OP Orthopaedics Lamon Willis - PowerPoint Presentation

Slide1

OP Orthopaedics

Lamon Willis

Slide2

Aspirations/Injections

Slide3

Aspirations & Injections

20526 Injection, therapeutic (

eg

, local anesthetic, corticosteroid), carpal tunnel

20550 Injection(s); single tendon sheath, or ligament, aponeurosis (

eg

, plantar “fascia”)

20551 Injection(s); single tendon origin/insertion

20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s)

Slide4

Cross Section of Wrist Joint

Carpal tunnel syndrome (CTS) is divided into:

Early

Intermediate

Advanced, and

Acute stages.

Patients with early CTS without thinner atrophy and mild symptoms respond well to steroid injection & splinting.

Slide5

Aspirations & Injections

Slide6

Aspirations & Injections

What is a trigger point?

A tender and painful area of a muscle.

Hyperirritable spots in muscle associated with palpable nodules in taut bands of muscle fibers.

They may also manifest as tension headaches, tinnitus, temporomandibular joint pain (TMJ), decreased range of motion in the legs, and low back pain.

Palpation of the trigger will illicit pain directly over the affected area and/or cause radiation of pain.

Slide7

Aspirations & Injections

Trigger Point Injection Info

Outpatient injection given into the trigger point

May be dry needling, an anesthetic, and also a steroid

Does not require imaging guidance

Needle does not go very deep

Slide8

Aspirations & Injections

These injections can be provided in various muscles throughout the body

Slide9

Aspirations & Injections

Joint injection are coded by joint size as follow:

20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (

eg

, fingers, toes) without ultrasound guidance

20604 Arthrocentesis, aspiration and/or injection; small joint or bursa (

eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) without ultrasound guidance

Slide10

Aspirations & Injections

20606 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (

eg

, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting

20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (

eg

, shoulder hip, knee joint, subacromial bursa)20611 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa); with ultrasound guidance, with permanent recording and reporting

Slide11

Aspirations & Injections

Arthrocentesis of a joint would occur to remove fluid which has built up due to an injury or illness that has caused swelling and discoloration of the area

Slide12

Aspirations & Injections

The synovial fluid analysis provides details to the physician related to current and future treatment

Slide13

Dupuytren’s Contracture

Slide14

Dupuytren’s

contracture is a progressive disease of the palmar fascia which results in shortening, thickening and fibrosis of the fascia and

aponeurosis

of the palm.

The palmar fascia is continuous with the

antebrachial

fascia, the deep fascia of the forearm, and the layer of fascia that covers the dorsum of the hand.

The Relevant Anatomy

Slide15

The palmar fascia is thicker in the center of the palm and fingers where it forms the palmar

aponeurosis

and digital sheaths.

The palmar

aponeurosis

covers the soft tissues of the palm and long flexor tendons. As the longitudinal bands of the palmar

aponeurosis undergo fibrosis, the metacarpophalangeal

and proximal interphalangeal joints get pulled into flexion.

The Relevant Anatomy

Slide16

The fourth metacarpal is most commonly affected, followed by the fifth, third, and second.

Recently,

Dupuytren’s

disease has become a more widely adopted term than

Dupuytren’s

contracture to name this condition, as the fingers are not always held in a fixed flexion deformity.

The Relevant Anatomy

Slide17

The Relevant Anatomy

Slide18

The exact origin of

Dupuytren

disease is unknown; however, researchers have identified a number of risk factors:

Genetic

Human leukocyte antigen (HLA) type

Family linkage

Zf9 genetic binding protein

Mitochondrial mutation

Mechanism of the Injury/Illness

Slide19

Environmental

Trauma and exposure to continuous vibrations

Alcohol consumption

Smoking

Age

These all provide oxidative stresses on the body, which is an imbalance between the production of reactive oxygen and body’s ability to detoxify and repair damaged tissue.

Mechanism of the Injury/Illness

Slide20

Associated Diseases

Diabetes

Epilepsy

HIV

Cancer

When there are multiple disease processes working in the body, these simply compound the impact of the problem of this disease.

Mechanism of the Injury/Illness

Slide21

Dupuytren

contracture occurs slowly and typically progresses over the course of several years, but can also develop more rapidly over weeks or months.

It typically affects older men of European decent.

This condition most commonly begins with thickening of the skin on the palm, resulting in a puckering or dimpled appearance.

As the condition progresses, bands of fibrotic tissue form in the palmar area and may travel distal toward the fingers.

Clinical Presentation

Slide22

This tightening and shortening eventually leads to the affected fingers being pulled into flexion.

Dupuytren’s

contracture typically occurs bilaterally, with one hand being more severely affected than the other.

Clinical Presentation

Slide23

Several features of

Dupuytren’s

disease can be noted upon examination:

sites of nodules and bands or contracted cords,

skin pitting,

degree of skin involvement,

measurement of the angle between the metacarpophalangeal and proximal

interphalangeal joints, presence of any surgical scarring and

sensation in the palm and digits.

Diagnostic Procedures

Slide24

ICD-10

Dx

code

M72.0:

Palmar fascial fibromatosis [

Dupuytren]

Diagnostic Procedures

Slide25

The degree of flexion contracture in the affected digit or digits can be measured with a goniometer.

A Staging System has been created and used by some to measure the flexion contracture of an affected digit to determine the severity of

Dupuytren’s

disease; stage 1 indicates the least severe flexion contracture deformity while stage 4 indicates the most severe flexion contracture deformity.

Diagnostic Procedures

Slide26

Stage

Contracture

Comment

0

0

healthy

N

0

feel nodules / cords

N/1

0-5 degrees

beginning contracture

1

6-45 deg.

 

2

46-90 deg.

 

3

91-135 deg.

 

4

> 135 deg.

 

Diagnostic Procedures

Slide27

Diagnostic Procedures

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Stage 1

Stage 2

Stage 3

Stage 4

Diagnostic Procedures

Slide29

Most common:SurgicalEnzyme Injection

Less common and unproven or clinically ineffective:

Splinting

Hyperbaric Oxygen

Radiation

Ultrasound TherapyVitamin EPhysical TherapyInterferon

Management / Interventions

Slide30

Simple

Fasciotomy

Performed

percutaneously

or through small incisions,

The surgeon dividing the contracted tissue cord to release the flexion contracture.

The contracted cord is simply cut, but is not surgically removed from the digit.Fasciectomy

Removal of the diseased palmar fascia, including the contracted tissue cord and nodule.

Partial or total depending on the severity of the disease.

Management / Interventions

Slide31

A partial

fasciectomy

involves removal of the diseased palmar fascia.

A total

fasciectomy

is more invasive, involving the removal of the entire palmar fascia; both areas affected by disease and areas not affected by disease.

Management / Interventions

Slide32

Dermofasciectomy

is the most invasive surgical procedure for

Dupuytren’s

disease.

Removal of the diseased palmar fascia, the contracted tissue cord and nodule included, and all overlying affected skin and subcutaneous fat.

