Musculoskeletal System Surgery – Coding Guidelines

Musculoskeletal System Surgery – Coding Guidelines:

The section is divided by the anatomical site (General, Head, Neck, Back, etc)
Under that subsections are based on procedures like,

· Incision (A surgical cut),

· Excision (Removing),

· Manipulation (Reduction),

· Introduction/Removal, Repair/reconstruction (Arthrography / Arthroplasty),

· Fracture /dislocation, Arthrodesis (Surgical fusion),

· Amputation (Surgical cutting) procedures.

General Guidelines:

Anesthesia: Local anesthesia administered by a physician to perform any

musculoskeletal procedure is considered as an inclusive procedure and should not be
billed separately.

Wound Exploration (20100 - 20103)

Traumatic wounds that result from penetrating trauma (gunshot or stabbing).

These codes describe;

· Surgical exploration and enlargement of wound

· Extension of dissection (Determine penetration)
· Debridement/foreign body removal
· Ligation and coagulation of minor blood vessels.
These codes cover both exploration and repair of that area.

If Simple/Intermediate/Complex repair performed that doesn’t require wound

enlargement then report specific Closure/Repairs codes from the Integumentary
system.
 If Thoracotomy or laparotomy is performed, wound exploration is included.

Excision:

Biopsy – examination of tissue removed from the living body

If a biopsy is performed along with any excision/repair/destruction/removal of internal

fixation procedure at the same site is considered as an inclusive procedure and should
not be billed (Biopsy) separately.

If the biopsy is performed at a different site – It is a billable service.

Biopsy procedures are divided by,

· Type of Biopsy (Muscle/Bone)

· Depth (Superficial/Deep)

· Method (Open/Percutaneous)

A. Excision of Subcutaneous soft tissue tumors:

Simple or Marginal resection of tumors from subcutaneous tissue (Above deep fascia)

Tumors are usually benign in nature. Resection doesn’t include surrounding normal
tissue.

Code selection is based on;

· Location and size of tumor.

· Size is measuring the greatest diameter of tumor with most narrow

margin required.

· If Complex repair is performed to close the wound - Reported additionally.

Note: Simple and Intermediate repair is included with this Excision procedure.

B. Excision of Fascial / Subfascial soft tissue tumors:

Simple or Marginal resection of tumors from fascia or below the deep fascia (Above
bone)
Tumors are usually benign in nature / Intramuscular. Resection doesn’t include
surrounding normal tissue.

Code selection is based on;

· Location and size of tumor.

· Size is measuring the greatest diameter of tumor with most narrow

margin required.

· If Complex repair is performed to close the wound - Reported additionally.

Note: Simple and Intermediate repair is included with this Excision procedure.

C. Radical resection of soft connective tissue tumors:

Resection of Subcutaneous / Subfascial tumor with wide margins of normal tissue

Tumors are usually malignant / Aggressive benign tumors in nature. Resections include
surrounding normal tissue (Removal of Tissue from one or more layers).

Code selection is based on;

· Location and size of tumor.

· Size is measuring the greatest diameter of tumor with the most narrow
margin required.

· If Complex repair is performed to close the wound - Reported additionally.

Note: Simple and Intermediate repair is included with this Excision procedure.

D. Radical resection of bone tumors:

Resection of the bone tumor with wide margins of normal tissue

Tumors are usually malignant / Aggressive benign tumors in nature. Resections include
surrounding normal tissue (Removal of Tissue from one or more layers).
Code selection is based on;

· Location of tumor.

· Size is measuring the greatest diameter of tumor with the most narrow
margin required.

· If Complex repair is performed to close the wound - Reported additionally.

Note: Simple and Intermediate repair is included with this Excision procedure.

If the surrounding soft tissue is removed during these procedures – Don’t report radical
resection of soft tissue tumor codes.

Introduction or Removal:

Injection of

· Sinus tract

· Tendon

· Trigger point

· Joints (Arthrocentesis/Aspiration/Injection)

Arthrocentesis/ Aspiration/ Injection of joint or Bursa (CPT 20600 – 20611)

· Codes are based on the size of the joints (Small/Intermediate/Large)

· Also based on Ultrasound guidance utilized or not.

· Different techniques performed in a single joint and surrounding structure

should be considered a single unit of service. Eg: Arthrocentesis of RT knee with an
aspiration of RT knee bursae should be coded as one unit of 20610 or 20611.

· If the procedures are performed more than one joint – Code both separately.

· Injection of substance doesn’t include drug, the drug should be billed

separately with HCPCS II codes.
Example: the provider injected 40 mg of Kenalog into the Left knee joint and removed 4
cc of fluid from the Right Knee using Ultrasound guidance. Ans: 20611, 20611 – 59, J3301
x4

SI joint Injection: CPT 27096 including guidance code.

