MHA
June 11, 2009
Irene Mueller, EdD, RHIA

• 2 nd hour – Coding Common MS Tx
– ICD-9-CM
– CPT coding
• Resources

• Procedures
– ICD-9-CM
– CPT

• ICD-9-CM
– 77.40-49 Bone Bx OR 41.31 Aspiration bone marrow
• CPT
– Bone biopsy - 20220
– Bone marrow aspiration performed alone
• 38220
– Bone marrow biopsy is performed
• 38221 (bone marrow biopsy)
• cannot report with CPT code 20220 (bone biopsy)
– 38220 and 38221 reported together
• If two procedures performed at separate sites or at separate encounters
• Separate sites = different bones OR 2 skin incisions over same bone
– 38221 and 38220 performed at same site through same incision
• Only CPT 38221 is reported

• ICD-9-CM
– 87.21
• CPT
– Myelography
• Brain 70010
• Spine
– Cervical 72240
– Lumbosacral 72265
– Thoracic 72255
– Total 72270

• ICD
– 81.91
Arthrocentesis
• includes: Joint aspiration
• excludes:
– for arthrography (88.32)
– bx of joint structure (80.30-80.39)
– for injection of drug (81.92)
• CPT
– Arthrocentesis
• Intermediate Joint 20605
• Large Joint 20610
• Small Joint 20600

• Type of fx doesn’t always correspond to type of tx
• ICD-9-CM - determine
• Open/closed (Remember open = MUST connect w fx site)
• Internal fixation used?
• Bone involved, part of bone
• Open reduction
– 79.6x Add’l code for debridement
– Extremities only
– Debridement included in open fx reductions of
• Skull, nasal, orbital, other facial, vertebral bones

• Many more specific fx proc codes than ICD
• Pinning
• Closed tx
– w/ manipulation (reduction)
– w/o manipulation
– w/ or w/o skeletal traction
• Open tx (fx site is surgically opened/exposed)
• Percutaneous Skeletal
Fixation
– External fixation (removal included in global pkge)
– Internal Fixation (ORIF)
• Application/Removal of initial cast/splint
• Normal, uncomplicated
Follow up

• ICD-9-CM
– 78.5.x w/out fx reduction
• Fx w/good alignment
• IF device reinserted – displaced/broken
– IF with bone grafts, shortening/lengthening bone, Int. Fix. is INCLUDED in those codes
• CPT
– Ex: ORIF of left mandibular fx 21470-LT

• ICD-9-CM
– Reduction w/
External fixator device
• add’l code 78.10-
78.19
• Type of device – add’l code
– Monoplanar – 84.71
– Ring system – 84.72
– Hybrid system (both of above) – 84.73
– No reduction
• 93.4x – traction
• 93.5x – Other immobilization, etc.
• 97.88 – Removal of these devices
– Mini-fixator
• 78.1 Application – add’l code to any fx reduction
• 78.6 Removal

• 20692 Add’l code, unless ext. fix included
• Ex: Closed tx of femoral shaft fx with manipulation and external fixation system application
– 27502, 20692-51
• Ex: Closed tx of tibial fx w/manipulation, application of cast, partial skin debridement of fx site
– 27752, 11040

• ICD-9-CM
– 79.6X Debridement of open fracture
– Used instead of 86.22, Excisional debridement of wound, infection, or burn
• CPT
– 11010, 11011 and 11012
• Differ by extent of debridement
• Must meet open fx definition

• Disarticulation OR
• Cutting thru bone
• ICD-9-CM
– 84.xx
• 3 rd digit = upper/lower limb
• 4 th digit = portion of limb
AND type of amputation
– 84.3 Revision of stump
– 84.1x – Revision of current traumatic amputation
• BKA = 84.15, AKA =
84.17
– If BKA converted to
AKA, code just the
AKA
• Metatarsal = toe amputation
• Transmetatarsal = foot amputation

• ICD-9-CM
– Associated w/reduction of fx
• Dislocation reduction incl. in fx reduction code
– Not assoc. w/fx
• 79.7x Closed reduction
• 79.8x Open reduction
• CPT
– Body part
– Open
• Acute/chronic
• Internal Fixation or not
– Closed
– w/wout Manipulation
– w/wout Anesthesia
– Application and removal of first cast or traction included in these codes

• ICD-9-CM and CPT
– Application included in reduction code
– Reported when cast/splint is
• Replacement procedure
• Initial service w/out restorative tx
• When performed in ED setting
– for comfort and stabilization
– patient is to follow-up with another physician for definitive treatment
– only splinting, strapping or casting service is reported
– Do NOT assign a CPT code for fracture treatment without manipulation.

