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CHAPTER 15

MUSCULOSKELETAL SYSTEM

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Musculoskeletal System (1 of 2)

Subsection divided: Anatomic site (Forearm and Wrist), then service (e.g., excision)

Used extensively by orthopedic surgeons

Many codes commonly used by variety of physicians

Extensive notes

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Subsections reflect anatomical sites. Within each anatomical site, subheadings reflect the procedures performed.

Many musculoskeletal codes, such as those used for splinting, casting, and fracture repair procedures, are also used by primary care and family practice physicians.

This section of the CPT includes many notes. Why is it important to carefully review these notes? (Notes tell you how to use the information to identify any qualifying conditions.)

Musculoskeletal System (2 of 2)

Most common:

Fracture and dislocation treatments

“General” subheading

Arthroscopic procedures

Casts and strapping

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What types of procedures are listed under the General subheading? (Miscellaneous procedures not specific to an anatomical site, i.e., incisions of soft tissue abscesses, wound exploration, or biopsies of muscle and bone tissue)

Fractures

Questions to ask:

Site of fracture or dislocation

Type of treatment (open, closed)

Manipulation performed and documented

Was traction used; if so, what type

Was percutaneous fixation used

Was internal fixation applied (make sure this is not included in code description)

Was an external fixation system applied

Did documentation support skin closure

What type of anesthesia was used

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Fracture Treatment (1 of 2)

Open: Surgically opened to view or remotely opened to place nail across fracture

Open reduction with internal fixation (ORIF)

Closed treatment, fracture site is not exposed by surgical incision

Percutaneous, neither open or closed. Fixation devices (such as pins) are placed across the fracture site under imaging

Treatment terms not to be confused with type of fracture

Open fracture: Bone penetrates skin

Closed fracture: Bone does not penetrate skin

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Fractures are coded by treatment, which may be open, closed, or percutaneous.

How do the three types of fracture treatment differ? (Typically, open and percutaneous treatments require surgical intervention, whereas closed treatment many times can be completed without taking the patient to the surgery suite.)

Type of treatment depends on type and severity of fracture

“Complicated” in a code descriptor may indicate excessive hemorrhage, infection, prolonged physician work, or difficulty in reaching the site or depth of the site.

Fracture Treatment (2 of 2)

Figure 15.1

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Which type of fracture treatment would most likely be used for a greenstick fracture? (A closed procedure)

For an open fracture? (An open procedure)

What about for other types? (Treatment depends on the type and severity of the fracture.)

Application of force to align bone

Traction

Figure 15.4

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The application of pulling force to bring a bone into alignment and hold it there is called traction.

Would traction be used with an open or a closed repair? Why? (With a closed repair, because it is the only option; in an open repair, the bones may be brought into alignment directly, and internal devices can hold them in alignment.)

Skeletal Traction

Use of force (distracting or traction force) applied to internal device (e.g., wire, pin, screw, or clamp) inserted into bone

Figure 15.5

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There are two types of traction—skeletal and skin.

With skeletal traction, internal devices such as pins, screws, or wires are inserted directly into the bone through the skin.

The protruding ends attach to traction devices that use weights and pulleys to hold the bone in place.

Does skeletal traction require an open procedure? (No. The internal devices are inserted through the skin.)

Skin Traction

Figure 15.6

Application of force by means of adhesion to skin

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When skin traction is used, devices are attached to strapping wraps or tapes that are placed around the limb. Force is applied by means of adhesion to the skin.

Why is skin traction less stable than skeletal traction? (Because the force is applied less directly)

Manipulation

Use of force to return a fractured bone to normal alignment

Fracture repair codes are often divided based on whether manipulation was or was not used

AKA: Reduction

Manipulation means a fracture has been reduced

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Manipulation is a reduction, which is an attempt to maneuver the bone back into proper alignment by bending, rotating, pulling, or guiding the bone.

Separate codes are provided for fracture repairs with and without manipulation.

Is manipulation always required for fracture repair? (Not always. In a simple greenstick fracture, manipulation may not be needed because the bones are not misaligned.)

Fracture Term

Fractures are described by a physician in terms of the direction of the fracture line (horizontal, vertical, oblique, spiral), and the direction and degree of angulation (the most distal fragment)

When the fracture results in more than two fragments, it is comminuted

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Dislocation

From Dorland's Illustrated Medical Dictionary, ed 32, Philadelphia, 2012, Saunders.

Vertebral dislocation/ Subglenoid dislocation

Bone displaced from normal joint position

Treatment: Return bone to normal joint location

Figure 15.7

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What is the difference between a fracture and a dislocation? (With a fracture, the bone is broken. With a dislocation, the bone is displaced from the normal joint position but is not broken.)

