Chapter 4 (p. 84) Surgery
MUSCULOSKELETAL
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Chapter Layout
General subcategory includes headers and codes that
can apply to almost any site on the body. Then
another subcategory of Head, Neck, ...
Will use lots of modifiers -LT, -RT, -50 (on paired body
sites if exactly the same procedure on both parts)
and ID'ing which digit on hand or foot.

Indexing: Excision, Tumor, Site
If skin: integumentary
If muscle: musculoskeletal
In a cavity: other sections possible.
Splints: Know static (no movement) or dynamic
(flexible) . Code the ones that need to be fitted
(often by a nurse), Ex: OCL, Volar, Splint Roll,
Sugar Tong, Ulna gutter splints. Can find this info in
physician orders if not documented otherwise.
Some splints are prepackaged -- do not code these.
Fractures and Dislocations (p. 84)
Coding procedures for Tx:
 Which body site dealing with.
 Is the Tx closed or open (not the Fx)
If closed Fx, the Tx may be open (surgeon)
Open Tx: Includes when an incision is made and when
Fx site is opened remote from the Fx site to insert a
nail across the Fx site.
Percutaneous Skeletal Fixation: Tx of Fx by placing
fixation devices (pins) across Fx site, usually with
X-ray imaging. (Neither open nor closed-has its own
set of codes) Also code imaging supervision.
Manipulated Fx/dislocation? (In ICD, synonymous with
Fx reduction) Manipulation may be tried in OR prior
to an open procedure -- Code open procedure.
Manipulation may be attempted and failed -- Then try
other Tx on another day: Code manipulation the
1st day. Then code the other Tx when it occurs. If
this is tried on the same date of service, but
perhaps in 2 dif't settings (ER, Obs) then they are
two separate events, coded separately.
Did the procedure include internal/external fixation?
Don't confuse the ones that are sticking out on the
outside of the body. 20690 Uniplane - 1 direction.
20592 Multiplane - multiple different angles.
Application of Casts and Strapping and Splints
(29000-29750)
Only use these codes if there is no greater procedure
being done that would include these procedures.
 To ID replacement of a cast or strapping during or after


the period of normal follow-up care (global post-op
period)
To ID an initial service performed w/out any restorative
Tx or stabilization of the Fx, injury, or dislocation and/or
to afford pain relief to the pt.
To ID an initial cast or strapping when the same phys.
does not perform, or is not expected to perform, any
other Tx or procedure
To ID an initial cast or strapping when another phys.
providing or will prove restorative Tx
Removal of cast is coded 29700-50 if it is a different
physician doing the removal. (office setting) Not
used in the hospital bcs it is part of a global surgical
package deal.
Amputations (CPT p. 145, 136)
27590 Thigh, thru femur, any level (above the knee up)
27596 Re-amputation (Diabetic/poor circulation needs
repeat procedure higher up)
If leg amputated on lower half (tibia/figula) once and
2nd time, amputate through thigh, then the 2nd
time is not a re-amputation. It is the first
amputation of the thigh. Even if surgeon says
`re-amputation'.
Fingers and Toes have different terminology.
26951 includes `primary or secondary' and that
means 1st amputation or re-amputation.
Ray amputation means if hand bone (metacarpal) is
removed, the finger that connects to it is also
removed. Also removes the tendons that go with
the finger. Neurectomy (takes the nerves out).
Modify for the site: LT, RT, fingers/toes HCPCS Level II
Arthroscopy (with scope) (p. 88)
 Know body part involved
 What type of procedure: surgical or diagnostic
Knees & Shoulders: high incidence
Diagnostic arthroscopy is always part of the surgical
endoscopy code. If doing diagnostic procedure and
they end up fixing something, then it becomes a
surgical procedure.
Diagnosis arthroscopy code that include (separate
procedure) would not be used. This is used when
just looking around.
If description of CPT code does not say `with scope', it is
an open procedure code. Can't use it with scope.
Look for HCPCS Level III, or Technical codes, or
unlisted procedure code.
3 Knee compartments - Medial, Lateral, Patella/femoral
Chapter 4 (p. 84) Surgery
MUSCULOSKELETAL
If arthroscopic procedures performed in same
compartment and one code is included within
another code, use the combination code (greater of
the two procedures).
If big arthroscopic procedure in Medial compartment
and small arthroscopic procedure in lateral
compartment, then code both comprehensive code
and component code with -59 on component code
bcs in separate and distinct compartment of knee.
If procedure performed in 1 compartment and did
diagnostic review of other compartments, don't
code the diagnostic parts at all. Assumed in code
that the whole knee was reviewed.
If no compartment is mentioned, its probably just a
diagnostic procedure.
For knee arthroscopies: Print paper copy of Op Rpt, 3
diff't color highlighters and assign each color to its
own compartment. Easier to code.
29866-29887 Arthroscopy, knee, surgical
29870 diagnostic only (separate procedure)
29877 is a component code of 29881 (included within
the larger one)
If using 29874 for medial compartment procedure and
using 29877 for lateral compartment procedure,
you can code both, tacking on -59 on the lesser
code.
If using 29874 for medial compartment procedure and
29877 also for medial component, then code only
29877 bcs those above are included in the codes
below.
Spine
Musculoskeletal includes spinal column bones,
vertebrae, discs.
Nervous System inncludes spinal cord,dura, nerves, etc.
Injury to spine will often include codes from both areas.
Percutaneous vertebroplasty: injection of cement into
the vertebral bone (22520-27) for stabilization.
1 code for each vertebra done.
Check Level of vertebra (thoracic or lumbar)
Add-on code for each additional vertebra
Kyphoplasty: Raise vertebra with baloon, then stabilize
with vertebroplasty. (22523) Including cavity
creation.
Both use imaging guidance. Usually Fluoroscopy. Add
code for this.
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Example:
Vertebroplasty on T6, T7, T8 = (T6-T8) 3 levels
22520, 22522, 22522
Vertebroplasty on T12, L1-L3
22520, 22521, 22522, 22522
Vertebroplasty on T11, T12, L1-L2
22520, 22521, 22522, 22522
Arthrodesis (CPT, p. 114)
Spinal fusion of vertebrae
May use donor bone products from a bone bank.
Includes note to include add-on codes (20930-38) if
using bone graft.
Morselized: small pieces of bone compacted together
Structural bone graft: a whole piece of bone
An autograft of bone would come from cancelous bone
(lattice-like/spongy bone). With arthrodesis: Code
arthrodesis/Fusion code and the bone graft code.
Bone Marrow Aspiration: comes from iliac crest. If
use aspiration of bone marrow, code it separately,
but the arthrodesis encompasses the use of that
bone marrow. No separate code for a gaft.
Minimum number of vertebrae in a fusion is 2.
If arthrodesis is for a spinal deformity (22800-19)
Also broken into type of Approach:
 Lateral Extracavitary (side)
 Anterior or Anterolateral
 Anterior Approach (front)
 Posterior, Posterolateral or Lateral Transverse
(back, side to back,
)
Example:
Fusion: L1-L2 = 1 fusion
L1-L5 = 4 fusions
Can excise an intervertebral disc at the same time as an
arthrodesis.
Bunions (See handout for inclusions)
(28290-28299) (CPT, p. 151)
Hallux-Valgus Corrections
Can be caused by heredity.
Muscles and tendons loosen and bones move out of
alignment.
Repair consists of realignment techniques
Medial: towards center of body
Lateral: away from the center of body
Chapter 4 (p. 84) Surgery
MUSCULOSKELETAL
Osteotomy: cut into the bone
Medial eminence: protrusion to the inside of the body
Sometimes cut off (osteotomy) of medial eminence of
metatarsal bone.
Keller-Type Procedure: Use Kirschner wires through
phalanx and into metatarsal bone.
Keller-Mayo Procedure with Implant: Cut off eminence
and push implant into the proximal phalanx.