A full-thickness skin graft is required to cover the surgical site.

In cases of chronic advanced proximal interphalangeal

joint contracture, external fixators may be indicated in addition to the dermofasciectomy procedure to keep the contracture from recurring.

Management / Interventions

Slide33

Fasciotomy

- Percutaneous

CPT-4 code

26040

Fasciotomy

, palmar (

eg, Dupuytren’s Contracture); percutaneous

is for the percutaneous procedure called needle fasciotomy or needle

aponeurotomy.

Modifier -50 should be reported if the procedure is performed bilaterally.

This code is reported once per hand, and not based upon the fingers involved.

Management / Interventions

Slide34

Fasciotomy

- Open

CPT-4 code

26045

Fasciotomy

, palmar (

eg, Dupuytren’s Contracture); open, partial

is for the invasive incisional service.

Management / Interventions

Slide35

Dermofasciectomy

CPT-4 codes

26121-26125.

26121 -

Fasciectomy

, palm only, with or without Z-

plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)

26123 - Fasciectomy, partial palmar with release of single digit including proximal

interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft);

26125 - each additional digit (List separately in addition to code for primary procedure)

Management / Interventions

Slide36

Dermofasciectomy

Management / Interventions

Slide37

Fasciotomy

– Enzyme Injection

In 2009 Clostridium

histolyticum

collagenase injection (J0775) became a promising new nonsurgical treatment for

Dupuytren’s

disease. The injection of this enzyme targets excessive collagen deposition and rupturing the fibrous tissue cords that cause the contractures.

Management / Interventions

Slide38

Fasciotomy

– Enzyme Injection: 1

st

Part

CPT-4 code

20527 Injection, enzyme

(eg, collagenase), palmar fascial cord (ie

, Dupuytren's contracture)

Management / Interventions

Slide39

Manipulation – 2

nd

Part Post Injection

26341 Manipulation, palmar

fascial

cord

(ie, Dupuytren's

cord), post enzyme injection (eg, collagenase), single cord

In this procedure the wrist is held in flexion while gentle but firm traction is placed across the contracted finger until rupture of the fascial cord is felt and the digit fully extends. This process can be repeated two more times at 10-minute intervals if full extension is not initially achieved. Once the digit is fully extended, the tendon function is evaluated.

Management / Interventions

Slide40

Manipulation – 2

nd

Part Post Injection

Clinical Example

A 60-year old male with

Dupuytren’s

contracture who underwent enzyme injection into a palmar cord the previous day presents for manipulation of the contracted finger. Post procedure the patient’s hand was placed in a molded brace for continued post procedure resolution.

Management / Interventions

Slide41

Management / Interventions

Slide42

Head, Neck & Spine

Slide43

Head, Neck & Spine

CPT codes 21010-21499 are for procedures performed on the head. Procedures cover a variety of items:

Tumor removal

Osteotomy, ostectomy, contouring, and

Bone grafts and reconstructive surgeries

NOTE

: Many procedure performed on the cervical, thoracic, and lumbar spine are performed in an inpatient setting.

Slide44

Head, Neck & Spine

CPT codes 21501-21899 involve soft tissues of the neck and thorax

The list is short but sufficient with description of tumor removals, excision of rib(s), sternum, various open and closed procedures, some of which are performed in an inpatient setting

Note: Spinal procedures are under a separate subheading Spine (vertebral column) in codes 22010-22899

Slide45

Head, Neck & Spine

CPT codes 21920-21936 are for the back and flank

These procedures are only for soft tissue tumor resection and removal

Slide46

Head, Neck & Spine

CPT codes 22010-22899 involve the spine or vertebral column

The spine is broadly arranged into several regions:

Term

# of Vertebrae

Body Area

Abbreviation

Cervical

7

Neck

C1-C7

Thoracic

12

Chest

T1-T12

Lumbar

5

Lower Back

L1-L5

Sacrum

5 (fused)

Pelvis

S1-S5

Coccyx

3

Tailbone

None

Slide47

Head, Neck & Spine

The majority of procedure codes for spine surgery are designated by the approach used to perform the procedure.

The two most common approaches are:

Anterior

Posterior

Whatever approach is used should be well documented in the operative note.

Slide48

Head, Neck & Spine

There is an important difference to take note of between vertebra/vertebrae and the vertebral interspace. CPT defines the vertebral interspace as:

“The non-bony compartment between two adjacent vertebral bodies, which contains the intervertebral disk, and includes the nucleus pulpous, annulus

fibrosus

, and two cartilaginous endplates.”

The vertebra or vertebral segment is the bone itself.

Slide49

Head, Neck & Spine

For example:

“L1” is a vertebra, whereas L1-L2 describes an interspace.

The span from L1 to L5 includes five vertebrae and four interspaces.

NOTE:

Decompression of the spinal cord is described with codes from the nervous system (60000 series) portion of CPT. For removal of a disc without decompression; utilize codes from the 22000 CPT series.

Slide50

Common Spine Surgeries

The most frequently reported spinal procedures for

orthopaedics

include:

Decrompression

/Laminectomy/Laminotomy/Hemi-laminectomy: CPT codes 63001-63103Laminotomy and laminectomy are spinal decompression surgeries performed on the lamina. Laminotomy is the partial removal of the lamina. Laminectomy is the complete removal of the lamina. It is important to know that the terms are often used interchangeably.

Slide51

Common Spine Surgeries

Arthrodesis: CPT codes 22532-22812

Arthrodesis in the spine is performed to fuse two vertebral bodies together. Arthrodesis is reported based on approach and technique. The different types of fusion include:

Posterolateral fusion – procedure is done through the back

Posterior lumbar interbody fusion (PLIF/TLIF) – the procedure is done from the back and includes removing the disc between two vertebrae and inserting bone into the space created between the two vertebral bodies

Slide52

Common Spine Surgeries

Anterior lumbar interbody fusion (ALIF) – the procedure is done from the front and includes removing the disc between two vertebrae and inserting bone into the space created between the two vertebral bodies

Anterior/posterior spinal fusion – the procedure is done from the front and the back

Slide53

Common Spine Surgeries

Instrumentation; including rods, plates, screws, etc.: CPT codes 22840-22849

The codes for spinal instrumentation are selected based on the whether the instrumentation is anterior or posterior and the number of vertebral segments.

If the surgeon removes instrumentation to necessitate a spinal procedure (such as a repeat fusion), you cannot charge for the instrumentation removal.

Slide54

Common Spine Surgeries

On rare occasions, however, the surgeon may have to remove spinal instrumentation because the instrumentation breaks, the patient’s body rejects it, or the patient requires an adjustment in the instrumentation type.

In these cases, you can separately code the instrumentation removal (22850, 22852, 22855).

If the surgeon reinserts instrumentation following the procedure (such as a repeat fusion), you should report 22849 (Reinsertion of spinal fixation device).