How is a dislocation treated? (By moving the bone back to the correct position)

Subheading “General” (20100-20999)

Begins “Wound Exploration”

Depth: Difference between Integumentary and Musculoskeletal incision codes

Musculoskeletal used when underlying bone or muscle is involved

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The General subheading contains codes for procedures that are not associated with a particular anatomical region.

The first codes in this section deal with incision treatments.

When should Integumentary Incision codes be used instead of Musculoskeletal codes? (Integumentary codes: for superficial incisions; musculoskeletal codes: for involvement of underlying bone or muscle)

General Subheading, Wound Exploration (20100-20103) (1 of 2)

Traumatic penetrating wounds

Divided on wound location (body site)

Includes

Enlargement

Debridement

Foreign body(ies) removal

Ligation

Repair of tissue and muscle

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Wound exploration codes are used for the treatment of traumatic, penetrating wounds.

These codes include wound enlargement and exploration, debridement, foreign body removal, ligation, and tissue repair.

How are wound exploration codes organized? (By location of the wound)

General Subheading, Wound Exploration (20100-20103) (2 of 2)

These procedures describe surgical exploration to an already open wound

These codes are “separate procedure” codes

They can be coded and reported in the following circumstances:

If only procedure performed

If totally unrelated to another procedure performed at the same session

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Biopsy (1 of 2)

Located in Excision subheading (20200-20251)

Biopsies for bone and muscle

Divided by:

Type of biopsy (bone/muscle)

Depth

Some by method

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Codes for biopsies of muscles and bones are listed under Excision under the General subheading.

These biopsy codes are further subdivided according to type (muscle or bone), depth (superficial or deep), and, in some cases, method used.

Do biopsy codes include the pathology workup that follows the procedure? (No, this is coded under Pathology.)

Can be percutaneous needle or excisional

Coded separately

If lesion is excised and biopsied, only the excision can be billed

If biopsy taken on one day and based on the results an excision was performed, modifier -58 may be appropriate on excision code

Biopsy (2 of 2)

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What is the key difference between percutaneous and excisional biopsy? (Percutaneous: open; Excisional: closed)

Describe how each type is performed.

Describe how coding may reflect several components of the procedure.

With a percutaneous biopsy, the surgeon may require use of ultrasonic guidance with or without a radiologist, if the biopsy is sufficiently complicated.

Introduction or Removal (20500-20697) (1 of 4)

Within “General” subheading

Codes for:

Injections

Aspirations

Insertions

Applications

Removals

Adjustments

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The Introduction or Removal category includes codes for a wide variety of injections, aspirations, insertions, applications, removals, and adjustments.

In what section of the CPT are these codes found? (Musculoskeletal)

Introduction or Removal (20500-20697) (2 of 4)

Therapeutic Sinus Tract Injection Procedures:

Not nasal sinus

Abscess or cyst with a passage (sinus tract) to skin

Antibiotic injected with use of radiographic guidance

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The term sinus describes a fistula that leads away from a pus-filled cavity (as well as the air-filled cavities in the bones of the skull).

Sinus tract injection procedure codes are used for the treatment of an abscess or cyst through injection of an antibiotic or other substance into the infected sinus via the sinus tract.

How does the use of radiographic guidance affect coding? (Coded separately)

Introduction or Removal (20500-20697) (3 of 4)

Removal: foreign bodies lodged in muscle or tendon sheath

Integumentary removal codes for removal from skin

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How do the removal procedure codes for Musculoskeletal and Integumentary differ? (Musculoskeletal removal codes are used when foreign bodies are lodged in muscle tissue. Integumentary removal codes are used when foreign bodies are lodged in the skin.)

Introduction or Removal (20500-20697) (4 of 4)

Injection: Into tendon sheath, ligament, or ganglion cyst, trigger joint

Arthrocentesis: Injection “and/or” aspiration of a joint

Both an aspiration and injection are reported with one code

Codes 20600, 20605, 20610 report not using ultrasound guidance

Codes 20604, 20606, 20611 include ultrasound guidance

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These injections distinguish between injections made into tendons, ligaments, trigger points, and ganglion cysts and those made into joints.

Arthrocentesis codes are used for injection into and/or the aspiration of a joint.

When arthrocentesis involves both injection and aspiration, how should it be coded? (Use the same code for both done at the same time, or for each done separately.)

Arthrocentesis (20600-20611)

Local anesthesia is integral to these codes and should not be reported

Report the drug separately with a “J” code

HCPCS modifiers used to report specific digits: “FA to T9” or “TA to F9”

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External Fixation (20690, 20692) (1 of 2)

Figure 15.13A

Application of a device that holds bone in place

These codes include the removal of the fixator

If it is necessary to adjust or revise an external fixator see 20693. Code 20694 describes removal under anesthesia and includes imaging

B from McCance KL, Huether SE: Pathophysiology: The Biologic Basis for Disease in Adults and Children, ed 7, St. Louis, 2014, Mosby.

