on
size and location of the tumor. Code selection is determined by
measuring the greatest diameter of the tumor plus that margin
required for complete excision of the tumor. The margins refer to
the most narrow margin required to adequately excise the tumor,
based on individual judgment. The measurement of the tumor plus
margin is made at the time of the excision. Appreciable vessel
exploration and/or neuroplasty should be reported separately.
Extensive undermining or other techniques to close a defect created
by skin excision may require a complex repair which should be
reported separately.
Excision
Radical resection of soft connective tissue tumors (including
simple or intermediate repair) involves the resection of the tumor
with wide margins of normal tissue. Appreciable vessel exploration
and/or neuroplasty repair or reconstruction (eg, adjacent tissue
transfer[s], flap[s]) should be reported separately. Extensive
undermining or other techniques to close a defect created by skin
excision may require a complex repair which should be reported
separately. Dissection or elevation of tissue planes to permit
resection of the tumor is included in the excision. Although these
tumors may be confined to a specific layer (eg, subcutaneous,
subfascial), radical resection may involve removal of tissue from
one or more layers. Radical resection of soft tissue tumors is most
commonly used for malignant connective tissue tumors or very
aggressive benign connective tissue tumors.
Example
• A 19-year-old male college student bumped his right thigh while playing intramural rugby on the lawn of the
Cathedral of Learning. He sustained a lump and bruise. and the pain was so intense he had to be taken to ED
for treatment. The ED physician was uncertain and concerned about the lump on the patent's thigh so he
asked the dermatologist on call to diagnose the suspicious lump. The dermatologist diagnosed the patient
with a 2.5 cm benign tumor of the right thigh. and recommend that he follow up with his dermatologist for
treatment. Two weeks later, the patient arrives to the dermatologist for excision of the benign tumor. The
patient was prepped, draped. and anesthetized appropriately. The physician makes an incision over the
tumor through the skin, subcutaneous tissue, and muscle. The tumor was visualized then removed. The site
was flushed with saline. Hemostasis was achieved with electrocautery. The site was closed with sutures in
layers. Which procedure code(S) best describe this encounter?
• A. 11404
• B. 27328. 12031-51
• C. 11404, 12031-51
• D. 27328
• ANSWER IS D
Wound exploration
20100-20103 relate to wound(s) resulting from penetrating trauma
These codes describe surgical exploration and enlargement of the
wound, extension of dissection (to determine penetration),
debridement, removal of foreign body(s), ligation or coagulation of
minor subcutaneous and/or muscular blood vessel(s), of the
subcutaneous tissue, muscle fascia, and/or muscle, not requiring
thoracotomy or laparotomy.
If a repair is done to major structure(s)
or major blood vessel(s) requiring thoracotomy or laparotomy, then
those specific code(s) would supersede the use of codes 2010020103. To report simple, intermediate, or complex repair of
wound(s) that do not require enlargement of the wound, extension
of dissection, etc, as stated above, use specific Repair code(s) in the
Integumentary System section
.
• ANSWER IS A
Introduction /removal
• Introduction or removal includes codes for
injections, foreign body removal, and placement of
catheters for radioelement application. Surgical
injections involve direct insertion of a needle into a
tendon, muscle, or joint for the aspiration of fluid or
the administration of medication. When coding
injections, watch for bundled procedures. For
example, trigger point injections (20552—20553) are
selected based on the number of muscles injected.
not the number of injections performed.
• Testing Technique
• Highlight the number of muscles in the code
descriptions for 20552 and 20553. Write a note that
states “Select code according to number muscles,
not the number of injections”.
• An arthrocentesis of a joint include aspiration of fluid
or the injection of an anesthetic agent or steroid.
• The codes are selected based on the size of the joint
and with or without ultrasound guidance. When a
joint aspiration and injection are performed on the
same joint. only report the procedure once- If the
procedures are performed on more than one joint, list
each procedure separately .
• Injection of a substance does not include the drug
itself. the drug supply may be billed separately using a
HCPCS Level II code.
• Example:
• The provider 3 cc of fluid from the left knee. He
injects 40 mg of Kenalog into the right knee. The knee
• is a major joint. The proper codes are 20610-LT and
20610-RT for the procedures. The Kenalog is reported
with HCPCS Level II code J3301 with four units because
the code is for 10 mg.
Example
• A 39-year-old involved in a motor vehicle accident (MVA) a year ago arrives to the pain
clinic with complaints of neck pain and left-sided radiculopathy complicated by cervical
degenerative disc disease. NSAIDs and physical therapy have been unsuccessful, and the
patient requires multiple trigger point injections. The left multifidus , trapezius, and right
levator scapular were injected. The area was cleansed and bandage applied. Which
procedure code(s) best describe this encounter?
• A. 20552
• B. 20553
• C. 20610
• D. 20553x3
• Answer is B
Spinal surgery often requires the skills of more
than one surgeon. When these surgeons work
together as surgeons performing a portion of the
same procedure, modifier 62 should be
appended to report the service. Each surgeon
dictates an operative report for his or her portion
of the surgery, and each surgeon reports the
same code with modifier 62.
Arthrodesis
Arthrodesis is the surgical immobilization of a joint, which is intended to result in bone fusion.
This procedure is often documented in the operative note as a fusion. A physician may implant pins,
plates, screws, wires, or rods to position the together until they fuse. Bone grafts may be needed if
there is significant bone Joss. When selecting codes for spinal arthrodesis, you need to know the
approach (anterior, posterior, posterolateral, or lateral transverse). You also need to know the
vertebral segment (cervical, thoracic, or lumbar).