Slide55

Common Spine Surgeries

Bone Grafting: CPT codes 20930-20938

Bone grafts are reported with many spine surgeries unless the code descriptions includes the bone graft.

Bone grafts can be allografts (grafts between individuals of the same species or autografts (grafts taken from the patient).

Slide56

Common Spine Surgeries

Placement of Biomechanical Device, such as synthetic cage(s): CPT codes 22853-22854, 22859

These are all add-on codes

22853 is “per interspace”

22854 and 22959 are “each contiguous defect”

Slide57

Vertebroplasty vs. Kyphoplasty

Things to look for:

Is a balloon used to create a cavity? Report kyphoplasty.

How many vertebral bodies are involved?

What type of imaging guidance is used?

Slide58

Vertebroplasty vs. Kyphoplasty

Terminology changes

Kyphoplasty now referred to as “percutaneous vertebral augmentation”

Codes are found at 22513-22515

Codes are for one “1” vertebral body for the body areas listed:

Thoracic

LumbarCodes are unilateral or bilateralImaging is included

Slide59

Vertebroplasty vs. Kyphoplasty

Vertebroplasty codes are 22510-22512

These are percutaneous codes

The codes are for one (1) vertebral body for the body areas listed:

Cervicothoracic

LumbosacralCodes are unilateral or bilateral

Imaging is included

Slide60

Kyphoplasty

Vertebroplasty vs. Kyphoplasty

Slide61

Vertebroplasty

Vertebroplasty vs. Kyphoplasty

Slide62

Vertebroplasty

Vertebroplasty is often utilized because:

More extensive repair experience

Good pain relief record

Relatively quick procedure

Performed as an outpatient procedureLess costly than kyphoplasty

Slide63

Spinal Injections

Slide64

Spinal Injections

Spinal injections may be either diagnostic or therapeutic (pain management), depending on the type/location of the injection, and the substance being injected.

Codes 62280–62282 describe subarachnoid or epidural injections, by location:

62280 Injection/infusion of neurolytic substance (

eg

, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid

Slide65

Spinal Injections

62281 Injection/infusion of neurolytic substance (

eg

, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic

62282 Injection/infusion of neurolytic substance (

eg

, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Slide66

Spinal Injections

Codes 62320-62327 describe spinal injections with and without indwelling catheters, with and without image guidance, and some with indwelling catheter placement.

62320 Injection(s), of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

Slide67

Spinal Injections

62321 Injection(s), of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (

ie

, fluoroscopy or CT)

Slide68

Spinal Injections

62322 Injection(s), of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

Slide69

Spinal Injections

62323 Injection(s), of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (

ie

, fluoroscopy or CT)

Slide70

Spinal Injections

62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

Slide71

Spinal Injections

62325 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (

ie

, fluoroscopy or CT)

Slide72

Spinal Injections

62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

Slide73

Spinal Injections

62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (

eg

, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (

ie

, fluoroscopy or CT)

Slide74

Spinal Injections

A final set of spinal injection codes describes transforaminal epidural injections by location:

64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Slide75

Spinal Injections

64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Slide76

Spinal Surgery

The X-STOP is an interspinous process decompression system for use in the cervical and lumbar area, touted as an alternative to fusion.

Use of this device is reported with codes 22867-22870:

22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level

Slide77

Spinal Surgery

22868 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)

22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level

Slide78

Spinal Surgery

22870 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)

Medicare will cover X-STOP with specific diagnosis and other requirements. Check with your individual payer for guidelines. Other payers may regard these devices as experimental, and they will not be covered.

Slide79

Spinal Surgery

Artificial disc placement has become more common. The procedures include:

22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes

osteophytectomy

for nerve root or spinal cord decompression and microdissection); single interspace, cervical

Slide80

Spinal Surgery

22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes

osteophytectomy

for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

Slide81

Spinal Surgery

22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

Slide82

Fractures

Slide83

Fractures

Fracture repair codes are arranged by anatomical site, and are further classified as with or without manipulation, and percutaneous or open treatment.

When a broken bone is misaligned, manipulation is necessary to move it back into place.

Percutaneous repair occurs through a puncture in the skin, usually with hardware placement.

An open repair requires that the physician create a surgical opening to view and repair the fracture directly.

Slide84

Fractures

Nonunion or malunion occurs in two to five percent of fractures.

For most body areas, there are specific codes to describe treatment of such fractures in the repair/ reconstruction—rather than the fracture treatment—portion of CPT.

Bone grafts are normally included with fracture nonunion/malunion treatments.

Slide85

Musculoskeletal, Blood Vessel, and Nerve Repairs

Slide86

Musculoskeletal Repairs

Musculoskeletal repairs may involve tissues other than bone, including:

Cartilage

Ligaments

Muscles

Tendons

Flexor-palmarExtensor-dorsumCPT codes for these repairs generally are listed by site or are indexed under the heading of arthroscopy.

Slide87

Blood Vessel Repairs

For repair of blood vessels (artery or vein), look to codes 35201–35286 in the cardiovascular portion of CPT, depending on the type of repair or graft used.

You should report 35201–35226 for direct vessel repair; 35231–35256 for vein graft, and 35261–35286 for non-direct repairs using other than vein graft.

Slide88

Nerve Repairs (Neurorhaphy)

For primary nerve repairs, look to codes 64831–64859, as appropriate to nerve location.

Add on codes +64872 and +64874 describe secondary or delayed suture and extensive mobilization or transposition of the nerve, respectively.

You should report these procedures, when performed, in addition to the appropriate nerve repair code.

Slide89

Nerve Repairs (Neurorhaphy)

For primary nerve repairs, look to codes 64831–64859, as appropriate to nerve location.

Add on codes +64872 and +64874 describe secondary or delayed suture and extensive mobilization or transposition of the nerve, respectively.

You should report these procedures, when performed, in addition to the appropriate nerve repair code.

Codes 64885–64911 describe nerve grafts, by location and length

Slide90

Neuroplasty

Codes for

neuroplasty

are specific to nerve or location.

Note the availability of “other than specified” codes (e.g., 64708) for those procedures not targeted to a nerve identified specifically in CPT.

64702

Neuroplasty; digital, 1 or both, same digit64704 Neuroplasty; nerve of hand or foot64708 Neuroplasty; major peripheral nerve, arm or leg, open; other than specified

Slide91

Neuroplasty

64712

Neuroplasty

; major peripheral nerve, arm or leg, open; sciatic nerve

64713

Neuroplasty; major peripheral nerve, arm or leg, open; brachial plexus

64714 Neuroplasty; major peripheral nerve, arm or leg, open; lumbar plexus

Slide92

Neuroplasty

Additional codes describe

neuroplasty

and/or transposition. For instance, for surgical treatment of carpal tunnel syndrome (G56.0X):

64716

Neuroplasty

and/or transposition; cranial nerve (specify)64718 Neuroplasty and/or transposition; ulnar nerve at elbow64719 Neuroplasty and/or transposition; ulnar nerve at wrist

64721 l 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel

Slide93

Coding for

Hallux Valgus, Hammertoe, and Bunionectomy

Slide94

Agenda

94

Mechanism of Illness/Injury

Clinical Presentation

Diagnostic Procedures

Management/Interventions

Slide95

Hallux Valgus/Bunionectomy

Slide96

Mechanism of Illness/Injury

A bony bump at the base of the big toe

Causes that toe to deviate toward the others

It throws foot bones out of alignment and producing the characteristic bump at the joint's base

Painful due to pressure or arthritis, and may also lead to corns.