• ICD-9-CM
–
Repair
• Ligament (see also
Arthroplasty) 81.96
– collateral, knee
NEC 81.46
•
– cruciate, knee NEC 81.45
– Reconstruction >
Construction and repair
• Knee (joint) NEC 81.47
•
• CPT
– Codes often include graft harvesting
Ligament, Repair
– Knee Joint 27405 - 27409
• Knee, Reconstruction
– Ligament 27427 - 27429
Knee, Repair
– Ligament 27405 - 27409
– Collateral 27405
– Collateral ligaments 81.46
– Collateral and Cruciate 27409
– Cruciate ligaments 81.45
– Cruciate 27407 – 27409
– Five-in-one 81.42
– Triad 81.43
–
Arthroscopic 29888 -
29889 (not in Index here)

• ICD-9-CM
• Bunionectomy (radical) 77.59
– with
• Arthrodesis 77.52
• Osteotomy of first metatarsal 77.51
• Resection of joint with prosthetic implant 77.59
• Soft tissue correction NEC 77.53

• Hallux valgus repair codes
– 28290-28299
– Bunion Repair
• Chevron Procedure 28296
• Concentric Procedure 28296
• Joplin Procedure 28294
• Keller Procedure 28292
• Lapidus Procedure 28297
• Mayo Procedure 28292
• McBride Procedure 28292
• Mitchell Procedure 28296
• Silver Procedure 28290
• with Implant 28293

• Austin Bunionectomy and Reverse Austin Bunionectomy
– 28296 Hallux valgus (bunion) correction, w/ or w/out sesamoidectomy; with metatarsalosteotomy
(eg, Mitchell, Chevron, or concentric type procedures).
• Distal modified McBride bunionectomy, correction of angular deformity of the first metatarsal w/ proximal osteotomy
– 28292, Correction, hallux valgus (bunion), w/ or w/out sesamoidectomy; Keller, McBride, or Mayo type procedure ,
28306 -59, Osteotomy, w/ or w/out lengthening, shortening or angular correction, metatarsal; first metatarsal ,
– reported with modifier 59 because this code describes the proximal metatarsal osteotomy performed at another site on the metatarsal (usually requiring a separate incision)

• ICD-9-CM
– 83.03 Bursotomy
• includes: Removal of calcareous deposit of bursa
• excludes: aspiration of bursa (percutaneous) (83.94)
– 83.5 Bursectomy (incl. debridement of bursa)
– 83.96 Injection bursa (therapeutic agent)
• CPT
– Many more codes than CPT
– Bursa, Bursocentesis, I&D, etc.

• ICD
– Converted to open, code only open w/ V64.43
– 80.20-80.29
• CPT
– Dx – visualization and synovial Bx ONLY
• 29870 (separate procedure)
– Surgical – anything else done
• Includes dx
• # of compartments important for some codes

• ICD-9-CM
– 04.43
Release of carpal tunnel
– (Decompression = main term)
• CPT
– Carpal Tunnel
• Injection
– Therapeutic 20526
– Carpal Tunnel Syndrome
• Decompression 64721
– Arthroscopic 29848

• ICD-9-CM coding
– Based on joint and total/partial replacement
– 81.5x = lower extremity joints
– 81.8x = upper extremity joints
– Add’l Codes
• Hip replacement – type of bearing surface
– 00.74 metal on polyethylene
– 00.75 metal on metal
– 00.76 ceramic on ceramic
• Bone-growth stimulator – add’l code
– 78.9x
– Bilateral replacement – code assigned X 2

• CPT coding
– 27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) notices: For prosthetic replacement following fracture of the hip, use 27236
– 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
– 27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft
– 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft
– 27137 acetabular component only, with or without autograft or allograft
– 27138 femoral component only, with or without allograft

• Due to infection
• ICD-9-CM coding (Dx)
– 1 st admission
• 996.66, 80.0x
• Infection must be cleared (1-2 months)
– 2 nd admission
• 736.x (Acquired deformity)
• Joint revision code

• Adjust or remove and replace
• ICD-9-CM coding
– Includes removal of component(s)
• 81.53 hip component NOS
• 00.7000.73 (hip components) add’l code
• 81.54 knee component NOS
• 00.8000.84 (knee components) add’l code
• 84.57 removal of joint spacer (cement) add’l code
• 81.59, 81.97 joint revision NEC (upper/lower extremities)
• 00.74 – 00.76 add’l code (if known)
• V43.6 Joint replacement status, if significant for pt care