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External fixation is a closed procedure that involves the application of devices outside the body that hold a bone in place.

Used primarily to treat limb fracture, major pelvic disruption, osteotomy, arthrodesis, bone infection, and bone lengthening.

Compare with internal fixation: Bones are held together by screws, wires, pins, etc., placed within the bone itself; an open procedure.

External Fixation (20690, 20692) (2 of 2)

Uniplane—pins or wires in one plane (flat, smooth surface)

Multiplane—requires complex adjustments and correction in alignment. Bedside adjustments are not separately billed

Code fracture treatment and external fixation

Unless treatment and fixation are both included in code description

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How should fracture treatment be coded when external fixation is also done? (External fixation is coded separately in addition to the fracture treatment code.)

Grafts (or Implants) (20900-20938) (1 of 2)

Used to report harvesting through separate incision of:

Bone

Cartilage

Fascia lata

Tissue

Involve “morselized” or “structural” bone taken from a donor (allograft) or from the patient (autograft)

Morselized—small pieces of bone

Structural—a segment of bone machined into the space

Report only one bone graft code per operative session

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Graft procedures involve harvesting bone, cartilage, fascia lata, tendon, or tissue through an incision separate from that used to implant the graft.

Graft material is used in a wide variety of repair procedures. For example, if a tibial fracture fails to heal within 20 weeks, the surgeon may decide to use bone grafting.

From where is graft material obtained? (From the patient or a donor)

Grafts (or Implants) (20900-20938) (2 of 2)

Fascia lata grafts: From mid-upper thigh where fascia is thickest

Some codes include obtaining grafting material

Then not coded separately

Composite grafts involve combinations of autogenous material and allograft or alloplast

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Fascia is fibrous connective tissue. It may be shaved off with a stripper or cut away. Codes for fascia lata grafts differentiate the method by which the graft material was obtained.

Some graft codes bundle together procedures; others do not. How should a graft procedure be coded?

When the codes bundle in obtaining and implanting the graft material, the appropriate bundled code should be used.

When obtaining and implanting the graft are not bundled for a particular procedural type, then both procedures should be reported with the use of separate codes.

Bone Marrow Aspiration for Bone Grafting (20939)

Most commonly used for lumbar spinal fusion

Only report in addition to primary procedure

When not performed with spinal surgery, reference 20999

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Other Procedures (20950-20999) (1 of 3)

Monitoring muscle fluid pressure (interstitial)

Pressure increases due to increased accumulation of fluids, causing blood supply to be compromised

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The Other Procedures subheading includes codes for monitoring muscles, bone grafting with microvascular technique, free osteocutaneous flaps with microvascular technique, and electronic/ultrasound stimulation.

Why is fluid pressure in the muscle monitored?

Elevated fluid pressure indicates that the muscle is not receiving sufficient blood supply because of fluid accumulation. This condition must be treated to preserve the muscle, which otherwise would deteriorate.

Other Procedures (20950-20999) (2 of 3)

Bone grafts are identified by site they are taken from (donor site)

Free osteocutaneous flaps: bone grafts

Taken along with skin and tissue overlying bone

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Bone grafting involves removing a piece of bone with blood vessels left intact. The graft is inserted and the blood vessels from the graft are attached with the use of an operating microscope.

How do the codes for grafts in the Other Procedures category differ from those in the Grafts/Implants category? (Codes in the Other Procedures category are used for grafts that include skin, blood vessels, and muscle as part of the graft.)

Other Procedures (20950-20999) (3 of 3)

Electrical or ultrasound stimulation

Used to speed bone healing

Placement of stimulators externally or internally

Often used in treatment of fractures

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When is electrical stimulation used?

When a repaired fracture fails to heal in a reasonable and timely fashion.

Stimulators may be placed externally or internally.

Ultrasound may be used in a similar fashion.

Divided by repair location:

Cervical (C1-C7)

C1 = Atlas

C2 = Axis

Thoracic (T1-T12)

Lumbar (L1-L5)

Sacral (SI)

Coccyx (tailbone)

Spine (Vertebral Column) (22010-22899)

From Elsevier: Buck’s 2021

ICD-10-CM for Hospitals, St. Louis, 2021, Elsevier.

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Services in the Spine (vertebral column) section are subdivided according to location: cervical, lumbar, or thoracic region.

Further subdivisions may be created with the use of separate codes for specific areas of the spine.

Why is it necessary to have procedural codes for specific areas of the cervical spine? (Because treatment may be different for a similar injury, depending on location)

Incision (22010, 22015)

Open incision and drainage of deep abscess of spine

Divided by location

Cervical, thoracic, or cervicothoracic

Lumbar, sacral, or lumbosacral

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This category is used for open incision and drainage of deep abscesses of the spine.