Slide97

Mechanism of Illness/Injury

Etiology

Essential extrinsic factor = shoe

Female/male = 2:1 to 15:1

Intrinsic cause

Heredity:

+ FH ~63%

Slide98

Treatment and Procedures

Pain relievers

Wearing roomy shoes and avoiding high heels

Stretching exercises

Slide99

Anatomy

Slide100

Pathophysiology

Slide101

Pathophysiology

Slide102

Pathophysiology

IMA (normal <9



) [8-9]

HVA (normal <15



) [15-20]

DMAA (normal <10



) [10-15]

Slide103

Hallux Valgus Classifications

Mild

Moderate

Severe

Hallux Valgus Angle

<20



20



-40



>40



Intermetatarsal Angle

<11



11



-16



>16



Sesamoid Subluxation

<50%

50-75%

>75%

Slide104

Treatment and Procedures

Pads to cushion the bunion

Custom shoe inserts or orthotics

Slide105

Treatment and Procedures

Cortisone injection

Slide106

Treatment and Procedures

Bunionectomy

The key to coding and billing the bunionectomy is to focus on the inherent procedure as opposed to one’s personal preference in regard to variations to the procedures, the use of specific fixation devices/material or even additional services.

For fixation of a first metatarsal osteotomy, there is no variation in reimbursement if you are using a K-wire, screw, plate or other fixation devices.

Slide107

Treatment and Procedures

Reimbursement is always based upon the inherent procedure performed and the standard of care.

The fixation unit and the extra work involved would not be payable as that is more of a doctor preference.

Utilizing other types of materials to reinforce tendons or capsules may or may not be covered if this is not a common practice in performing the given bunionectomy procedure.

Slide108

Treatment and Procedures

Certain insurance carriers may have specific guidelines for the use of these materials.

Some “newer” devices/materials which bind metatarsals together to decrease angles are generally not covered by insurance companies.

Slide109

Treatment and Procedures

The CPT codes for Bunionectomy include as integral parts of the operation:

capsulotomy,

arthrotomy,

synovial biopsy,

synovectomy,

tendon release, tenotomy, tenolysis, excision of medial eminence, excision of associated osteophytes,

Slide110

Treatment and Procedures

The CPT codes for Bunionectomy include as integral parts of the operation:

placement of internal fixation,

scar revision,

articular shaving,

and removal of bursal tissue when done at the first MTP joint.

Slide111

Common Codes

28111 – Ostectomy, complete excision; first metatarsal head

Physician incises first MTP joint

Inserts a retractor to remove the joint capsule and any proliferative synovial tissue

Detaches the abductor hallucis tendon from base of phalanx and cuts the metatarsal head and base

Slide112

Common Codes

28288 – Ostectomy, partial,

exostectomy

or

condylectomy

, metatarsal head, each metatarsal headThere is no mention in the code descriptor as to which specific metatarsal this applies to. However, this code most commonly applies to the lesser metatarsals.

Slide113

Ostectomy 1

st

Metatarsal Head

Slide114

Ostectomy 1

st

Metatarsal Head

Slide115

Ostectomy 1

st

Metatarsal Head

Slide116

Proximal Osteotomy (Scarf)

Slide117

Proximal Osteotomy (Ludloff)

Slide118

Stability of Osteotomies

Slide119

Proximal Phalangeal Osteotomy

28298/28299 Akin, Akin/Austin Procedure

Slide120

Medial Cuneiform Osteotomy

28299 -

Riedl

& Coughlin

Slide121

CPT 28289 - Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint

Similar in nature to CPT 28288, this code is specifically for the first metatarsal joint.

This is the best code to use when one is performing a cheilectomy procedure to increase motion at the joint in order to address hallux limitus/rigidus.

NOTE:

“Cheilectomy” refers to excision of the lip of the first MTP joint.

Common Codes

Slide122

Common Codes

CPT 28289 (continued)

This procedure code also includes any capsular release the surgeon deems necessary, as well as dissection and removal of additional prominences on the base of the proximal phalanx that are jamming the joint.

Bony irregularities may be removed using a chisel, and edges smoothed with a rasp.

When adequate flexion is reached the tendon is returned to its correct position and the skin is closed with sutures.

Slide123

Common Codes

CPT 28292 - Correction, hallux valgus (bunionectomy), with

sesamoidectomy

, when performed; with resection of proximal phalanx base, when performed, any method (formerly known as Silver, Keller, McBride, and Mayo type procedure) 

This code describes a simple

exostectomy

bunionectomy procedure. This would involve resecting the medial eminence. This code also covers releasing or excising the sesamoid.

Slide124

Common Codes

Keller procedure

is a simple resection of the base of the proximal phalanx with removal of the medial eminence. It provides excellent pain relief for Hallux rigidus (MTP arthritis) and decompression for medial breakdown.

Resulting diminished toe function however, has led many physicians to seek other procedures in active individuals.

Slide125

Common Codes

28292

Slide126

Common Codes

28292

Simple resect 1/3 of proximal phalanx

Decompress joint and relax tight lateral structure

Allow correction deformity

High recurrence rate

Little improve IMA

MetatarsalgiaDifficult salvage of failure procedure

Slide127

Common Codes

McBride procedure

, now modified and referred to as the distal soft tissue release, corrects all soft-tissue deformity at the MTP joint by releasing the tight lateral capsule, ligament complex and adductor tendon, and reefing the loose medial capsule with resection of the medial eminence.

The lateral sesamoid is no longer removed. McBride procedure is seldom being performed.

Slide128

Common Codes

28292 – Modified Bunionectomy (modified McBride)

Slide129

Common Code

28292 - McBride

Slide130

Common Codes

28292

Mayo procedure

historically involves resection of the first metatarsal head and is now rarely done for bunions.

Slide131

Common Codes

CPT 28291 - Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant

The use of flexible silicone type implants for arthritis in the first MTP joint is controversial.

They may be subject to acute inflammatory reaction, local bone resorption, synovitis, proximal lymphatic involvement, wear and fracture.

Cemented implants are also being used but significant long term follow-up is not yet available.

Slide132

Common Codes

CPT code 28294 Correction, hallux valgus (bunion), with or without

sesamoidectomy

; with tendon transplants (e.g., Joplin type procedure)

was deleted for 2018.

Unlisted code 28899 Unlisted procedure, foot or toes would be used in place of that code.If tendon transplant is a major part of the procedure this code should be used.

