Ch. 8 Musculoskeletal System

Question 1

Hallux rigidus is a condition affecting what part of the body?

Answer 1

c.

Foot

Question 2

The acronym BKA means:

Answer 2

c. below knee amputation

Question 3

What is segmental instrumentation?

Answer 3

d. A spinal fixation device attached at each end of a rod and at additional bony attachment

Question 4

What information is required to accurately code osteoarthritis in ICD-10-CM?

Answer 4

a. Whether the osteoarthritis is primary, secondary, post-traumatic, the site and laterality.

Question 5

What is the acromion?

Answer 5

a. Extension of the scapula

Question 6

A 63 year-old man presents with a neck mass to be excised. The neck mass was palpated and an incision was then made and carried down through the dermis with electrocautery. The subcutaneous tissue of the skin was opened encountering an organized mass with a benign appearance of a lipoma. Using careful blunt and sharp dissection, the mass measuring 5 cm was completely excised around its entire circumference leaving the capsule intact. The mass was removed from its posterior attachments using electrocautery. What CPT® code is reported for this procedure?

Answer 6

b. 21552

Rationale: In the CPT® Index, look for Neck/Tumor/Excision. You are referred to 21552-21558. Review the codes to choose the appropriate service. 21552 is the correct code to report the excision of a 5 cm mass where the surgeon incised the subcutaneous tissue to remove the mass. Codes 11426 and 11626 are reported for removal of a benign or malignant lesion, not an internal mass. Any lesions removed from the skin are coded from the Integumentary section.

Question 7

The patient fell and fractured his left femoral shaft in three places. The fracture is treated with an ORIF of the left femur with an intramedullary nail and interlocking screws (peritrochanterically). The orthopedist also places the leg in a plaster splint prior to leaving the OR. What CPT® code(s) is/are reported?

Answer 7

b. 27506

Rationale: Documentation shows the patient had a fracture of his left femoral shaft. The fracture was repaired with open reduction and internal fixation (ORIF) using an intramedullary nail and interlocking screws. Selection of codes depends on the fracture site and the method of treatment (closed, open, or percutaneous). The range of codes can be found in the CPT® Index by looking for Fracture/Femur/Peritrochanteric/Intramedullary Implant Shaft. Check the numeric section to select the correct code. Code 27245 is not correct, because this was not a peritrochanteric fracture; it is a femoral shaft fracture. The approach is from the peritrochanteric region. The application of the first cast or splint is included in 27506. See the guidelines for Application of Casts and Strapping in the CPT® codebook.

Question 8

A patient presented with a closed, displaced supracondylar fracture of the left elbow. After conscious sedation, the left upper extremity was draped and closed reduction was performed, achieving anatomical reduction of the fracture. The elbow was then prepped and with the use of fluoroscopic guidance, two K-wires were directed crossing the fracture site and piercing the medial cortex of the left distal humerus. Stable reduction was obtained, with full flexion and extension. K-wires were bent and cut at a 90-degree angle. Telfa padding and splint were applied. What CPT® code(s) is/are reported?

Answer 8

a.
24538-LT

Rationale: This is a supracondylar fracture of the elbow repaired by percutaneous fixation. In the CPT® Index look for Fracture/Humerus/Supracondylar/Percutaneous Fixation and you are referred to 24538. Modifier LT is appended to indicate the procedure is performed on the left side. The application of the first cast or splint is included in the fracture codes. See the guidelines before Application of Casts and Strapping in your CPT® codebook. Fluoroscopy guidance 76000, is listed as a separate procedure; therefore, is included in the procedure.

Question 9

A 14 year-old status post injury over one year ago to her left wrist presented with recurrent wrist pain. The patient was taken to the operating room and placed under general anesthesia. She was placed in wrist traction. The radiocarpal joint was entered endoscopically through sharp skin incisions and blunt dissection into the joint. There was found to be mild synovitis in the dorsal ulnar aspect of the wrist. This was debrided arthroscopically with a shaver. There was a peripheral tear of the triangular fibrocartilage. This area was shaved to promote healing. Using outside-in technique, a PDS suture was placed across the TFCC and into the capsule. There was synovitis within the midcarpal joint, but there was no articular injury. All instruments were removed and the wounds were closed with interrupted nylon sutures. What CPT® code(s) is /are reported?

Answer 9

d. 29846-LT

Rationale: In the CPT® Index, look for Arthroscopy/Surgical/Wrist. You are referred to 29843-29847. Code 29846 describes the arthroscopic excision and repair of triangular fibrocartilage and joint debridement. Endoscopically, arthroscopically and through the scope all mean the same thing. This is not an open surgery; it is arthroscopic. Modifier LT is appended to indicate the procedure is performed on the left side. Only one code is reported. The debridement (partial synovectomy) is included in the more intensive procedure.