• CPT Coding
– 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft
– 27137 acetabular component only, with or without autograft or allograft
– 27138 femoral component only, with or without allograft
• Many other joint arthroplasties in CPT

• Usual tx – current surgical techniques allow 9 out of 10 pts w/bone cancer in arm/leg to keep limb
• ICD-9-CM
– Excision, lesion, bone (no distinction for type)
• CPT
– Inconsistent Index
• Tumor, Excision, Bone, Malignant
• Go to specific bone
– Tumor (usu. Means ca), Radical, etc.

• Distinguish bet. Spinal segments from interspaces
– T1 = one vertebra/one segment
– T1-T2 = one interspace OR two segments
• Bone grafts – sep. codes
– Only one code per operation, even if more than one level
• Instrumentation procedures – sep. codes
• Arthrodesis procedures – sep. codes
• -62 modifier for 2 surgeons

• Anterior/Posterior approach
• Osteotomy code includes
– Corpectomy, discectomy, laminectomy

• 3 basic approaches
– Anterior, posterior, lateral transverse
• ICD-9-CM coding
– Anterior (81.02-81.36)
• Incision of neck/abdomen
• Front of vertebrae
(anterior annulus)
– Posterior (81.03 –
81.38)
• Incision of back, directly over vertebrae
– Lateral Transverse
(81.07, 81.37)
• Incision of side
• Lamina approach
• Add’l Codes
– Insertion of interbody fusion device – 81.51
• Bak cage, ray-threaded fusion cage, synthetic cage, spacer, bone dowels
– Number of fused discs
• 81.62 – 2-3
• 81.63 – 4-8
• 81.64 – 9+

• Both anterior & posterior portions
• Single incision (usually lateral)
• 1 st – fusion or refusion procedure
• 2 nd – ALIF, PLIF, OR TLIF
– Anterior Lumbar Interbody Fusion
• 81.06, 81.36
– Posterior Lumbar Interbody Fusion
• 81.08, 81.38
– Transforaminal Lumbar Interbody Fusion
• 81.08, 81.38

• Pseudoarthrosis
– False joint due to inadequate immobilization of fx bone
– Greater original fusion, more likely pseudoarthosis will occur, need refusion
• 81.34, 81.35, 81.36, 81.39 = Refusion
– Various sites, various approaches

• Kyphoplasty – reestablish vertebral height
– Uses inflatable balloon to gain height
– Injection of Polymethylmethacrylate to stabilize
– ICD-9-CM - 81.66
– CPT
• 22523 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic
• 22524 lumbar
• 22525 each add’l thoracic or lumbar vertebral body
(List separately in addition to code for primary procedure)

• Stabilize/strengthen bone
– Insertion of cement (glue) into body
• Polymethylmethacrylate
– NO balloon
– ICD-9-CM – 81.65
– CPT
• 22520 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic
• 22521 lumbar
• 22522 each additional thoracic or lumbar vertebral body
• Add’l code for fluoroscopic/CT guidance

• ICD-9-CM Coding
– Type of prosthesis – total/partial
– Spinal segment
• Cervical – 84.61, 84.62
• Thoracic – 84.63 (total/partial – same code)
• Lumbarsacral – 84.64, 84.65
• No location – 84.60
– Revision/replacement – 84.66-84.69
• Synchronous insertion of new prosthesis

• Arthodesis of T1-T3; autograft from ribs
Dual rods inserted w/multiple hooks/wires
– 22610, 22614, 22614 – 3 fusions
– 22842 - rods
– 20936 – autograft
• Surgical repair of L1-2 and L3-L4 by 2 surgeons (distinct parts of procedure)
– 22612-62 (reported by each surgeon)
– 22614-62 (reported by each surgeon)

• Primary osteoarthritis of hip
– 715.95 (Localized NOT documented)
• Admitted for removal of internal fixation nail that has protruded into surrounding tissue, causing pain
– Main term? Complication, mechanical
– Type of care? NOT routine follow-up
– Code? 996.40

• Compound fracture, shaft of radius and ulna, due to tackle in football game
– 813.93, E886.0, E849.4
• Aftercare for fracture of L4 vertebra
– V54.17
• Cervical strain due to MVA, 2ndary to loss of control and collision w/tree. Pt was restrained driver.
– 847.0, E816.0 (tree off highway) OR E815.0 (fallen tree on hwy)
• Derangement of knee due to fall from ladder while working on house
– 836.2, E881.0, E849.0