Slide133

Common Codes

28296 Correction, hallux valgus (bunionectomy), with

sesamoidectomy

, when performed; with distal metatarsal osteotomy, any method

This procedure was formerly called the Mitchell or Chevron, or concentric type procedure.

Mitchell procedure

is a complex, biplane, double step cut osteotomy through the neck of the first metatarsal, and is indicated for moderate hallux valgus with a subluxed MTP joint.

Slide134

Common Codes

Distal chevron or concentric osteotomy

involves a resection of the medial eminence, combined with a transverse osteotomy in the coronal plane of the metatarsal neck to lateralize the head.

Proximal osteotomies

in the base of the first metatarsal (CPT code 28306), often required for severe metatarsus primus

varus

( > 15 degrees), are done through a separate incision at a more proximal anatomic area and require a -59 modifier.

Slide135

Common Codes

28297 Correction, hallux valgus (bunionectomy), with

sesamoidectomy

, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method

Formerly referred to as the “Lapidus-type” procedure

This involves a

metatarsocuneiform fusion plus a distal soft tissue bunion repair when there is arthritis or suspected instability at the first metatarso-cuneiform joint.

Slide136

Common Codes

28298 Hallux Valgus (bunion) correction, with or without

sesamoidectomy

; by phalanx osteotomy

Formerly known as “Akin” procedure involves the removal of a medially based bony wedge from the base of the of the proximal phalanx to reorient its axis.

It is the procedure of choice for Hallux valgus

interphalangeus, but offers too little correction to correct a major bunion deformity by itself.

Slide137

Common Codes

28299 Hallux valgus (bunion) correction, with or without

sesamoidectomy

; by other methods (e.g., double osteotomy)

With severe hallux valgus or a congruent joint, a double osteotomy of the first metatarsal or metatarsal and proximal phalanx might be required.

Slide138

Common Codes

28750 Arthrodesis, great toe; metatarsophalangeal joint

This is an important option that is considered in severe hallux valgus and when there are associated arthritic changes at the first MTP joint.

Slide139

Hammertoe

Slide140

Mechanism of Illness/Injury

Occurs from muscle and ligament imbalance around the toe joint, causes the middle joint of the toe to bend and become stuck in this position

Most common complaint is rubbing and irritation on the top of the bent toe

Toes that may curl rather than buckle are also considered hammertoes

Slide141

Mechanism of Illness/Injury

The causes for Hammertoe are threefold:

Genetic – Flatfoot or high arch

Injury – High heels, pointed toe, ill-fitting

Arthritis – Constant inflammation

Women are more likely to get pain associated with hammertoes

Serious problem in people with diabetes or poor circulation.

Slide142

Two Types of Hammertoe

Flexible

If the toe can still be moved at the joint, it’s a flexible hammertoe.

This is an earlier, milder form of the problem which may be treated by several different options.

Slide143

Two Types of Hammertoe

Rigid

If the tendons in the toe become rigid, they press the joint out of alignment. At this stage, the toe can't be moved. It usually means that surgery is needed.

Slide144

Types of Corrective Surgery

Soft tissue correction

Soft tissue corrective surgery redirects the tendons and joint capsule of your toe which will correct the position.

Digital arthroplasty

This involves correcting the soft tissue and removing a piece of bone in order to straighten the toe.

Arthrodesis

The technique involves fusing two bones together in order to straighten the toe.

Slide145

Types of Corrective Surgery

Often a combination of procedures using techniques from the different types of toe surgeries mentioned is performed.

Many times hammertoe surgery requires a metal wire or other implant to be inserted into the toe that will hold it into place while it heals.

The end result will be a straightened toe.

Slide146

Materials and Products

Pins, K-wires, and screws of various kinds are often employed in various aspects of these procedures.

Since 2007, the Smart Toe implant has been utilized widely by many

Orthopaedic

surgeons. Proper use of this product appears to provide faster fusion of repaired toes, has less pain during recovery period, and fewer complications following surgery.

Slide147

A)

 Distal Phalange

B)

 Interphalangeal Articulation

C)

 Proximal Phalange

Example – Smart Toe Information

A)

 Distal Phalange

B)

 Medial & Proximal Fused

C)

 Smart Toe Implant

D)

Proximal Phalange

Slide148

A)

 

Before insertion, the implant is cooled by the surgical team.

B)

 After insertion, body heat expands and contracts the implant.

Angled Smart Toe implant provides a natural angle to the surgically corrected toe.

Example – Smart Toe Information

Slide149

Common Codes

28285 Correction, hammertoe (e.g., interphalangeal fusion, partial or total

phalangectomy

)

28286 Correction, cock-up fifth toe, with plastic skin closure (e.g., Ruiz-Mora type procedure)

The Ruiz-Mora procedure has been advocated for treatment of congenital overlapping fifth toes, fifth hammertoe, and clavus deformities. 

The toe is shortened by removing the proximal phalanx and leaving a space between the base of the metatarsal and distal phalanx.

Slide150

Q:

Is it appropriate to report a 28285 hammertoe correction along with a corresponding 28270 metatarsophalangeal joint capsulotomy during the same surgical encounter when both procedures are medically necessary to completely correct the presenting deformities?

A:

Yes. It is not unusual to have to perform both of these procedures during the same surgical session to completely correct a complex ray deformity.

Questions

Slide151

Questions

A:

A hammertoe can be defined by a digital contracture at the distal interphalangeal joint and/or proximal interphalangeal joint. A contracted metatarsophalangeal joint is a

dorsiflexory

positioning of the proximal phalanx on the metatarsal head. These are two distinct deformities that can and do exist in isolation, but if both conditions are present, no single CPT code describes the correction of both deformities.

Slide152

Questions

Q:

Is it appropriate to append modifier 

50, Bilateral procedure

, to procedure code 28285, Correction, hammertoe (e.g., interphalangeal fusion, partial or total

phalangectomy, if the procedure is performed on the same toes of both the right and left foot?

Slide153

Questions

Yes. The use of this modifier is only applicable to services or procedures performed on identical anatomic sites, aspects, or organs (e.g., arms, legs, eyes) during the same operative session.

The intent is for the modifier to be appended to the appropriate unilateral code as a one line entry on the claim form to indicate that the procedure was performed bilaterally.

Slide154

Persistent dorsiflexion contracture at the metatarsophalangeal joint and plantar flexion contracture at the proximal interphalangeal joint of the fifth toe (Figures 1A and 1B) is frequently associated with a painful hyperkeratosis

Figures 1A and 1B

Techniques and Images

Slide155

Some techniques involve the excision of an elliptical portion of the plantar skin is excised, a possible cause of vascular impairment of the fifth toe and hypertrophic scarring.

Figures 2A and 3B

Techniques and Images

Slide156

Figures 2A and 3B

Some minimally invasive procedures often produce insufficient correction of the deformity. 

