Musculoskeletal system 20000
- 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?
- 63090, 22558-51, 22585, 22845, 20931
- 63085, 22533, 22585-51, 22808-59
- 22612 x 2, 22808, 22840-51, 20931
- 22558, 22858-51, 22845-51, 20931-59
- 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?
- 27275, 27236-59
- What modifier should you report when the same physician provided a re-reduction of a fracture?
- 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?
- This procedure is bundled with the laparotomy
- 49000, 97602-51, 20100-59
- 49000, 20102-59
- 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?
- 27420, 836.3
- 27562, 836.4, E884.9, E849.0
- 27840, 27562-51, 836.3, E884.9
- 27562, 836.4
- 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?
- 99244-57, 24138-RT
- 99214, 99244-57
- 99214, 23172-59
- How should you report a deep biopsy of soft tissue of the thigh or knee area?
- 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?
- 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?
- 22526, 22527
- 22526, 22527, 77002-26
- 22899, 77002-51
- 22526, 22527, 77003-26
- What modifier is exempt from the following codes:20974, 61107, 93602, 95900, 94610?
- RT and LT
- 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?
- 21932, 214.9 B. 21935, 214.1 C. 21931, 214.1 D. 21925, 789.39
- 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?
- 25628-RT B. 25624-RT C. 25645-RT D. 25651-RT
- 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?
- 27470-50 B. 27475-50 C. 27477-50 D. 27485-50
- 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?
|C. 29805-LT, 29806-51-LT|
- 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|
- 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|
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?
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:
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?
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” 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.
- “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.
- “a” You can find this answer in the CPT Professional Edition in the main section guidelines for the Musculoskeletal System.
- “d” One way to find this answer is in the index of the CPT Professional Edition under Wound, Exploration, Back.
- “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.
- “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.
- “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.
- “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.
- “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.
- “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.
- 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.
- 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.
- D Your keywords in the scenario to narrow your choices down to code 27485 are: “genu valgum” and “hemiepiphysiodesis”
- 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.
- 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.
- 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).
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.”