Joplin Procedure: Include tendon transplant to help
hold the toe.
Mitchell Procedure: Osteotomy cuts thru bone, move it
over, and hook it together w/wire link.
Double Osteotomy: Very common type of bunion
repair.
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May use operating Microscope (31531,36,41): Use for
magnification.
(Do not use 69990 with these codes.)
69990 Operating Microscope; Add-on code.
If for any procedure they use an operating microscope
and it is not part of the code, add the code on.
Flexible Fiberoptic Laryngoscopy: Using flexible scope
down thru nasal cavity. Use vasoconstrictors to
reduce bleeding and allow more room to move.
Bronchoscopy (31622-51) (p. 99)
Common procedure. Often need multiple codes.
Flexible (more commonly used) or Rigid (open-tube)
bronchoscope.
Bunion (Hallux-Valgus) Correction reports can be long
and detailed, talking about muscles & tendons.
Fluoroscopic guidance is part of parent code
Each of the codes includes:
Capsulotomy: cutting into the joint capsule
Synovial Biopsy:
Neuroplasty: Moving nerves
Synovectomy: Taking out part of the synovium
Tenolysis: Fixing tendons
Excision of medial eminence
Excision of osteophyte: bone calcification
Placement of internal fixation: Kirschner wires,
etc.
Bronchoscopies are Bilateral
Respiratory (p. 93)
Nasal Sinus Endoscopy: (with scope) (31231-97)
Diagnostic procedure included in the surgical procedure
as with any endoscope. Will look into interior nasal
cavity, middle and superior meatus, the turbinates
(concha), the sphenoethmoid recess.
Is it just diagnostic? Usually gonna do something if they
are in there with a scope.
Sinusotomy is included with a diagnostic procedure.
Need to incise sinus walls to move into different
cavities.
Codes in this range are assumed to be unilateral. Use
modifiers to indicate side or bilateral (if exactly the
same)
If no mention of scope, it is probably an open
procedure/ Incision (31000-31230)
Laryngoscopy (31505-31579) (CPT, p. 169)
Indirect: Not using a scope. Using a mirror + Light
source.
Surgical Bronchoscopy includes diagnostic.
BAL: Bronchioalveolar Lavage 31624
Push saline in and pulling it back out along with
cells.
Total Lung Lavage 32997 is unilateral (No -Lt/-Rt)
Protected Specimen Brushings (PSB) obtain tissue that
could not be obtained with biopsy forceps.
Code biopsies only once, no matter how many they do
from the bronchus or endobronchial area.
Lung biopsy via a bronchoscopy cross the bronchial
wall, into the lung tissue (transbronchial biopsy)
31628 (lung tissue). One code for as many biopsies
of one lobe. 31632 is the add-on code for biopsy of
another lobe.
2 lungs = 5 lobes
A transbronchial biopsy from both upper lobes
31628, 31632
Maximum # of times 31632 can be used = 4
1 account could have endobronchial and transbronchial
biopsies, so will need 31625 and 31628.
Aspirations also allow multiple biopsies (fluid) per lobe.
Lung Procedures
Wedge Resection = technique being used.
May be used for diagnostic or therapeutic purposes.
Is the lesion being totally excised or just being sampled?
Chapter 4 (p. 84) Surgery
MUSCULOSKELETAL
A lobectomy  a pneumonectomy
A lobe vs entire lung
Thoracoscopy (video-assisted thoracic surgery [VATS])
Similar to laparoscopy in approach.
Pushes some air in chest and will cause a collapsed lung.
Do not code this as a Dx code.
Thoracotomy (No scope) Open procedure
VATS (with scope)
Lung Transplantation
Recipient of cadaver lung will indirectly pay for the
organ. Midamerica Transplant bills the recipient so
information is not breached. They also keep the
registry.
May need to code donors in S. Illinois.
Backbench Work: Harvested organ comes out with
extra tissue. It needs to be custom fitted on site of
the recipient. The recipient will also pay for this.
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