The Augustine and Jacobs technique consists of a plantar closing wedge osteotomy of the 5

th

 toe at the base of its proximal phalanx associated with an exostosectomy of the head of the proximal phalanx and at the base of the middle phalanx.

Techniques and Images

Slide157

Lastly, a complete tenotomy of the deep and superficial flexor tendons and of the tendon of the extensor digitorum longus is undertaken.

In this way, correction of the deformity is achieved without interfering with the joint surface and producing only minimal shortening of the 5

th

 toe, and no vascular or skin compromise.

Techniques and Images

Slide158

Tenotomy of the tendon of extensor digitorum longus to the 5

th

 toe

A 2 mm incision is performed just above the extensor tendon and parallel to it at the level of the metatarsophalangeal joint.

28010 – Tenotomy, percutaneous, toe; single tendon

Figures 3A and 3B

Techniques and Images

Slide159

Tenotomy of the tendon of extensor digitorum longus to the 5

th

 toe

The patient is then asked to extend the 5

th

 toe, allowing to better locate the tendon, which is fully tenotomised (Figures 3A and 3B). 

Figures 2A and 3B

Techniques and Images

Slide160

Dorsal metatarsophalangeal capsulotomy

In patients with severe rigidity, capsulotomy of the metatarsophalangeal joint is performed, releasing only the superior portion of the capsule and the extensor sling.

Correction of the hyperextension is usually remarkable.

28270 - Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure)

 

Techniques and Images

Slide161

Lateral condylectomy

If the hyper-flexion of the interphalangeal joints is difficult to correct, there often is an exostosis at the lateral condyle of the proximal phalanx of the 5

th

 toes and at the base of the middle phalanx.

If this is the case, a lateral condylectomy is indicated.

A 2 mm incision is made over the dorso-lateral aspect of the 5

th

 toe. The blade is introduced until it touches the underlying bone.

28288 - Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head

Techniques and Images

Slide162

Lateral condylectomy

The periosteum is detached from the bone with a rasp, and the exostosis is removed with the short Shannon 44 burr (Figures 4A and 4B) at slow speed with gentle oscillating movements.

Figures 4A and 4B

Techniques and Images

Slide163

Tenotomy of the flexor tendons

A 2 mm incision is performed just proximal to the plantar fold of the toe, just medial to the toe itself.

The surgeon extends the 5

th

 toe to tense the flexor tendon, which is severed with the tip of the scalpel.

It should then be possible to appreciate the loss of resistance to extension in the proximal and distal interphalangeal joints.

28010 – Tenotomy, percutaneous, toe; single tendon

Techniques and Images

Slide164

Osteotomy of the proximal phalanx

A rasp is introduced through same incision used for the tenotomy of the flexor tendons, the periosteum is detached from the lateral aspect of the phalanx.

A plantar closing wedge osteotomy is performed (Figure 5A and 5B) using the short Shannon 44 burr.

Figures 5A and 5B

Techniques and Images

Slide165

Osteotomy of the proximal phalanx

Complete correction of deformity is thereby achieved (Figures 6A and 6B).

28312 - Osteotomy, shortening, angular or rotational correction; other phalanges, any toe

Figures 6A and 6B

Techniques and Images

Slide166

Q:

Why wouldn’t 28313 - Reconstruction, angular deformity of toe, soft tissue procedures only (e.g., overlapping second toe, fifth toe, curly toes) be used INSTEAD OF 28312 - Osteotomy, shortening, angular or rotational correction; other phalanges, any toe?

Figures 6A and 6B

Techniques and Images

Slide167

A:

28313 – This procedure involves the correction of the toe deformity by releasing soft tissues and possibly involving tendon transfers.

It does not include cutting or realigning the shafts of the bones.

Figures 6A and 6B

Techniques and Images

Slide168

Bones of the Toes

There are 14 bones called phalanges located in the toes of a foot. The 1st toe (also called great toe or hallux) has a proximal phalanx and a distal phalanx. The 2nd, 3rd, 4th, and 5th toes each have 3 phalanges:

proximal phalanx,

middle phalanx and

distal phalanx.

Some physicians refer to an entire toe as a "phalanx," so be careful when reading the operative reports to distinguish between an entire toe and 1 of the toe bones when "phalanx" is referenced.

Other Coding Tips

Slide169

Bones of the Toes

For example, if a physician dictates that the "distal phalanx of the left 3rd phalanx was removed entirely," this means that the distal phalanx bone was removed from the left 3rd toe. Code such a procedure as CPT code 28150-T2 (Phalangectomy, toe, each toe — left foot, 3rd digit).

Confirm that the OR report documentation supports the specific phalanx when it impacts the CPT code assignment.

Other Coding Tips

Slide170

Bones of the Toes

For example, if a patient has a right hallux proximal phalanx osteotomy performed, assign code:

28310-T5 Osteotomy, shortening, angular or rotational correction; proximal phalanx, 1st toe (separate procedure), right foot, great toe

.

Other Coding Tips

Slide171

Arthroscopy

Slide172

Arthroscopy

Arthroscopic procedures may be performed in most joints of the body.

Codes are distributed throughout the CPT manual by anatomic area.

Be aware that surgical scope or open surgical intervention always includes same-session diagnostic scope in the same anatomic area.

Slide173

Arthroscopy

29805–29828—shoulder

29830–29838—elbow

29840–29848—wrist

29860–29863, 29914-29916—hip

29866–29889—knee

29891–29899—ankle29900–29902—metacarpophalangeal29904–29907—subtalar joint

Slide174

Shoulder Anatomy - Bones

Clavicle

Medial end articulates with the sternum = sternoclavicular joint

Lateral end articulates with the acromion process of the scapula = acromioclavicular joint

Slide175

Shoulder Anatomy - Bones

Scapula

Posterior to ribs, has no bony attachment to the axial skeleton

Acromion process

Coracoid process

Coracoacromial ligament connects the coracoid process with the acromion processCoracoclavicular ligament unites the clavicle with the acromion process

Slide176

Shoulder Anatomy - Bones

Glenohumeral

joint - attachment of the

humerus

to the scapula at the glenoid

Glenoid fossa – depression on the lateral scapula, provides articulation for the head of the humerus with the scapula

Labrum – collar-like structure that surrounds the glenoid fossa

Slide177

Shoulder Anatomy – Muscles & Tendons

Trapezius – thin sheet of muscle covering the upper back, helps form the contour of the neck

Deltoid – so-named as it resembles the Greek letter, Delta, stretches from the clavicle and the scapula to the deltoid tuberosity of the

humerus

Slide178

Shoulder Anatomy – Muscles & Tendons

Rotator cuff – composed of the tendons for four muscles:

Subscapularis

Supraspinatus

Infraspinatus

Teres minor

Slide179

Shoulder Anatomy – Muscles & Tendons

Coracobrachialis – originates at the tip of the coracoid process and inserts on the medial surface, mid-

humerus

Biceps

brachii

- anterior of the armTriceps

brachii – posterior of the armNOTE: Most commonly dislocated joint in the body

Slide180

Shoulder Pathology

Shoulder instability – weakening of the

glenohumeral

joint by subluxation or

discloation

Bankart lesion - A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.