· If CT or Fluoroscopic imaging is used – Code 27096

· If CT or Fluoroscopic imaging is not used – Code 20552

· Bilateral sacroiliac joint injection – Append Modifier 50 with the CPT code.

ARTHROGRAPHY: Radiographic visualization of a joint after injecting a contrast.

A special form of X-ray called fluoroscopy to guide and evaluate the injection of
contrast material directly into the joint cavity. Some time Ultrasound may be used.

What is the difference between Arthrography and MRI study?

In MRI contrast is administered into the vein but in Arthrography contrast is injected
into the joint under guidance (Fluoroscopy).

What is Supervision and Interpretation (S&I)?

A radiologist can perform percutaneous procedures alone or else guide a surgeon

technically with guidance (Ultrasound / Fluoroscopy / CT / MRI)

· If a radiologist bill a procedure solely done by him – Bill both surgery code and
S&I code

· If he guides a surgeon – Bill only S&I code with modifier 52. The surgeon would
have billed for his procedures.

· Some procedures codes include the guidance codes – Radiologist shouldn’t bill
separately.

Arthrography coding guidelines:

1. If fluoroscopy is utilized without interpretation– Code Arthrography with

Fluoroscopy codes

2. Both guidance and Interpretation – Code Arthrography with S&I codes

Note: All S&I codes include guidance (Fluoroscopy) codes.

REPLANTATION (20802 - 20838)

· These codes are used based on anatomical location with complete amputation.

Note: For incomplete amputation repair – Assign specific codes with modifier 52.

Repair/ Revision/ Reconstruction:

Arthroplasty – Surgical reconstruction / Replacement of a joint

An open surgical procedure, articular surface of the joint is replaced by artificial

(Prosthesis)

· Most common in Knee or Hip, Complete removal of damaged surface and

replaced with an artificial prosthesis.

· It may be complete (Both articular surface) or partial (one articular surface)

Reconstruction of ligaments – Surgical procedure to replace torn ligaments using a

graft.

Fracture / Dislocation:

Fracture – Break in the continuity of a bone, Maybe Traumatic / Pathological.

Dislocation – Displacement of a bone from its normal position.

Fractures are treated either by Closed/Open/Percutaneous

The type of fracture does not have any coding correlation with the type of treatment.

1. Closed Treatment - fracture site is not surgically opened, it can be treated by

A. With or without manipulation

B. With or without traction.
2. Open Treatment – Making incision and surgically opened the fracture site. The
fracture can be treated by

A. Internal fixation

B. Intramedullary nail across the fracture site.

 3. Percutaneous skeletal fixation – Fracture fragments are not visualized but fixation
pins are placed across the fracture site using x-ray imaging.

The codes for treatment of fractures and dislocations are categorized by the type of
manipulation and stabilization (Fixation or immobilization)

Skeletal Traction – Application of a force to a limb segment via pin attached to the
bone

Skin Traction – application of a force using strapping applied directly to the skin.

External Fixation – Usage of skeletal pins and attaching the device to treat acute or
chronic conditions.

Re-reduction of a fracture/dislocation by the same physician would be identified by

adding modifier 76.

Note: Manipulation is used throughout the musculoskeletal fracture and dislocation

subsection to specifically mean reduction/restoration to its normal anatomic alignment
by application of manual forces.

Generally, Removal of external devices in the postoperative period is included with an

application of external immobilization devices (Casts, strapping and splints).

Removal of a superficial or deep implant (Pin/rod/buried wire) requires a surgical

procedure to remove the implant would be billed with appropriate CPT (20670 -
20680). Note: If another procedure is necessary to do in the same site during the
removal of implant can’t be coded separately.

If a closed fracture treatment procedure fails and followed by an open procedure at

the same session, code only the open procedure.

CPT codes for closed, percutaneous, or open treatment of fractures or

dislocations include the application and removal of cast, strap or splint. Hence
should not be billed separately.

Cast and Strapping (29000-29584) – would be billed only under the circumstances like

· If the physician treats the fracture or dislocation only with cast or splint without
a restorative treatment or procedure to stabilize fracture/dislocation. Note: Initial
cast/strap or splint is included in the treatment of fracture or dislocation codes
performed at the same session.
 · During follow up care

Dynamic splint: Allow movements with stability

Static Splint: Prevent movements

Procedures performed on fingers should be reported with modifiers FA, F1-F9 and on
toes should be reported with modifiers TA, T1-T9

Arthrodesis:

Arthrodesis: Fusion of two bones to prevent movement.

· Surgical procedure performed in Joints (Ankle, Carpals, Tarsal’s, Spine, etc)

· The ends of two bones are fused together with screws and bone graft.