• View ORlive http://www.or-live.com/
– Previous webcasts
– Browse by specialty
– Orthopaedics
– April 7, 2009
Spotlight on Beth Israel Orthopedics, New York
City
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– Code the 4 operations
– Dx? Procedures – ICD and CPT

imueller@email.wcu.edu

• Brown, F. ICD-9-CM Coding Handbook with
Answers , 2006. AHA Press.
• Frazier, M. S. & Drzymkowski, J. W. Essentials of
Human Diseases and Conditions , 4 th ed.,
Saunders, 2009
• Green, M. A. 3-2-1 Code It!
2 nd ed. 2010. Delmar.
• Moisio M. A. & E. W. Moisio, Understanding
Laboratory and Diagnostic Tests , Delmar, 1998
(2 nd ed? later)
• Scott, A. S. & Fong, E. Body Structures and
Functions , 11 th ed., Delmar, 2009

• ORlive http://www.or-live.com/
• Laminectomy Back Surgery Video. Spine-
Health.
– http://www.spine-health.com/video/laminectomy-back-surgery-video
• Microdiscectomy: Lumbar Microdecompression
Spine Surgery Video. Spine-Health .
– http://www.spine-health.com/video/microdiscectomylumbar-microdecompression-spine-surgery-video

• Minimally Invasive Discectomy. ORLive.
– http://www.or-live.com/distributors/NLM/rnh.cfm?id=310
• Pediatric Spinal fusion to correct scoliosis.
ORLive. (via NLM link)
– www.or-live.com/distributors/NLM/rnh.cfm?id=321
• Spine Fusion Surgery Video. Spine-Health.
– http://www.spine-health.com/video/spine-fusion-surgery-video

• Acute vs. Chronic Pain. Cleveland Clinic .
– http://my.clevelandclinic.org/services/Pain_Management/hic_Acute_vs_Chronic_Pain.
aspx
• A Guided Tour of the Visible Human
– http://www.madsci.org/~lynn/VH/tour.html
• Bone scan. Mayo Clinic.
– http://www.mayoclinic.com/health/bone-scan/MY00306
• Bunionectomy. Clinical Policy Bulletin: Aetna.
– http://www.aetna.com/cpb/medical/data/600_699/0629.html
• Bursitis and Tendinitis; Questions and Answers. National
Institute of Arthritis and MS and Skin Diseases. April
2007.
– http://www.niams.nih.gov/Health_Info/Bursitis/default.asp

• Drugs of Abuse, Chapter 1 The Controlled Substance
Act. Drug Enforcement Administration, US DoJ.
– http://www.usdoj.gov/dea/pubs/abuse/1-csa.htm
• Feinberg, S. D. MD. Medications and Chronic Pain, 2007
Supplement. American Chronic Pain Association.
– http://www.theacpa.org/documents/ACPA%20Meds%202007%20Final.pdf
• Hallux Valgus (Bunion Deformity)
.
Institute for Foot and
Ankle Reconstruction. Mercy Hospital, Baltimore, MD.
– http://footandankle.mdmercy.com/conditions/bigtoe/hallux_valgus.html

• Myelography. American Society of Radiologic Technologists.
– https://www.asrt.org/content/ThePublic/AboutRadiologicProcedures/Myelography.aspx
• Osteosarcoma Overview. American Cancer Society.
– http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?rnav=criov&dt=52
• Planes of Section. A Guided Tour of the Visible Human
– http://www.madsci.org/~lynn/VH/planes.html
• Rheumatoid Arthritis: Treatment options. Arthritis Foundation.
– http://www.arthritis.org/disease-center.php?disease_id=31&df=treatments
• Staging: Questions and Answers
– http://www.cancer.gov/cancertopics/factsheet/Detection/staging
• WebMD.
– http://www.webmd.com/default.htm

• Carpal Tunnel Release – Open. X-plain module. Patient
Education Institute, Nat’l Library of Medicine
– http://www.nlm.nih.gov/medlineplus/tutorials/carpaltun nelsyndromeopensurgery/htm/index.htm
• Myelogram. X-plain module. Patient Education Institute,
Nat’l Library of Medicine
– http://www.nlm.nih.gov/medlineplus/tutorials/myelogram/htm/inde x.htm