How are these codes further divided? (22010 is for cervical, thoracic, and cervicothoracic and 22015 is for lumbar, sacral, and lumbosacral)

There are many notes under codes 22010 and 22015 with coding rules.

Arthrodesis (22532-22819)

Fixation of joint (arthro = joint, desis = fusion)

Fixation with pins, wires, rods, etc., to immobilize the joint

Often performed with other procedure

Such as fracture repair

Use -51 on arthrodesis code

Unless service reported with add-on code

Coded by approach, site, and number of interspaces or segments

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Arthrodesis, the fixation of a joint, can be performed alone or with another surgical procedure, such as fracture care or a laminectomy.

How should arthrodesis be coded when it is delivered with another procedure? (With a more major procedure, use the modifier -51 on the arthrodesis code to indicate multiple procedures. Exception: When the code is an add-on code, it is exempt from the use of modifier ‑51.)

Types of Spinal Instrumentation

Segmental: Devices at each end of repair area plus at least one other attachment

Nonsegmental: Devices at each end only

Extensive notes

Report in addition to definitive procedure without the -51 modifier

Spinal Instrumentation (22840-22865)

Figure 15.15

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Spinal instrumentation may be used to stabilize the spinal column in some repair procedures.

What is the difference between segmental and nonsegmental instrumentation?

Both involve attaching a fixative device to the ends of the area being repaired.

With segmental instrumentation, a fixative device is attached to a third area for greater stability.

Subsequent Subheadings

After first subheading, General, divided by anatomic location

Anatomic subheadings divided based by type of procedure

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The subsections of the Musculoskeletal System included after the General subheading reflect anatomical sites. The anatomical subheadings are subdivided according to type of procedure.

How are codes in the General subheading organized? (By procedure, with anatomical location typically not included in code descriptions)

Subheadings

Example subheading “Head” divided by procedure (21010-21499):

Incision

Excision

Manipulation

Head Prosthesis

Introduction or Removal

Repair, Revision, and/or Reconstruction

Fracture and/or Dislocation

Other Procedures

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How are the Anatomic region subheadings further classified? (On the basis of the procedure performed)

From which category under the “Head” subheading would the code for an application of a halo-type appliance for maxillofacial fixation be located in? (Introduction or Removal)

Casts and Strapping (29000-29799) (1 of 2)

Replacement procedure or initial placement stabilizes without additional restorative treatment

Initial fracture treatment includes placement and removal of first cast

Subsequent cast applications are coded separately

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Casts and Strapping codes are used when initial fracture treatment aims to stabilize without additional treatment provided at the time. These codes are also used when new casts are applied after restoration. Why may a cast/splint/strap be applied before a fracture is restored?

Swelling may prevent restoration at the time of injury.

The cast/splint/strap is applied to stabilize and prevent further damage until swelling decreases.

Casts and Strapping (29000-29799) (2 of 2)

Initial cast

Not coded when part of a surgical procedure

Removal is bundled into surgical procedure

Supplies are reported separately

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Are casts and strapping codes used when the cast, splint, or strap is applied as a part of a musculoskeletal surgical procedure?

No. The application and removal of an initial cast, splint, or strap applied after a surgical procedure is bundled into the musculoskeletal surgical procedure code. No additional code is required or appropriate. However, supplies used in the procedure are recorded separately.

Endoscopy/Arthroscopy (29800-29999) (1 of 2)

Surgical arthroscopy always includes diagnostic arthroscopy

Codes divided by joint

Subdivided on procedure

Diagnostic arthroscopy codes only reported for cases where no surgical scope is performed (exception is diagnostic scope that determines need to do open surgery, same day)

Use modifier -51 on the diagnostic scope

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Why is arthroscopy often the treatment of choice for orthopedic surgical procedures? (Incisions are smaller, risk of infection is lower, and recovery time is shorter.)

Surgical codes for arthroscopic surgery always include diagnostic arthroscopy. Arthroscopy codes are subdivided, however, on the basis of the joint affected.

When should you code separately for procedures included in a surgical bundle? (Never)

Endoscopy/Arthroscopy (29800-29999) (2 of 2)

Note: Parenthetical information following codes indicates which code to use if procedure was an open procedure

Most arthroscopies include the following procedures:

Local infiltration of medication

Suture removal by operating surgeon

Surgical approach

Wound culture

Intraoperative photos and video imaging

Isolation of neurovascular structures

Stimulation of the nerves for identification

Placement of drains and suction devices

Wound closure

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Be sure to note any parenthetical statements attached to CPT codes.

For arthroscopy, parenthetical notes indicate which code to use if the procedure was open (incisional) instead of endoscopic.

Why is it important to distinguish open and endoscopic procedures during coding? (The nature and extent of these two services are different, even though the reason for the procedure and the patient outcome may be the same.)

Conclusion CHAPTER 15

MUSCULOSKELETAL SYSTEM

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