SPINE – Arthrodesis (Surgical fusion between vertebras)

Key terms to be noted in spine Arthrodesis,

1. Approach and location

2. Bone Graft

3. Instrumentation

Approach

· Lateral extracavitary approach (22532 - 22534)

· Anterior (or) anterolateral approach

· Posterior (or) postero-lateral or Lateral transverse process technique

Anterior (or) anterolateral approach (22548 - 22586)

· CPT 22554 – 22558 is for single interspace, for additional interspace use +on 22585

Vertebral interspace – Non-bony compartment between two adjacent vertebral bodies

(contain the disc)
 Vertebral segment – Single complete vertebral bone

· CPT 22586 – Arthrodesis, pre-sacral interbody technique, including disc space

preparation, discectomy, with posterior instrumentation, with image guidance, includes
bone graft when performed, L5-S1 interspace (Don’t report bone graft or
instrumentation or fluoroscopy guidance code along with this CPT).
· If two surgeons work together as primary surgeons performing distinct parts – Each
surgeon should report his distinct work by appending modifier 62.

Note: Bone grafting procedures are reported separately in addition with Arthrodesis.
But don’t use modifier 62 along with bone graft codes (20930 - 20938)

Similarly, the instrumentation is also reported separately in addition with Arthrodesis.

But don’t use modifier 62 along with definitive or add on spinal instrumentation
procedure codes. (22840- 22848, 22850, 22852, 22853, 22854, 22859)

When Arthrodesis is performed along with another procedure (Fracture care,

laminectomy, osteotomy and vertebral corpectomy) then bill Arthrodesis service with
modifier 51 (Except +add on codes).

Bone Graft: During spinal fusion, a solid bridge is formed between two vertebral
segments in the spine to stop the movement in that particular section of the spine.
Bone graft / Bone graft substitute is needed to create the environment for the solid
bridge to form. It allows the new bone formation to fuse the section of the spine
together.

Types of Bone graft:

· Autograft – Graft from one site to another site of the same individual.

· Allograft – Graft from a donor of the same species. Some times from Cadaver.

Note: Morselized (The process of dividing into small portions)

During the spine fusion surgery same incision or a separate incision is made to remove
bone graft from the patient’s body (Usually iliac bone, Ribs or spine) called Harvesting.
Instrumentation: Hardware implants used in spine surgery. Devices include,

· Rods
· Hooks
· Plates
· Screws
· Interbody cages

There are two types of Spinal instrumentation procedures,

1. Segmental

2. Non – segmental (There are no codes for anterior non - segmental

instrumentation)

Segmental: Stabilize the spine by attaching to each individual segment that was fused.

Non – Segmental: Doesn’t attach at each level. Curved rod is attached at top and
bottom.

SAMPLE

Eg 1: Posterior Arthrodesis of L4-L5 for DDD utilizing morselized autogenous iliac bone
graft harvested through a separate fascial incision.

Ans: CPT 22612, 20937

Eg 2: Posterior Arthrodesis of L4-S1, utilizing morselized autogenous iliac bone graft

harvested through a separate fascial incision and pedicle screw fixation.

Ans: 22612, 22614, 22842, 20937

Eg 3: L2 Burst fracture treatment by corpectomy and followed by Arthrodesis of L1-L3,

utilizing anterior instrumentation (L1-L3) and structural allograft.

Ans: 63090, 22558-51, 22585, 22845, 20931 (Don’t append modifier 51 with add on
codes)

Eg 4: A 53 yrs old man with the history of posttraumatic DDD at L3-L4 and L4-L5
underwent surgical repair. Surgeon A performed an anterior exposure of the spine with
the mobilization of the great vessels. Surgeon B performed anterior (minimal)
discectomy and fusion at L3-L4 and L4-L5 using an anterior interbody technique.
Ans: Surgeon A: 22558 – 62, 22585 – 62
Surgeon B: 22558 – 62, 22585 – 62, 20931 (Bone graft don’t append mod 62)

Arthrodesis for the spinal deformity (Scoliosis / Kyphosis)

Codes are based on the approach and vertebral segments

· Posterior (22800 - 22804)

· Anterior (22808 – 22812)

Percutaneous Vertebroplasty and vertebral augmentation:

CPT codes 22510 – 22515 (includes bone biopsy)

Vertebroplasty: Is the process of injecting a material (Cement) into the vertebral body
to reinforce the structure of the body using imaging guidance.

Vertebral Augmentation: Is the process of cavity creation followed by the injection of

material (Cement) under imaging guidance.

Sacroplasty: 0200T – 0201T

Note: Vertebral Augmentation includes Vertebroplasty

Arthroscopy – Look within the joint,

A minimally invasive surgical procedure on a Joint, orthopaedic surgeons views the joint
without making a large cut through the skin and other soft tissues. An endoscope is
inserted into the joint via small incisions.

Surgical arthroscopy includes diagnostic arthroscopy.

Arthroscopy procedure is inclusive with the open procedure is performed at the same
site.

Arthroscopy and open procedure at a different site would be coded with the
appropriate modifier.

If arthroscopy is performed along with arthrotomy – append modifier 51