An initial Bankart lesion (sprain/strain) will code to S43.0XXA.A recurrent Bankart

lesion will code to M24.41X.

Slide181

Shoulder Pathology

SLAP tears – S46.111A, S46.919A, S43.431A, S43.439A, S43.491A

Rotator cuff tear – S43.421A, S43.422A,

Infraspinatus (muscle or tendon) – S43.80XA, S43.81XA, S43.82XA

Supraspinatus (muscle or tendon) – S43.80XA, S43.81XA, S43.82XA

Subscapularis (muscle) – S43.80XA, S43.81XA, S43.82XA

Slide182

Shoulder Pathology

Impingement Syndrome – M75.4X

Rotator cuff tendinopathy

Degenerative – M66.211, M66212, M66.219, M66.811, M66.812, M66.819, M75.100, M75.101, M75.102

Nontraumatic rupture – M75.120, M75.121, M75.122

Biceps tendinopathy

Degenerative – M75.20, M75.21, M75.22Nontraumatic rupture – Multiple codes to choose from in the M66.XXX section of ICD-10-CM

Slide183

Shoulder Procedures

Superior labrum from anterior to posterior (SLAP)

The SLAP tear is identified and a small ball burr may be used to remove excess tissue and prepare the bony bed (glenoid)

A small hole is drilled into the bone where the labrum has torn off

An anchor with suture attached is placed it this hole

The suture is used to tie the torn labrum snugly against the bone

Slide184

Shoulder Procedures

Arthroscopic Biceps Tenodesis

29828 Arthroscopy, shoulder, surgical; biceps tenodesis

A procedure that cuts the biceps tendon (long head) from where it attaches to the upper rim of the glenoid (labrum), and reinserts it into another area.

Slide185

Shoulder Procedures

Slide186

Shoulder Procedures

Slide187

Rotator Cuff Repair/Reconstruction

CPT code series 23410 to 23420 includes acute or chronic conditions within the CPT verbiage.

The operative documentation should provide whether the patient has an acute versus chronic condition.

If no indication is provided in the clinical documentation, don’t assume.

Slide188

Rotator Cuff Repair/Reconstruction

AMA guidelines state that three of the four muscles/tendons of the rotator cuff should be torn, with further clarification from the AMA stating that CPT 23420 is an extreme tear, typically requiring rearrangement of the nor- mal anatomy with occasional grafting of biological or nonbiological material.

Slide189

Rotator Cuff Repair/Reconstruction

The AMA says that code determination is not necessarily based on the number of tendons.

Remember, four tendons make up the rotator cuff:

supraspinatus (top of humeral head),

subscapularis (front of humeral head),

infraspinatus (back of humeral head) and

teres minor (also back of humeral head).

Slide190

Rotator Cuff Repair/Reconstruction

The American Academy of

Orthopaedic

Surgeons reiterates that you shouldn’t use CPT 23420 simply for a repair of a massive tear but for a reconstruction of a massive tear with significant retraction that involves extensive releases and mobilization, as well as fascial or synthetic material when applicable, in order to return the tendon to its original anatomical location.

In other words, we aren’t simply suturing and repairing a tendon via anchors and tacks.

In addition, three tendons need not be torn to support reporting CPT 23420.

Slide191

Rotator Cuff Repair/Reconstruction

Use CPT code series 23410 to 23412 to report mini open rotator cuff tear repairs, with code selection determined by acute versus chronic conditions.

While CPT provides a parenthetical statement under CPT 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) directing the CPT user to report 23412 for mini open rotator cuff repair, you still need to determine the final code selection based on the acute versus chronic condition.

Recall that CPT code verbiage in 23410 to 23420 is specific to an acute versus chronic condition.

Slide192

Rotator Cuff Repair/Reconstruction

Mini open rotator cuff tear repairs typically don’t involve entry into the shoulder joint while the tear can still be visualized and repaired.

When a surgeon performs an arthroscopic rotator cuff repair, report CPT 29827 regardless of whether the condition is acute versus chronic.

The operative report should specify an acute versus chronic condition.

The technique (open versus arthroscopic) will need to be apparent to include a detailed description of a repair versus reconstruction of the specific tendon(s) or cuff.

Slide193

Distal Claviculectomy

Excision of the distal clavicle (approximately 1cm) involving more than a simple shaving of osteophytes at the AC joint is reported separately whether performed open or closed, according to the AAOS.

The operative report must indicate the size of the distal clavicle excision to justify the separate reporting of this code.

Slide194

Arthroscopic Labrum Repairs

Report CPT 29806 for surgical capsular repairs when performed arthroscopically.

Simply because a labrum is torn and repaired, it doesn’t automatically warrant reporting 29807 if the torn labrum isn’t a SLAP (superior labrum from anterior to posterior) tear.

CPT 29807 is specific for a SLAP repair; don’t use it for labral tears that aren’t SLAP tears. The surgeon will determine whether this is a true SLAP tear and also the “type” of SLAP.

Slide195

Arthroscopic Labrum Repairs

Report both 29807 and 29806 per AAOS if the surgeon performs SLAP Type II or Type IV in addition to

capsulorrhaphy

for a different indication.

To simplify, there should be two separate and distinct indications to report the capsular repair and the SLAP tear repair.

Slide196

Arthroscopic Labrum Repairs

Medicare edits bundle CPT code 29807 into CPT 29806 at this time, but allows for a modifier if the surgeon performs SLAP separately and distinctly from the

capsulorrhaphy

.

Use caution when considering the application of a modifier.

Remember the terms “separate” and “distinct.”

Simply because you can use a modifier doesn’t imply automatic application of a modifier with every scenario.

Slide197

Arthroscopic Labrum Repairs

Don’t confuse the surgeon’s repair of the labrum by attaching it to the capsule as a separately identifiable

capsulorrhaphy

.

The separate reporting of the

capsulorrhaphy

is indicated when there is a capsular defect unrelated to the labrum tear that in itself also warrants a repair.

Slide198

Arthroscopic Labrum Repairs

Arthroscopic SLAP debridement is reported from the arthroscopic shoulder debridement codes pending other debridements performed during the operative session.

These debridement codes may be considered inclusive into other surgical procedures performed during the same operative session.

The operative report should specify the type of SLAP (I, II, III, IV, etc.), document the diagnosis for either or both the SLAP and

capsulorrhaphy

, and describe the procedure(s) in detail.

Slide199

Decompression & Acromioplasty

Acromioplasty is an arthroscopic surgical procedure of the acromion.

Generally, it implies removal of a small piece of the surface of the bone that is in contact with a tendon causing, by friction, damage to the tendon.

Slide200

Decompression & Acromioplasty

The Centers for Medicare & Medicaid Services (CMS) and the American Academy of

Orthopaedic

Surgeons (AAOS) have opposing views on shoulder anatomy.

