Category Archives: musculaskeletal system

Bunionectomy

How to Code Bunionectomy

Hello Coders!

In this article, I will explain everything about bunion and coding of bunion surgery procedures (bunionectomies) important for AAPC coding Exam 2017. Go through the article, practice CPC exam questions and post your queries in comments section at the end of article.

Bunion or Halux Valgus

What is BUNION :

Halux – great toe

Valgus – angulation of toe away from the midline

  • Bursa formed along the medial aspect of great toe.

bursa

  • Enlargement of bone or tissue around the joint at the bottom of the big toe (known as the metatarsaophalangeal joint).
  • It forms when your big toe pushes against your next toe, forcing joint of big toe to get bigger and stick out.

bunion

Causes :

  • Wearing tight, narrow shoes might cause bunions or make them worse
  • Bunions also can result of an inherited structural defect.
  • Stress on your foot or medical condition, such as arthritis.

What is Bunionectomy :

  • Surgery to excise all the parts of bunion that involves removing soft tissue, tendones and bone and may also involve reallining the toe joint.

bunionectomy

Types of Bunionectomy procedures:

  • There are different types of Bunionectomy procedures and it is very imprtant to know the type of procedure performed to select correct CPT code.
  • Some common bunion procedures includes:
  1. Austin,
  2. Reverse Austin ,
  3. Mitchell,
  4. Chevron,
  5. Kalish,
  6. youngswick,
  7. Reverdin,
  8. Reverdin-Green and
  9. Hohmann procedures,
  10. Akins procedures / phalanx osteotomy procedures.
  • The most commonly performed bunionectomy procedures are the Austin and Akin procedures.

Must Visit this site for more information : http://www.surgerybunion.com/ Continue reading How to Code Bunionectomy

CPC Practice Questions For 2017 – Part 2

20000 Series

  1. A 22-year-old female sustained a dislocation of the right elbow with a medial epicondyle fracture while on vacation. The patient was put under general anesthesia and the elbow was reduced and was stable. The medial elbow was held in the appropriate position and was reduced in acceptable position and elevated to treat non-surgically. A long arm splint was applied. The patient is referred to an orthopedist when she returns to her home state in a few days. What CPT® code(s) are reported?
  • 24575-54-RT, 24615-54-51-RT
  • 24577-54-RT, 24600-54-51-RT
  • 24576-54-RT, 24620-54-51-RT
  • 24565-54-RT, 24605-54-51-RT
  1. A 45-year-old presents to the operating room with a right index trigger finger and left shoulder bursitis. The left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. An incision was made over the A1 pulley in the distal transverse palmar crease, about an inch in length. This incision was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. Clean dressing was applied. What CPT® codes are reported?
  • 26055-F6, 20610-76-LT.
  • 26055-F6, 20610-51-LT.
  • 20552-F6, 20605-52-LT.
  • 20553-F6, 20610-51-LT
  1. A patient presents with a healed fracture of the left ankle. The patient was placed on the OR table in the supine position. After satisfactory induction of general anesthesia, the patient’s left ankle was prepped and draped. A small incision about 1 cm long was made in the previous incision. The lower screws were removed. Another small incision was made just lateral about 1 cm long. The upper screws were removed from the plate. Both wounds were thoroughly irrigated with copious amounts of antibiotic containing saline. Skin was closed in a layered fashion and sterile dressing applied. What CPT® code(s) should be reported?
  • 20680-LT
  • 20670-LT
  • 20680-LT, 20680-59-LT
  • 20680-LT, 20670-59-LT
  1. A patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF (open reduction) procedure was performed and included the following techniques: An incision was made in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. The pins were cut off below skin level. The wound was closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. What CPT® codes are reported?
  • 24579-RT, 29065-51-RT
  • 24579-RT
  • 24577-RT
  • 24575-RT
  1. A 47-year-old patient was previously treated with external fixation for a Grade III left tibial fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied with three screws. The harvested bone graft was packed into the fracture site. What CPT® codes are reported?
  • 27724-LT
  • 27722-LT
  • 27722-LT
  • 27724-LT