Disarticulation is the separation of two bones at the joint, either traumatically or by surgical
amputation.
Spinal instrumentation
• Spinal instrumentation codes are add-on codes; they are to be coded in addition
to the primary surgery (eg, arthrodesis 22800—22812). Add-on insertion codes
22840—22848 are not to be reported with reinsertion code 22849 or removal code
22850. Add-on insertion codes are reported when new hardware is put in for the
first time or when new hardware is put in which exceeds the previously placed
hardware and includes removal of the old hardware.
• Reinsertion (22849) is reported when the hardware is going back in the same
spinal levels as
• the previous placed hardware and includes the removal of the old hardware.
• Removal codes (22850, 22852, and 22855) are reported when only the hardware
is taken out.
Grafts
• Grafts (or implant) codes are used when
obtaining bone, cartilage, tendon or fascia Iata
grafts, or other tissue. An autograft is a graft of
tissue or bone harvested from the patient. In
coding orthopedic surgery, an autograft can be
bone, cartilage, muscle or tendon. If the
material being grafted is from a donor, it is
known as an allograft. Bone grafting to stabilize
the spine is common. Codes 20930—20938
report the grafting procedures, are add-on
codes listed separately in addition to the code
for the primary procedure.
• Testing Technique
• If the procedure code description includes the
harvesting of the graft, do not report the graft
code separately. Add a notation in this section to
indicate graft is only reported If not included in
the procedure note description. For example,
21194 includes obtaining the graft.
21193 Reconstruction of mandibular rami,
horizontal, vertical, C,
or L osteotomy; without bone graft
21194 with bone graft (includes obtaining graft)
Example
Within the spine section, bone grafting procedures are reported
separately and in addition to arthrodesis. For bone grafts in other
Musculoskeletal sections, see specific code(s) descriptor(s) and/or
accompanying guidelines.
To report bone grafts performed after arthrodesis, see 2093020938. Do not append modifier 62 to bone graft codes 2090020938.
Example:
Posterior arthrodesis of L5-S1 for degenerative disc disease
utilizing morselized autogenous iliac bone graft harvested through
a separate fascial incision.
Report as 22612 and 20937.
Example
Within the spine section, instrumentation is reported separately and
in addition to arthrodesis. To report instrumentation procedures
performed with definitive vertebral procedure(s), see 22840-22855,
22859. Instrumentation procedure codes 22840-22848, 22853,
22854, 22859 are reported in addition to the definitive
procedure(s). Modifier 62 may not be appended to the definitive or
add-on spinal instrumentation procedure code(s) 22840-22848,
22850, 22852, 22853, 22854, 22859.
Example:
Posterior arthrodesis of L4-S1, utilizing morselized autogenous
iliac bone graft harvested through separate fascial incision, and
pedicle screw fixation.
Report as 22612, 22614, 22842, and 20937.
Example
Vertebral procedures are sometimes followed by arthrodesis and in
addition may include bone grafts and instrumentation.
When arthrodesis is performed in addition to another procedure,
the arthrodesis should be reported in addition to the original
procedure with modifier 51 (multiple procedures). Examples are
after osteotomy, fracture care, vertebral corpectomy, and
laminectomy. Bone grafts and instrumentation are never performed
without arthrodesis.
Example:
Treatment of a burst fracture of L2 by corpectomy followed by
arthrodesis of L1-L3, utilizing anterior instrumentation L1-L3 and
structural allograft.
Report as 63090, 22558-51, 22585, 22845, and 20931
The surgeon performs the spine procedure for an anterior thoracic two-level arthrodesis,
anterior single level discectomy, anterior plate instrumentation, and structural, autograft iliac
crest bone graft. What code(s) would be reported?
A) 63077, 22556-51, 22845, 20938
B) 63077, 22556, 22585, 22845,20930
C) 63077, 22556-51, 22585, 22845, 20938
D) 63077, 22610, 22556, 22845-51, 20938-51
Example
• A 37-year-old male with a history of neck pain and radiculopathy with failed physical
therapy. CT, MRI, and Myelogram all confirm C6-C7 spondylosis and right disc protrusion. The
patient will have to have his disc removed. The patient is prepped and draped in sterile
fashion. After administration of anesthesia, a transverse incision is made anteriorly. The
muscles are excised for access to the target disc. The disc between C6-C7 is identified and
removed. The posterior longitudinal ligament was removed to provide access to excise the
osteophytes, and decompression is achieved. The disc space was prepared utilizing a burr
drill, homogenous structural bone grafting was inserted. and segmented instrumentation
with endplates were applied anteriorly to achieve arthrodesis.
• A. 63075, 22551-51, 22845, 20931
• B. 22551, 22840, 20930
• C. 22551, 22845, 20931
• D. 63075, 22551-51, 22840, 20930
• Answer is c
Cast / strapping
• When a physician reports a treatment of a fracture and then
applies a cast or strapping, the cast or strapping is included in
the procedure. A physician may code for a cast or strapping
when the cast or strapping is the only treatment given at the
first visit and no surgical treatment is planned. Each
replacement cast or strapping can be reported.
• Modifier 58 is reported with a cast or strapping procedure
performed in the postoperative period. The removal of a cast
or strapping is not reported separately unless the service is
provided by a physician who did not apply the cast
CPT modifiers
CPT modifiers
Example
• Answer is c
Example
• ANSWER IS A
Example
• Answer is c
Example
• Answer is d