AAOS recognizes the

glenohumeral

joint, the acromioclavicular (AC) joint, and the subacromial bursa as separate anatomic areas. CMS, by contrast, considers the shoulder to be a single anatomic region.

Slide201

Decompression & Acromioplasty

Subacromial Decompression with Partial Acromioplasty

CPT 29826 requires both a subacromial decompression and a partial acromioplasty.

If acromioplasty is not performed, report only a debridement.

Keep in mind that 29826 is an add-on code requiring a primary procedure.

When coding the acromioplasty, look for discussion about the morphology (specifically type I, II, or III) in the operative notes.

This determines if the acromion is flat, curved, or hooked.

Slide202

Decompression & Acromioplasty

Slide203

Decompression & Acromioplasty

Was the creation of the 1 cm space in the AC joint due to a distal

claviculectomy

, acromioplasty, or both?

If the bur was used to reshape the acromion by removing osteophytes or excess bone, this could be a form of debridement.

If the acromioplasty is the only service performed, report a debridement (29822 or 29823).

If acromioplasty is performed with distal claviculectomy, it’s possible the two procedures created the 1 cm space. In this situation, it may be appropriate to report 29824 

or 29826, but not both.

Slide204

Decompression & Acromioplasty

Encourage providers to describe the acromioplasty with morphology and the distal

claviculectomy

of approximately 1 cm separately, rather than to indicate the creation of a 1 cm space at the AC joint.

Slide205

Decompression & Acromioplasty

Example:

 

If a 1 cm space is created by removing 7 mm from the distal clavicle and 3 mm from the acromion, this is a debridement (29822) because the documentation does not meet the minimum requirements for the distal

claviculectomy

or the acromioplasty.

If the 3 mm removed from the acromion is a true acromioplasty — achieved by converting the acromion to a type I morphology with a subacromial decompression — proper coding is 29822 and 29826. The 7 mm does not meet the requirements of the claviculectomy.

Documentation must support both services.

Slide206

Rotator Cuff Repair

There are three possible codes for open rotator cuff surgery, depending on whether it’s an acute or chronic repair, or if it’s a reconstruction.

CPT 29827 is the only code for arthroscopic rotator cuff repair. 

Slide207

Shoulder Debridement

CPT code 29822 cover

limited

debridement of soft or hard tissue.

Use it for

limited

labral debridement, cuff debridement, or the removal of osteophytes and degenerative cartilage.CPT code 29823 cover extensive debridement of soft or hard tissue. It includes for example, an abrasion chondroplasty of the humeral head or glenoid and associated osteophytes, or multiple soft tissue structures that are debrided, such as the labrum, subscapularis and supraspinatus.

Slide208

Shoulder Debridement

Operative documentation should describe all areas, sites, tendons and lesions debrided or excised.

A sentence stating, “I performed an extensive debridement” does not justify reporting CPT code 29823.

What was debrided?

How much was debrided?

Did the surgeon debride from two or three joint areas/regions?

If so, could this debridement stand alone, or was it part of another procedure.

Slide209

Shoulder Debridement

Example

The surgeon may debride the rotator cuff in preparation for repairing the rotator cuff via the arthroscope. If this were the only debridement he performed, you’d consider this inclusive to the arthroscopic rotator cuff repair, since he performed the debridement in preparation for the repair.

Slide210

Shoulder Debridement

Example

However, if the surgeon thoroughly describes the debridement of multiple areas/sites, such as the labrum debridement, abrasion arthroplasty, biceps tendon debridement and partial synovectomy, which are not typically included in a rotator cuff, then you can feel comfortable reporting CPT 29823.

Slide211

Knee Joint

Slide212

Anatomy of the Knee - Bones

Femur – articulates with the acetabulum proximally and with the tibia and patella distally

Patella – a sesamoid bone, serves as a fulcrum and as protection for the underlying structures

Tibia the weight bearing, medial bone in the lower leg

Fibula – thin, lateral bone in the lower leg, primarily for muscle attachment

Slide213

Anatomy of the Knee - Ligaments

ACL – Anterior Cruciate Ligament

PCL – Posterior Cruciate Ligament

MCL – Medial Collateral Ligament

LCL – Lateral Collateral Ligament

Slide214

Anatomy of the Knee – Muscles & Tendons

Quadriceps

Rectus femoris

Vastus lateralis

Vastus intermedius

Vastus medialis

HamstringsBiceps femorisSemitendinosusSemimembranosus

Slide215

Anatomy of the Knee - Meniscus

Medial meniscus is C-shaped

Lateral meniscus is more circular in shape and covers a larger portion of the tibial plateau

Thick at the edges and thin in the center

Avascular, except for 10-30% at the periphery

Slide216

Pathology of the Knee

Sprains & strains of the knee

Lateral collateral ligament

Medial collateral ligament

Cruciate ligament

Testing for ACL injury

Lachman’sAnterior DrawerPivot shift

Slide217

Pathology of the Knee

Degeneration/old disruption of the knee

Lateral collateral ligament

Medial collateral ligament

Anterior cruciate ligament

Posterior cruciate ligament

Slide218

Pathology of the Knee

Tear of meniscal cartilage or meniscus of knee, current – ICD-10-CM choices include:

“Bucket-handle” tear of medial meniscus

Peripheral tear of medial meniscus

Complex tear of medial meniscus

Other tear of medial meniscus

Slide219

Pathology of the Knee

Derangement of medial meniscus - ICD-10-CM choices include:

Old bucket handle tear

Derangement of anterior horn

Derangement of posterior horn

Derangement of lateral meniscus

Old bucket handle tearDerangement of anterior hornDerangement of posterior horn

Slide220

Pathology of the Knee

Meniscal Tears

Vertical longitudinal

Complete/incomplete longitudinal

Bucket handle

Displaced bucket handle

ObliqueParrot beakFlapDisplaced Flap

Slide221

Pathology of the Knee

Meniscal Tears

Radial – transverse tear that follows the radial fibers

Horizontal

Complex

Double flap

Degenerative

Slide222

Pathology of the Knee

Slide223

Pathology of the Knee

MRI classifications of meniscal change

Grade 0 normal with homogeneous signal intensity

Grades I & II – high signal intensity within the meniscus, does not go to the surface

Grade III – high signal intensity that does go to the surface of the meniscus

Approximately one third of meniscal injuries occur in tandem with ACL tears

Slide224

Arthroscopic Procedures

Slide225

Arthroscopic Procedures

29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

Slide226

Arthroscopic Procedures

29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

Slide227

Arthroscopic Meniscus Repair

Three basic options

Inside-Out Suture – large bucket-handle and longitudinal tears

Outside-In Suture – tears of the anterior and middle thirds of the meniscus and for radial tears

All-Inside Repair – posterior horn tears

Meniscal Arrow

Slide228

Arthroscopic Ligament Repair

29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction