Musculoskeletal System

 The Musculoskeletal System subsection is formatted by

anatomic site,such as General, Head, and Neck…..
 The other subheadings are further divided by anatomic site,
procedure type, condition, and description. They usually include:
 ■ Incision
 ■ Excision
 ■ Introduction or Removal
 ■ Repair, Revision, and/or Reconstruction
 ■ Fracture and/or Dislocation
 ■ Arthrodesis – surgical immobilization of a joint by fusion of
the bones
 ■ Amputation
 Any or all of these categories of procedures may be located
under each subheading.
DEFINATION
Closed treatment refers to a fracture/dislocation treated
without making an incision into the fracture site; the site is
not surgically opened and there is no direct visualization.
There are three different methods of fracture care
1. Closed Treatment without Manipulation
2. Closed Treatment with Manipulation
3. Closed Treatment with or without the Application of
Traction
 Manipulation" "the attempted reduction or restoration of
a fracture or joint dislocation to its normal anatomic
alignment by the application of manually applied forces
Open Treatment and Reduction of a
Fracture/Dislocation a fracture so severely displaced or
out of alignment the bones cannot be manipulated
through the skin.
In these cases, a deliberate surgical incision to expose
the fractured bone is performed by the surgeon to
visualize the fracture/dislocation and repair the defect
The ends of the broken bone(s) are brought together and
held in place by some form of fixation, such as pins,
wires (Kirschner wires), or rods
usually performed under x`regional or general anesthesia
Percutaneous Skeletal Fixation This fracture
treatment is neither open nor closed. X-rays are taken
by the physician to verify that the fracture can be
treated by placing a fixation through the skin, into the
bone, without making an incision to expose the bone.
The screws or pins will hold the fracture together and
then a cast, splint, or brace may be applied for further
stabilization.
External and Internal Fixation
Some fractures are treated with fixation, either internal or
external, to maintain the alignment of the bone while it
heals,or to reinforce the bone permanently.
Internal fixation can be done with pins, screws, plates, or
wires placed directly on the bone to immobilize it. usually
through an incision over the fracture site. The acronym
ORIF (open reduction inlternal fixation)
External fixation is primarily on the outside of the body,
and can include a cage-like structure, as well as pins and
rods. Codes for application of an external fixation (20690-
20692, 20696)- Uniplane external Fixation system and
Multiplane External Fixation system
Traction is the application of pulling force to hold a
bone in alignment
Skeletal traction is the use of internal devices, such
as pins, screws, or wires. The devices are inserted into
the bone through the skin, with ends of the pins,
screws, or wires sticking out through the skin, so
traction devices can be attached
Wound exploration 20100-20103
 Report traumatic wounds that result from a penetrating trauma
 These codes describe;
1. Surgical exploration and enlargement of wound
2. Extension of dissection (Determine penetration)
3. Debridement/foreign body removal
4. Ligation and coagulation of minor blood vessels.
5. 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
Separate procedure- procedure is minor one. Along
with major procedure no need to code to separately.
Excision
Biopsy – Examination of tissue removed from the
living body If a biopsy is performed along with any
excision/repair/destruction/removal or internal fixation
procedure at the same site is considered as inclusive
procedure and should not be billed (Biopsy) separately
Biopsy procedures are divided by:
• Type of Biopsy (Muscle/Bone)
• Depth (Superficial/Deep)
• Method (Open/Percutaneous).
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
Injections 10 trigger points in 10 muscle =
20600-20611 – joint size- gudance
Small,intermediate,major
Different techniques performed in 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 x 4.
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.
20802-52
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)
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)
Look for
1. Approach and location 161
2. Bone Graft 147 add on
3. Instrumentation 167 add on
Modifier 51- arthrodesis performed with fracture
care,osteotomy, laminectomy- put modifier 51 to
arthrodesis
Laminectomy=arthrosesis
Laminectomy, arthrodesis approch -51, not bone graft,
not instrumentation
Modifier 62 – two surgeon working as primary
surgeon
Approch procedure, not to bone graft not on
instrumentation
Approach
• Lateral extracavitary approach (22532 - 22534)
 • Anterior (or) anterolateral approach (22548 - 22586)
• Posterior (or) postero-lateral or Lateral transverse
process technique (22590 - 22634)
You may find this words
Vertebral interspace – Non bony compartment between
two adjacent vertebral bodies (contain the disc)
Vertebral segment – Single complete vertebral bone
Spine structure
Cervical (C1-C7) C1-C2-C3-C4-C5-C6-C7
Interspace---- ?
Vertebral segment....?
THORACIC (T1-T12)
LUMBAR (L1-L5)
SACRAL (S1)
TAIL BONE (COCCYX)
 If two surgeons works together as primary surgeons performing
distinct parts – Each surgeon should report his distinct work by
appending modifier 62.
 Bone grafting procedures are reported separately in addition with
Arthrodesis. But don’t use modifier 62 along with bone graft codes
(20930 - 20938)
 Similarly 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 new bone
formation to fuse the section of the spine together.
 Types of Bone graft: • Auto graft – Graft from one site to another
site of the same individual. • Allograft – Graft from a donor of the
same species. Some times from Cadaver.
 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 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 is
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
Examples
Eg 1: Posterior Arthrodesis of L4-L5 for DDD
Degenerative disc disease utilizing morselized
autogenous iliac bone graft harvested through a
separate fascial incision.
Ans: CPT 22612, +20937
 Eg 2: Posterior Arthrodesis of L4-S1,L4-L5-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 transperitoneal
approch and followed by Arthrodesis anterior approch of L1-L3,
L1-L2-L3 utilizing anterior instrumentation (L1-L3) and structural
allograft. Ans: (Don’t append modifier 51 with add on codes)
63090, 22558-51,+22585, +22845, 20931
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.
Using structural allograft
22558,+22585, 20931
Ans: Surgeon A: 22558 – 62, 22585 – 62 ,
Surgeon B: 22558 – 62, 22585 – 62, 20931 (Bone graft don’t
append mod 62)
Arthrodesis for spinal deformity (Scoliosis / Kyphosis)
Codes are based on 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
 Vertebral Augmentation includes Vertebroplasty
ARTHROSCOPY 29880-29881
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
Application of casts and strapping
 29000-29799
 used for the initial or subsequent treatment of fractures, ligament
sprains/tears, and overuse injuries
 each cast is unique in terms of size and position. The cast immobilizes
the fracture with materials such as plaster, fiberglass, or thermoplastics.
 Strapping is the taping of a body part used to exert pressure on a
body part to give it more stability, and is used in the treatment of
sprains, strains, and dislocations
 Splints are made of wood, cloth, metal, or plastic
 The removal of the cast, strapping, or splint is included in each of the
Application of Casts and Strapping codes.
 The surgery, application, and removal are all bundled into the surgical
code