Donloadable CPC Practice Exam

  1. A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was prepped, draped, and positioned. Intramedullary rodding was carried out with proximal and distal locking screws. What CPT® codes should be reported?
  • 27506-RT, 11044-51-RT
  • 27507-RT, 11012-51-RT
  • 27506-RT, 11012-51-RT
  • 27507-RT, 11044-51-RT
  1. A 49-year-old female had two previous rotator cuff procedures and now has difficulty with shoulder function, deltoid muscle function, and axillary nerve function. An arthrogram is scheduled. After preparation, the shoulder is anesthetized with 1% lidocaine, 8 cc without epinephrine. The needle was placed into the shoulder area posteriorly under image intensification. It appeared as if the dye was in the shoulder joint. She was moved and a good return of flow was obtained. The shoulder was then mobilized and there was no evidence of any cuff tear from the posterior arthrogram. What CPT® codes are reported?
  • 20551, 73040-26
  • 23350, 73040-26
  • 20610, 73040-26
  • 20552, 73040-26
  1. A 31-year-old secretary returns to the office with continued complaints of numbness involving three radial digits of the upper right extremity. Upon examination, she has a positive Tinel’s test of the median nerve in the left wrist. Anti-inflammatory medication has not relieved her pain. Previous electrodiagnostic studies show sensory mononeuropathy. She has clinical findings consistent with carpal tunnel syndrome. She has failed physical therapy and presents for injection of the left carpal canal. The left carpal area is prepped sterilely. A 1.5 inch 25 or 22 gauge needle is inserted radial to the palmaris longus or ulnar to the carpi radialis tendon at an oblique angle of approximately 30 degrees. The needle is advanced a short distance about 1 or 2 cm observing for any complaints of paresthesias or pain in a median nerve distribution. The mixture of 1 cc of 1% lidocaine and 40 mg of Kenalog-10 is injected slowly along the median nerve. The injection area is cleansed and a bandage is applied to the site. What codes are reported?
  • 20526, J3301 x 4
  • 20526, J3301
  • 20551, J3301 x 4
  • 20550, J3301
  1. An elderly female presented with increasing pain in her left dorsal foot. The patient was brought to the operating room, and placed under general anesthesia. A curvilinear incision was centered over the lesion itself. Soft tissue dissection was carried through to the ganglion. The ganglion was clearly identified as a gelatinous material. It was excised directly off the bone and sent to pathology. There was noted to be a large bony spur at the level of the head of the 1st metatarsal. Using double action rongeurs, the spur itself was removed and sequestrectomy was performed. A rasp was utilized to smooth the bone surface. The eburnated bony surface was then covered, utilizing bone wax. The wound was irrigated and closed in layers. What CPT® codes are reported?
  • 28122-LT2, 28090-51-LT
  • 28045-LT, 28090-51-LT
  • 28111-LT, 28092-51-LT
  • 28100-LT, 28092-51-LT
  1. Under general anesthesia, a 45-year-old patient was sterilely prepped. The wrist joint was injected with Marcaine and epinephrine. Three arthroscopic portals were created. The articulating surface between the scaphoid and the lunate clearly showed disruption of the ligamentous structures. We could see soft tissue pouching out into the joint; this was debrided. There was abnormal motion noted within the scapholunate articulation. At this point the C-arm was brought in; arthroscopic instruments were placed in the joint and confirmed the location of the shaver as a probe in the scapholunate ligament. There was a significant gap between the capitate and lunate. K-wire was utilized from the dorsal surface into the lunate, restoring the space. Further examination revealed gross instability between the capitate and lunate. With the wrist in neutral position, a K-wire was passed through the scaphoid, through the capitate and into the hamate. This provided stabilization of the wrist joint. Stitches were placed, and a thumb spica cast was applied. What CPT® code(s) should be reported?
  • 29847
  • 29840
  • 29846
  • 29847, 29840-51

Donloadable CPC Practice Exam

Operative Note Practice Scenario -1

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Pre-operative diagnoses: Lumbar spinal stenosis L3-4 and L4-5 with a grade 1 anterolisthesis L4 on 5.

Post-operative diagnoses: Lumbar spinal stenosis L3-4 and L4-5 with a grade 1 anterolisthesis L4 on 5.

Name of Procedure: Decompressive lumbar laminectomy L3 and L4 with microscopic decompression of L3, L4, and L5 nerve roots bilaterally.

Findings: Grade 1 anterolisthesis of L4 on 5 was present with significant spinal stenosis present here. Ligamentum flavum hypertrophy and facet joint overgrowth was present. In addition, the L3-4 level also showed ligamentum flavum and facet joint enlargement. Decompression of the thecal sac at both levels with the exiting 6 nerve roots performed.

Description of Procedure: The patient had endotracheal tube placed and general anesthetic administered. Pneumatic compression stockings were placed on the lower extremities. The patient was placed in the Andrews lumbar spinal frame in the kneeling position. Chest roll was placed. Care was taken to ensure that the extremities were properly padded and positioned and the abdomen and breasts were free of compression. A surgical pause was taken with the patient and the appropriate surgical site was identified. The patient’s lumbosacral area was prepped with Dura Prep and draped to a sterile field. Xylocaine 1% with epinephrine used to locally infiltrate the skin in the midline over the spinous processes of L3-L5. A midline incision was accomplished and carried down through the subcutaneous tissues. Dorsal lumbar fascia incised in the midline and subperiosteal elevation of the paravertebral musculature accomplished bilaterally. Intra-operative x-ray obtained with a marker on the spinous process of L4. Self-retaining cerebellar retractors placed. The spinous processes and lamina of L3 and L4 were removed using Adson rongeurs, angled Kerrison punches and high-speed Stryker drill. Operating microscope utilized to complete that laminectomy and to decompress the L3, L4, L5 nerve roots and the lateral recesses, as well as performing foraminotomies over the individual 6 nerve roots. Two mm Kerrison utilized to decompress each of the nerve roots with care taken to undercut the facet joints and prevent further instability. Double-ended ball hook could be passed out over each of the nerve roots at the conclusion of the procedure. Hemostasis obtained using Malis bipolar cautery and thrombin soaked pledgets Gelfoam. The wound was irrigated with saline. All micropatties, sponges and instruments were removed from the wound. Hemovac drain placed in the epidural space, brought out through a separate stab wound incision in the back and connected to closed drainage suction. The closure then accomplished in layers using interrupted 2-0 Vicryl suture on the muscle and fascial layers, interrupted 3-0 Vicryl suture on the subcutaneous tissues and a running 3-0 Vicryl subcuticular stitch utilized to approximate the skin edges along with Steri-Strips. Telfa and Op-Site dressings were placed. The patient was then awakened, extubated, and transported to the recovery room in stable condition.

Replacement: With crystalloid only.

CPC Practice Questions – 20000 series

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Musculoskeletal system 20000

  1. Sally suffered a burst fracture to her lumbar spine during a skiing accident. Dr. Phyllis performed a partial corpectomy to L2 by a transperitoneal approach followed by anterior arthrodesis of L1-L3. She also positioned anterior instrumentation and placed a structural allograft to L1-L3. How would Dr. Phyllis report this procedure?
  2. 63090, 22558-51, 22585, 22845, 20931
  3. 63085, 22533, 22585-51, 22808-59
  4. 22612 x 2, 22808, 22840-51, 20931
  5. 22558, 22858-51, 22845-51, 20931-59
  1. A patient suffered a fracture of the femur head. He had an open treatment of the femoral head with a replacement using a Medicon alloy femoral head and methyl methacrylate cement. How would you report this procedure?
  2. 27236
  3. 27235
  4. 27238
  5. 27275, 27236-59
  1. What modifier should you report when the same physician provided a re-reduction of a fracture?
  2. 76
  3. 59
  4. 77
  5. 54
  1. A patient suffered a penetrating knife wound to his back. A surgeon performed wound exploration with enlargement of the site, debridement, and removal of gravel from the site. The surgeon decided a laparotomy procedure was not necessary at this time. How would you report this procedure?
  2. This procedure is bundled with the laparotomy
  3. 49000, 97602-51, 20100-59
  4. 49000, 20102-59
  5. 20102
  1. While playing at home, Riley dislocated his patella, when he fell from a tree. The surgeon documented an open dislocation. Riley underwent a closed treatment under anesthesia. How would you report the treatment and diagnoses?
  2. 27420, 836.3
  3. 27562, 836.4, E884.9, E849.0
  4. 27840, 27562-51, 836.3, E884.9
  5. 27562, 836.4
  1. Sarah presented to her primary care physician with pain and swelling in the right elbow. After careful examination he referred her to an orthopedic surgeon for a second opinion. Dr. Femur diagnosed Sarah with acute osteomyelitis of the olecranon process and recommended surgery. Sarah agreed to the surgery and underwent a sequestrectomy, through a posterior incision, with a loose repair over drains ending the procedure. Dr. Femur sent a written report back to Sarah’s primary care physician along with the operative report. How would you report the procedure?
  2. 99244-57, 24138-RT
  3. 99214, 99244-57
  4. 24138-RT
  5. 99214, 23172-59
  1. How should you report a deep biopsy of soft tissue of the thigh or knee area?
  2. 27323
  3. 27324
  4. 20206
  5. 27328
  1. Mike had a bicycle accident and suffered deep hematomas in both knees. He underwent a bilateral incision and drainage. How would you report the procedure?
  2. 27301-50
  3. 10040
  4. 27303
  5. 27301-59
  1. A patient had a unilateral percutaneous intradiscal electrothermal annuloplasty on L3-L5 with fluoroscopic guidance for needle placement. How would you report this professional service procedure?
  2. 22526, 22527
  3. 22526, 22527, 77002-26
  4. 22899, 77002-51
  5. 22526, 22527, 77003-26
  1. What modifier is exempt from the following codes:20974, 61107, 93602, 95900, 94610?
  2. RT and LT
  3. 63
  4. 59
  5. 51
  6. 52 year old female has a mass growing on her right flank for several years. It has finally gotten significantly larger and is beginning to bother her. She is brought to the Operating Room for definitive excision. An incision was made directly overlying the mass. The mass was down into the subcutaneous tissue and the surgeon encountered a well encapsulated lipoma approximately 4 centimeters. This was excised primarily bluntly with a few attachments divided with electrocautery. What CPT should be reported?
  7. 21932, 214.9 B. 21935, 214.1 C. 21931, 214.1                  D. 21925, 789.39
  1. PREOPERATIVE DIAGNOSIS: Right scaphoid fracture. TYPE OF PROCEDURE: Open reduction and internal fixation of right scaphoid fracture. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, anesthesia having been administered. The right upper extremity was prepped and draped in a sterile manner. The limb was elevated, exsanguinated, and a pneumatic arm tourniquet was elevated. An incision was made over the dorsal radial aspect of the right wrist. Skin flaps were elevated. Cutaneous nerve branches were identified and very gently retracted. The interval between the second and third dorsal compartment tendons was identified and entered. The respective tendons were retracted. A dorsal capsulotomy incision was made, and the fracture was visualized. There did not appear to be any type of significant defect at the fracture site. A 0.045 Kirschner wire was then used as a guidewire, extending from the proximal pole of the scaphoid distalward. The guidewire was positioned appropriately and then measured. A 25-mm Acutrak drill bit was drilled to 25 mm. A 22.5-mm screw was selected and inserted and rigid internal fixation was accomplished in this fashion. This was visualized under the OEC imaging device in multiple projections. The wound was irrigated and closed in layers. Sterile dressings were then applied. The patient tolerated the procedure well and left the operating room in stable condition. What code should be used for this procedure?
  1. 25628-RT B. 25624-RT C. 25645-RT                         D. 25651-RT
  1. An infant with genu valgum is brought to the operating room to have a bilateral medial distal femur hemiepiphysiodesis done. On each knee, the C-arm was used to localize the growth plate. With the growth plate localized, an incision was made medially on both sides. This was taken down to the fascia, which was opened. The periosteum was not opened. The Orthofix figure-of-eight plate was placed and checked with x-ray. We then irrigated and closed the medial fascia with 0 Vicryl suture. The skin was closed with 2-0 Vicryl and 3-0 Monocryl. What procedure code should be used?
  1. 27470-50 B. 27475-50 C. 27477-50                         D. 27485-50
  2. 42 year old male has a frozen left shoulder. An arthroscope was inserted in the posterior portal in the glenohumeral joint. The articular cartilage was normal except for some minimal grade III-IV changes, about 5% of the humerus just adjacent to the rotator cuff insertion of the supraspinatus. The biceps was inflamed, not torn at all. The superior labrum was not torn at all, the labrum was completely intact. The rotator cuff was completely intact. An anterior portal was established high in the rotator interval. The rotator interval was very thick and contracted and this was released with electrocautery and the Bovie including the superior glenohumeral ligament. After this was all released, the middle glenohumeral ligament was released as well as the tendinous portion of the subscapularis. After this was all done with a shaver and electrocautery, the arthroscope was placed anteriorly and the shaver and used to debride some of the posterior capsule and the posterior capsule was released in its posterosuperior and then posteroinferior aspect. After this was done, the arthroscope was then placed back posteriorly and used to release the anteroinferior capsule down to 6’oclock. This was done with electrocautery. The arthroscope was then placed anteriorly and used to release the posteroinferior capsule. The arthroscope was then placed anteriorly and used to release the posteroinferior capsule. The arthroscope was then placed back posteriorly and used to confirm that there was still one little strip of capsule around the biceps superiorly and there was one little strip from 6-7 o’clock posteroinferiorly that was only partially cut. The rest of the capsule was completely circumferentially released. What CPT code describes this procedure?
A. 23450-LT
B. 23466-LT
C. 29805-LT, 29806-51-LT
D. 29825-LT
  1. After adequate anesthesia was obtained the patient was turned prone in a kneeling position on the spinal table. A lower midline lumbar incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped way from the lamina down to the facets and discectomies and laminectomies were then carried out at L3-4, L4-5 and L5-S1. Interbody fusions were set up for the lower three levels using the Danek allografts and augmented with structural autogenous bone from the iliac crest. The posterior instrumentation of a 5.5 mm diameter titanium rod was then cut to the appropriate length and bent to confirm to the normal lordotic curve. It was then slid immediately onto the bone screws and at each level compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible. Select the appropriate CPT code(s) for this visit?
A. 22612, 22614 x 2, 22842, 20938, 20930
B. 22533, 22534 x 2, 22842
C. 22630, 22632 x 2, 22842, 20938, 20930
D. 22554, 22632 x 2, 22842
  1. PREOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. POSTOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. OPERATIVE PROCEDURE: Reduction with application external fixator, left wrist fracture FINDINGS: The patient is a 46-year-old right-hand-dominant female who fell off stairs 4 to 5 days ago sustaining an impacted distal radius fracture with possible intraarticular component and an associated ulnar styloid fracture. Today in surgery, fracture was reduced anatomically and an external fixator was applied. PROCEDURE: Under satisfactory general anesthesia, the fracture was manipulated and C-arm images were checked. The left upper extremity was prepped and draped in the usual sterile orthopedic fashion. Two small incisions were made over the second metacarpal and after removing soft tissues including tendinous structures out of the way, drawing was carried out and blunt-tipped pins were placed for the EBI external fixator. The frame was next placed and the site for the proximal pins was chosen. Small incision was made. Subcutaneous tissues were carried out of the way. The pin guide was placed and 2 holes were drilled and blunt-tipped pins placed. Fixator was assembled. C-arm images were checked. Fracture reduction appeared to be anatomic. Suturing was carried out where needed with 4-0 Vicryl interrupted subcutaneous and 4-0 nylon interrupted sutures. Sterile dressings were applied. Vascular supply was noted to be satisfactory. Final frame tightening was carried out. What CPT and ICD-9-CM codes should be reported?
A. 25600-LT, 20692-51
B. 25605- LT, 20690-51
C. 25606-LT
D. 25607-LT

17. The patient is a 66-year-old female who presents with Dupuytren’s disease in the right palm and ring finger. This results in a contracture of the ring digit MP joint. She is having a subtotal palmar fasciectomy for Dupuytren’s disease right ring digit and palm. An extensile Brunner incision was then made beginning in the proximal palm and extending to the ring finger PIP crease. This exposed a large pretendinous cord arising from the palmar fascia extending distally over the flexor tendons of the ring finger. The fascial attachments to the flexor tendon sheath were released. At the level of the metacarpophalangeal crease, one band arose from the central pretendinous cord-one coursing toward the middle finger. The digital nerve was identified, and this diseased fascia was also excised. What procedure code should be used?

A. 26123-RT, 26125
B. 26121-RT
C. 26035-RT
D. 26040-RT

18. This is a 32 year old female who presents today with sacroilitis. On the physical exam there was pain on palpation of the left sacroiliac joint and imaging confirmation was done for the needle positioning. Then 80 mg of Depo-Medrol and 1 mL of bupivacaine at 0.5% was injected into the left sacroiliac joint with a 22 gauge needle. The patient was able to walk from the exam room without difficulty. Follow up will be as needed. The correct CPT code is:

A. 20610, 77003-26
B. 20551
C. 27096-LT, 77003-26
D. 20555

19. PREOPERATIVE DIAGNOSIS: Medial meniscus tear, right knee POSTOPERATIVE DIAGNOSIS: Medial meniscus tear, extensive synovitis with an impingement medial synovial plica, right knee TITLE OF PROCEDURE: Diagnostic operative arthroscopy, partial medial meniscectomy and synovectomy, right knee The patent was brought to the operating room, placed in the supine position after which he underwent general anesthesia. The right knee was then prepped and draped in the usual sterile fashion. The arthroscope was introduced through an anterolateral portal, interim portal created anteromedially. The suprapatellar pouch was inspected. The findings on the patella and the femoral groove were as noted above. An intra-articular shaver was introduced to debride the loose fibrillated articular cartilage from the medial patellar facet. The hypertrophic synovial scarring between the patella and the femoral groove was debrided. The hypertrophic impinging medial synovial plica was resected. The hypertrophic synovial scarring overlying the intercondylar notch and lateral compartment was debrided. The medial compartment was inspected. An upbiting basket was introduced to transect the base of the degenerative posterior horn flap tear. This was removed with a grasper. The meniscus was then further contoured and balanced with an intra-articular shaver, reprobed and found to be stable. The cruciate ligaments were probed, palpated and found to be intact. The lateral compartment was then inspected. The lateral meniscus was probed and found to be intact. The loose fibrillated articular cartilage along the lateral tibial plateau was debrided with the intra-articular shaver. The knee joint was then thoroughly irrigated with the arthroscope. The arthroscope was then removed. Skin portals were closed with 3-0 nylon sutures. A sterile dressing was applied. The patient was then awakened and sent to the recovery room in stable condition. What CPT and ICD-9-CM codes should be reported?

A. 29880-RT, 717.0, 727.00, 733.92, 717.7
B. 29881-RT, 717.1, 727.09, 733.92, 717.7
C. 29881-RT, 29822-59-RT, 717.2, 727.09, 733.92, 717.7
D. 29880-RT, 29822-59-RT, 717.2, 727.09, 733.92, 717.7

20. A 61 year-old gentleman with a history of a fall while intoxicated suffered a blow to the forehead and imaging revealed a posteriorly displaced odontoid fracture. The patient was taken into the Operating Room, and placed supine on the operating room table. Under mild sedation, the patient was placed in Gardner-Wells tongs and gentle axial traction under fluoroscopy was performed to gently try to reduce the fracture. It did reduce partially without any change in the neurologic examination. More manipulation would be necessary and it was decided to intubate and use fiberoptic technique. The anterior neck was prepped and draped and an incision was made in a skin crease overlying the C 4-C5 area. Using hand-held retractors, the ventral aspect of the spine was identified and the C2-C3 disk space was identified using lateral fluoroscopy. Using some pressure upon the ventral aspect of the C2 body, we were able to achieve a satisfactory reduction of the fracture. Under direct AP and lateral fluoroscopic guidance, a Kirschner wire was advanced into the C2 body through the fracture line and into the odontoid process. This was then drilled, and a 42 millimeter cannulated lag screw was advanced through the C2 body into the odontoid process. What procedure code should be used?

A. 22505
B. 22305
C. 22315
D. 22318
21. Patient is having ongoing back and hip pain. The physician elects to perform a sacroiliac injection at an ambulatory surgery center. After sterile prep, the patient is placed prone and under fluoroscopic guidance; the needle is placed into the SI joint with a mixture of 20 mg of Celestone and Marcaine for pain relief. Code the procedure(s).

A. 27096, 77003-26                                                                           B. 20610

C. 27096, 73542-26                                                                           D. 27096

22. Patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF procedure was performed, which included the following techniques: An incision was made in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. The pins were cut off below skin level. The wound was closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. Which are the correct ICD-9-CM and CPT® codes assignment?

A. 24579, 29065-51, 812.52                                                                           B. 24577, 812.42

C. 24579, 812.42                                                                                                D. 24575, 812.52

23.  35-year-old female patient presents with acute onset of severe pain since October. Her workup has revealed evidence of disk herniation with loss of lordosis at the C5-C6. Intraoperative findings were consistent with two large fragments of free disk fragments in the foramen at C5-C6 on the right side. After general anesthesia, the patient was placed on the operative table in the supine position. All pressure points were cushioned and a transverse skin incision was fashioned under fluoroscopic guidance over the C5-C6 disc space. Dissection through the platysma eventually allowed for exposure of the anterior entrance to the vertebral body of C5 and C6 and retractors were inserted to maintain adequate exposure. The operating microscope was brought into the field. Caspar posts were placed and slight distraction allowed exposure. A complete discectomy was performed at C5-C6 by using endplate curets pituitary rongeurs and Kerrison rongeurs. The posterior longitudinal ligament was resected and beneath the posterior longitudinal ligament, two significant sized disc fragments were noted in the foramen at C5-C6. These were removed using pituitary and Decker instruments. The endplates were then decorticated so that they were parallel to each other and a midline keel was performed on AP and lateral fluoroscopy. A size #1 by 5 mm interbody Kineflex-C device was placed under fluoroscopic guidance. Satisfied with the positioning of the device, the decision was made to close. What is the correct code for this procedure?

A. 63075                                                                                               B. 63081

C. 22856                                                                                               D. 22554

24. A 17-year-old male presents to the emergency department after being involved in a car accident. The patient’s primary physician calls the orthopedic surgeon to the emergency department. The orthopedist diagnoses a sprained knee ligament. He places a long leg walking cast and instructs the patient to return to his office for follow-up care. What are the procedure and diagnosis codes?

A. 29358, 844.8                                                                                  B. 29355, 844.9

C. 27520-54, 844.0                                                                            D. 29345, 844.9

25. Patient complains of chronic/acute arm and shoulder pain following bilateral carpal tunnel surgery. Patient is followed by pain management for over a year. Physician finally diagnoses patient with reflex dystrophy syndrome (RSD). Physician performs six trigger point injections into four muscle groups. Code the procedure(s).

A. 20552                                                                                               B. 20610 x 6

C. 20552 x 5                                                                                         D. 20553

26. A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was then reprepped, redraped, and repositioned. Intramedullary rodding was then carried out with proximal and distal locking screws. What are the correct codes for this diagnosis and procedure?

A. 27506, 11044-51, 821.11                                                           B. 27506, 11012-51, 821.11

C. 27507, 11012-51, 821.01                                                            D. 27507, 11044-51, 821.10

27. This 45-year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried down thru the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL(inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4.5 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was then closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What is the correct CPT® code for this service?

A. 23076                                                                                                               B. 23066

C. 23075                                                                                                               D. 23030

28. Postoperative Diagnosis: 1. Impingement syndrome left shoulder. 2. AC synovitis left shoulder Procedure: Arthroscopy with subacromial decompression and AC resection left shoulder. The patient was placed supine on the operating table prepped and draped in usual sterile fashion. The scope was introduced from a posterior portal and the joint was inspected. The rotator cuff looked in good condition. The articular surfaces looked good. The bicep also was in good condition. We went subacromially and there was a fair amount of bursal inflammation encountered. We did a thorough bursectomy. A ligament chisel was used to take down the coracoacromial ligament. A high-speed bur was used to do a subacromial decompression going from lateral to medial. We took off about 2 cm of bone anteriorly. Next we opened the AC joint through an anterosuperior portal. We ground off about 10 mm of distal clavicle because there was a large subchondral cyst and we wanted to get this totally ground out, which we did. Then the wounds were irrigated out, Nylon suture was placed in our portals. The patient was placed in a bulky dressing and an arm sling and sent to the recovery room in stable condition. Code the procedure.

A. 29826-LT, 29824-LT                                                                     B. 29825-RT, 29824-RT

C. 23120-LT, 23130-LT                                                                     D. 29826-LT, 29824-LT, 29825-LT

29. The patient presented for medial meniscal tear left knee. Arthroscopy with partial medial menisectomy left knee and arthroscopic picking (drilling pick holes) of the lateral femoral condyle left knee was performed. Code the procedure and diagnosis codes.

A. 29880-LT, 29879-LT, 836.0                                                        B. 29881-LT, 29879-LT, 836.0

C. 29882-LT, 29885-LT, 836.1                                                        D. 29881-RT, 29885-LT, 836.2

30. A 47-year-old patient was previously treated with external fixation for a Grade III left tibia fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied and three screws and the harvested bone graft were packed into the fracture site. What are the correct codes for this diagnosis and procedure?

A. 27724, 733.82, 905.4                                                                                   B. 27722, 733.82

C. 27722, 733.81, 905.4                                                                                   D. 27724, 733.82

31 . A patient reports a history of right groin pain, which is worse with sitting and rising from a sitting position. Physical examination, x-rays, and CT scans confirm a cam lesion in the right femoral head-neck region and noted as the cause for loss of rotation. Dr. Curtis completed an arthroscopy of the right hip with debridement and a femoroplasty. How should Dr. Curtis report her procedure?

a. 29914-RT

b. 29862-RT, 29914-59

c. 29861-RT, 29862, 29914

d. 29860-RT, 29862-59, 29914-59

32 . Dr. Reese completed a deep transfer of the anterior tibial and flexor digitorum tendons. Which code(s) should be used to report this procedure?

a. 27658 x 2

b. 27690, 27692-51

c. 27691, 27692

d. 27691, 27692 x 2

33. Which code(s) should you report for the following case?

Preoperative diagnosis: Procedures:

Left knee medial collateral ligament tear Exam under anesthesia

Anterior cruciate ligament tear Diagnostic arthroscopy of left knee

Possible meniscus tear Left knee arthroscopic repair of lateral meniscus

Postoperative diagnosis: Same

Tourniquet time: 2.5 hours

Procedure: The patient was taken to the operating room and positioned, and an epidural anesthetic was placed. Once the anesthetic had taken effect, the patient’s left leg was examined under anesthesia and noted to have increased valgus laxity with end point, a positive Lachman test, and positive pivot-shift test. The patient was prepped and draped in the normal fashion, exsanguinated, and the tourniquet applied to a 350 mmHg. The knee was then insufflated and irrigated with fluid. Using the arthroscopic sheath, visualization of the knee joint began. Attention was turned to the lateral meniscus where the tear was debrided. Using the arthroscope, the lateral meniscus was sutured with two mattress-type sutures of non-absorbable 2-0 material. The sutures were then tied and visualized with arthroscopy to reveal the meniscus to be in excellent shape and stable position. The 3.5-cm wound was thoroughly irrigated and closed with intermediate subcutaneous sutures. A sterile compression dressing was applied. The patient was placed in a TED hose and Watco brace, setting the brace between 40º and 60º of free motion. He was then taken to the recovery room in stable condition. The instrument, sponge, and needle counts were correct.

a. 29882, 29877-52, 29870-51

b. 29866, 29868

c. 29870, 29882, 12032

d. 29882

34 . Two weeks ago, Sam underwent an open repair of his lower femur due to a traumatic fracture suffered while snow skiing. His leg is healing as expected, and no new treatment is required to the femur. Today, he returns as planned for an application of a new long leg cast. The cast application is completed by the same physician who performed the surgery. How should today’s services be reported?

a. 29345-58, V53.7, V54.16

b. 99024, V53.7, V54.16

c. 29345, 29700-59, 99024, V53.7, V54.29

d. 29345-76, 821.22, V53.7, V54.16

35. What type of soft tissue tumor resection is commonly used for malignant tumors or very aggressive

benign tumors?

a. Manipulative soft tissue resection

b. Radical soft tissue resection

c. Residual soft tissue resection

d. Manageable soft tissue resection

36 . A patient was stabbed in the right arm. A surgeon took the patient to an operating suite and completed wound exploration. The surgeon widened the wound to achieve proper visualization and completed subcutaneous debridement and ligation of minor subcutaneous blood vessels. No further procedures were required  for this wound exploration. The arm wound was closed and dressed in the usual fashion. The patient tolerated the procedure well and was returned to the recovery room in good condition. How would you report this procedure?

a. 20103, 11011-51

b. 20103

c. 20103, 11011-59

d. 11043, 12036-59, 20103-51

37. A patient underwent an anterior interbody arthrodesis with discectomy, osteophytectomy, fusion, and decompression of nerve roots at level C3, C4, and C5. The fusion was explored and then stabilized with application of anterior instrumentation placed from C3 to C5. Which codes would you use to report this procedure?

a. 22551, 22585 x 2, 22845-51, 22830-59

b. 22554, 22585 x 2, 22845, 22830-51

c. 22600, 22614, 22842, 22830-59

d. 22551, 22552 x 2, 22845, 22830-51

38. Which code(s) would you report for an aspiration and injection of a ganglion cyst to the bone of the left great toe?

a. 20600

b. 20612

c. 20615

d. 20600, 20612-59

39. A patient suffering from a nonhealing knee tendon underwent a platelet-rich plasma injection under imaging guidance. How should you report this procedure?

a. 0232T

b. 20551

c. 20551, 77002

d. 0232T, 20551, 77002

40. Dr. Bender completed a therapeutic manipulation of the temporomandibular joint. An anesthesiologist placed this healthy 54-year-old patient under general anesthesia and monitored the patient during the procedure. The intraservice time was noted as one hour. The patient tolerated the procedure well and was returned to the recovery room in good condition. How would Dr. Bender’s services be reported?

a. 21073, 99144, 99145 x 2

b. 21480

c. 21073

d. 21480, 99149, 99150 x 2

ANSWERS

  1. “a” The primary procedure is a partial corpectomy (you can find this in the CPT Professional Edition index under corpectomy). An arthrodesis was done in addition to the definitive procedure; therefore modifier -51 is necessary (you can find this in the subcategory guidelines under Arthrodesis). Do not attach modifier -51 to add-on codes (see Appendix A for this definition). You would report the code for a structural allograft.
  1. “a” One way to find this answer is in the index of the CPT Professional Edition under Fracture, Femur, Neck, Open Treatment. There is an illustration under the code 27236 for a prosthetic replacement.
  1. “a” You can find this answer in the CPT Professional Edition in the main section guidelines for the Musculoskeletal System.
  1. “d” One way to find this answer is in the index of the CPT Professional Edition under Wound, Exploration, Back.
  1. “b” Refer to the index of the CPT Professional Edition under Dislocation, Patella closed treatment for a code range. It is necessary to look up the code range and read the descriptions to select the correct code. You can find the ICD-9-CM codes under Dislocation, patella, open. The E code Alphabetic listing is in Volume 2, Section 3. Look up, Fall, (from off), tree; the second code, look up Accident, (occurring at in), house.
  1. “c” This question asks for you to report the procedure. There is not enough information to report the evaluation and management code. You can find the procedure in the index of the CPT Professional Edition under Sequestrectomy, Olecranon Process. The modifier -RT provides additional information.
  1. “b” The code 20206 reports a needle biopsy of soft tissue. Use code 27324 to report a deep biopsy of soft tissue of the thigh or knee area.
  1. “a” Modifier -50 indicates a bilateral procedure. You can find this procedure in the index of the CPT Professional Edition under Incision and Drainage, Hematoma, Knee.
  1. “a” One way to find this answer is in the index of the CPT Professional Edition under Annuloplasty.” This procedure was done to more than one level, which requires use of the add-on code 22527.
  1. “d” You can find codes exempt from modifier -51 in Appendix E of the CPT Professional Edition. You could also look up each code and locate the symbol that indicates modifier -51 exempt.
  2. C The mass growing turned out to be a lipoma found in the subcutaneous tissue of the flank. In the ICD-9-CM alphabetic index, look up Lipoma/subcutaneous tissue. You are referred to code 214.1, eliminating multiple choice answers A and D. Since the 4 cm tumor was found in the subcutaneous tissue code 21931 is the correct code to report.
  1. A Patient had an open reduction, meaning an incision was made to get to the fracture, eliminating multiple choice answer B. The fracture site was the scaphoid of the wrist (carpal), eliminating multiple choices C and D.
  1. D Your keywords in the scenario to narrow your choices down to code 27485 are: “genu valgum” and “hemiepiphysiodesis”
  2. D To start narrowing down your choices was the procedure an open procedure or performed with an arthroscope? It was performed with an arthroscope, eliminating multiple choice answers A and B. The diagnostic arthroscopy (29805) is a separate procedure, and according to CPT Surgery guidelines “The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component”. Meaning code 29806 already includes the diagnostic arthroscopy code, so you would only report code 29806. Code 29806 represents suturing of the capsule (capsulorrhaphy); however, this was not the procedure performed. The procedure performed was a lysis of adhesions for a frozen shoulder (29825) noted in multiple choice answer D.
  1. C To start narrowing the correct arthrodesis code to report, you first need to determine the approach. The scenario tells us that the patient was placed in prone position (lying face down) and a lumbar incision was made indicating a posterior approach, eliminating multiple choices B and D. The next bit of information to look for is the technique that was used for the arthrodesis, which was the interbody fusion technique guiding you to code 22630.
  2. B In the beginning of the procedure note it documents, “the fracture was manipulated”, eliminating multiple choice answer A. Was the fracture treatment opened or closed? There is no indication in the op note that an incision was made for internal fixation, eliminating multiple choice answer D. The key words to choose the correct code between B and C is “external fixator” where pins are connected to bone and to an external fixator to help the fracture heal. The fixator was a uniplane system as only one external fixator was applied in one plane (20690).
  3. A The patient is having a fasciectomy, eliminating multiple choice answers C and D. The fasciectomy was performed on the hand as noted in “the fascial attachments to the flexor tendon sheath were released” and “subtotal palmar fasciectomy” The op note also mentions the middle finger where diseased fascia was also excised.
  1. C The injection of is being performed in a joint, eliminating multiple choice answers B and D. The injection was performed on the sacroiliac joint with imaging confirmation eliminating multiple choice answer A. Arthrography was not performed; therefore, fluoroscopic guidance is reported with 77003-26 as noted in the notes below 27096.

19.C For this op note scenario only the meniscus was performed on, eliminating multiple choice answers A and D. There are two ways to choose the correct codes for this op note. One way, is procedure code 29875 is a separate procedure, according to CPT Surgery Guidelines: “The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.” A limited synovectomy (29875) was performed; however, it was performed in the medial compartment of the knee along with the medial meniscectomy; therefore, is not reported. Debridement was performed in the lateral and patellofemoral compartments; therefore, it is reported with 29822. Modifier -59 is appended to show a different compartment from the compartment for the meniscectomy. The diagnosis of chondromalacia (733.92) for the fibrillated articular cartilage of the tibial plateau and patella (717.7) are report with the debridement. The other way to choose the correct code for this procedure is by the diagnoses. The patient had a meniscus tear, but the op note indicates a more specific area of the tear. It documents that, “An upbiting basket was introduced to transect the base of the posterior horn flap tear”, indexed in the ICD-9-CM as Tear/meniscus/medial/posterior horn/old.

  1. D the procedure performed is the reduction of an odontoid fracture, by incising (open treatment) the anterior neck (anterior approach) to reduce the fracture and placement of internal fixation (Kirschner wire and lag screw). Gardner-Wells tongs (20660) were applied originally to try to reduce the fracture with axial traction; however, this procedure is listed as a separate procedure and it should not be reported during the same session for reduction of the fracture.
  2. A 27096 is the correct code since a steroid injection (Celestone and Marcaine) is placed into the sacroiliac (SI) joint. Code 77003 is coded since there is a parenthetical note under the code descriptive that states: (For fluoroscopic guidance without formal arthrography, use 77003). Modifier 26 is appended to the radiology code for the professional component, physician not owning the equipment.
  1. C There is a diagnosis of a closed fracture of the lateral condyle. The fracture is closed since the scenario does not mention a piece of bone has broken through the skin and is exposed. In the ICD-9-CM manual, look up Fracture/humerus/condyle(s)/lateral (external). You are referred to code 812.42. You have eliminated multiple choice answers A and D. The next step is to figure out if the fracture care is opened or closed treatment. A hint is that the surgeon made “an incision” to get to fracture site. Code 24579 is the correct code since this was an open treatment due to the surgeon making an incision to get to fracture site along with performing an internal fixation (two pins). Also ORIF means Open Reduction and Internal Fixation which is also an indication an open approach is used to perform the surgery.
  1. C The keyword in this op note is “disectomy,” which in this scenario is a removal of the herniated disk in the cervical spine (neck). Eliminating multiple choice B. There is no documentation of the vertebrae being fused together (arthrodesis), eliminating Multiple choice D. The scenario documents end plates were decorticated to insert an artificial disk (Kineflex-C device) to replace the cervical disk that was removed, guiding you to code 22856.
  2. B. The key term is “long leg walking cast,” which is found in the code description of procedure code 29355. Code 29345 does have long leg cast in its description, but it does not include a walker type of a long leg cast. This patient did not have a fracture, eliminating choice C; neither did the patient have a long leg cast brace, eliminating choice A. The diagnosis is indexed in the ICD-9-CM manual under Sprain/knee.
  1. D. Trigger point is your key term in this scenario, eliminating choice B. Trigger points are coded by the number of muscles that the injections are performed on, not by the number of trigger point injections. The scenario tells you that six trigger points were injected into four muscle groups which lead you to the procedure code 20553.
  1. B. One way to start finding the correct answer is to look up the diagnosis in the ICD-9-CM manual. It is indexed under Fracture/femur/shaft/open which refers you to code 821.11, eliminating codes C and D. The only difference between choices A and B are the second procedure codes. Code 11012 is the correct code since extensive debridement was performed all the way to the bone on an open fracture.
  2. A. This patient is having a mass removed from the shoulder area, eliminating multiple choices B, which is biopsy and D, which is incision and drainage of an abscess. The size of the mass that was excised was 4.5 cm, which leads you to code 23076.
  1. A. This surgery is being performed by arthroscopy, eliminating multiple choice answer C, which is an open procedure code without using any type of scope. Our next clue is that a “subacromial decompression” was performed, which leads you to code 29826. The scenario does not mention that the physician lyses and resects adhesions, eliminating multiple choice answers B and D. 29824 is performed when the physician opens the AC (acromioclavicular) joint to the anterosuperior portal grounding of 10 mm of “distal clavicle” then totally grounding it out due to a cyst.
  1. B. One way to narrow down the choices is to code for the diagnosis first, which is a medial meniscus tear of the left knee. In the ICD-9-CM index, look up Tear/meniscus/medial; you are referred to code 836.0. You eliminated choices C and D. 29881 (medial OR lateral) is the correct procedure code, since the menisectomy (removing torn fragments) was performed on the medial meniscus only.
  1. A .The physician is repairing a nonunion tibia fracture (failure of two ends of a fracture to completely heal). Next you need to find out what type of graft was used. Your hints are “bone grafting” and “iliac crest,” which leads you to the code 27724, eliminating multiple choice codes B and C. The bone graft was harvested from the iliac crest, and then the graft is placed at the fracture site of the tibia compressing it for desired position and alignment and the screws were used to stabilize the fracture. In the ICD-9-CM index, look up Fracture/nonunion referring you to code 733.82. The late effect code is also appropriate in this case.
  2. a. Code 29914 has two symbols listed to indicate this code is new and resequenced. Additionally, theparenthetical note listed with this code provides information related to correct reporting of codes used in conjunction.
  3. c. One way to find the code range in the index of the CPT® Professional Edition is under the main term. “Tendon,” “Transfer,” then “Leg, Lower.” Reporting the add-on code is required for the additional tendon. According to the modifier -51 definition in the CPT® Professional Edition, this modifier should not be appended to add-on codes.
  4. d. This is a surgical arthroscopy procedure, which includes the diagnostic arthroscopy. You can find the coding note related to diagnostic and surgical arthroscopies multiple times in the CPT® Professional Edition. Specifically, this note can be found under the subcategory heading “Endoscopy/Arthroscopy” with this code set. The wound closure is included with the procedure and should not be coded separately.
  5. a. The casting would be coded for the application of a new cast by the same physician who completed the surgery. As stated in the question, this was a planned application; therefore, modifier -58 should be appended. The guidelines are listed under the subheading for application of casts and strapping in the CPT® Professional Edition.
  6. b. You can find the definition of a radical resection of soft tissue tumors in the CPT® Professional Edition at the beginning of the section on the musculoskeletal system.
  7. b. You can find this answer in the index of the CPT® Professional Edition under “Exploration,” “Extremity,”then “Penetrating Wound.” The exploration of wound subcategory guidelines list the procedures that are included or bundled. This was a wound exploration only; therefore, no other codes would be reported, according to the subcategory guidelines.
  8. d. Careful review of the approach and level of spinal surgery is important to determine the correct code selection. Modifier -51 should not be appended to add-on codes for spinal instrumentation; however, guidelines with spinal fusion exploration indicate modifier -51 should be appended to this code when performed with a definitive procedure.
  9. c. This question is specifically for a bone cyst. There is no mention of an arthrocentesis in this question.

39.a. The parenthetical note under code 20551 indicates the use of a Category III code for this procedure. According to CPT® Changes:  An Insider’s View 2011, the imaging guidance, harvesting, and preparation are included with the code and should not be reported separately.

  1. c. This procedure was completed under general anesthesia, not moderate sedation. The codes for moderate sedation should not be reported with this procedure as the description of the code includes the words “general anesthesia.”