Question 10

A 63 year-old man sustained a gunshot wound through the right maxillary sinus penetrating into the right neck. CT scan revealed no hard evidence of arterial injury but a bullet was directly in line with the internal jugular vein. He was sent to the operating room for neck exploration to rule out vascular injury and injury to the aerodigestive tract (respiratory and digestive tracts). A sternocleidomastoid incision was performed and carried down through the platysma muscle. There was no penetration of the internal jugular vein, but a foreign body was identified resting on the internal jugular vein at approximately the level of the angle of the mandible and it was removed. The parotid gland was noted to have a blast injury near the tail. This was not surgically repaired or resected. Once all bleeding was controlled, a 10 French round drain was placed in the wound. The wound was copiously irrigated. The platysma muscle was closed and the skin was closed with subcuticular closure. What CPT® code is reported?

Answer 10

d. 20100

Rationale: In the CPT® Index, look for Exploration/Neck/Penetrating Wound. You are referred to 20100. Review the code to verify accuracy. 20100 is the correct code because the patient was sent to the operating room for exploration of a gunshot (penetrating trauma) wound to identify damaged structures. The category guidelines for Wound Exploration-Trauma indicate that these codes include removal of foreign bodies, ligation or coagulation of minor subcutaneous and muscular blood vessels, damaged tissue debridement, repair and wound closure.

Question 11

A 72 year-old female sustained a left radius fracture, resulting in volar angulation, radial shortening and loss of radioulnar inclination. A general anesthetic was administered. A standard dorsal central approach to the wrist was made. The capsule was opened in a T fashion and the malunion site was identified. A series of osteotomes was utilized to open the fracture site and the normal distal radial architecture was restored. The pie-plate was placed on the distal radius utilizing a combination of 2.0 and 1.8 screws and threaded pins for the distal segment and 2.7 screws proximally. Fragments were secured, and Norian SRS was packed into the defect and allowed to harden. With this completed, the wounds were copiously irrigated with normal saline. Soft tissue was closed over the plate and distal radius, and secured with 2-0 Vicryl. What CPT® code is reported?

Answer 11

c.
25400-LT

Rationale: This is not the repair of a fracture; it is repair of a malunion. In the CPT® Index look for Repair/Radius/Malunion or Nonunion, 25400, 25405, 25415, 25420. Code 25400 reports repair of a malunion of the radius. There is no mention of an autograft; therefore, 25405 is incorrect. Norian SRS is a biocompatible bone gap filler, not a graft. Modifier LT is appended to indicate the procedure is performed on the left side.

Question 12

A 66 year-old sustained a left proximal humerus fracture. Standard deltopectoral approach was used and dissection was carried down to the fracture site. The fracture site was identified and fragments were mobilized and the humeral head fragments removed. Once this was done, the stem was prepared up to a size 10. A trial reduction was carried out with the DePuy trial stem and implant head. Sutures were placed in key positions for closure of the tuberosities down to the shaft including sutures through the shaft. The shaft was then prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and reduced. A bone graft was placed around the area where the tuberosities were being brought down. The tuberosities were then tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with Vicryl over a drain and also staples in the epidermis. A sterile dressing and sling was applied. The patient was taken to recovery in stable condition. No immediate complications. What CPT® code is reported?

Answer 12

b. 23616-LT

Rationale: In the CPT® Index, look for Fracture/Humerus/Open Treatment. You are referred to 23615-23616. Review the codes to choose appropriate service. 23616 is the correct code because the surgeon made an incision to expose the fracture site. The fracture repair included a prosthetic replacement (implant head) and the repair of the tuberosities. Modifier LT is appended to indicate that the procedure was performed on the left side. The bone graft isn’t reported separately because bone grafts are common when implants are used (it’s inherent to that procedure).

Question 13

A patient presented with a right ankle fracture. After induction of general anesthesia, the right leg was elevated and draped in the usual manner for surgery. A longitudinal incision was made parallel and posterior to the fibula. It was curved anteriorly to its distal end. The skin flap was developed and retracted anteriorly. The distal fibula fracture was then reduced and held with reduction forceps. A lag screw was inserted from anterior to posterior across the fracture. A 5-hole 1/3 tubular plate was then applied to the lateral contours of the fibula with cortical and cancellous bone screws. Final radiographs showed restoration of the fibula. The wound was irrigated and closed with suture and staples on the skin. Sterile dressing was applied followed by a posterior splint. What CPT® code is reported?

Answer 13

a.
27792-RT

Rationale: In the CPT® Index look for Fracture/Fibula/Open Treatment and you are referred to 27784, 27792, 27814. Code 27784 reports open treatment of a proximal fibular fracture or shaft fracture. The correct code is 27792 for the open treatment and internal fixation. Modifier RT is appended to indicate the procedure is performed on the right side.

Question 14

A 6 year-old male suffered a fracture after falling off the monkey bars at school. He fell on an outstretched hand and suffered a transcondylar fracture of the left humerus. After prep and drape, a manipulation was done to achieve anatomic reduction. Once the joint was adequately reduced, pins were placed through the skin distally and proximally into the bone to maintain excellent fixation and anatomic reduction. The pins were bent, trimmed and covered with a sterile dressing and a posterior splint was placed on the patient’s arm. What CPT® code is reported?

Answer 14

c.
24538-LT

Rationale: Fracture codes are based on the location of the fracture and the treatment method. Documentation describes a closed reduction of a transcondylar fracture with percutaneous placement of pins. This is described with code 24538. This can be found in the CPT® Index by looking for Fracture/Humerus/Transcondylar/Percutaneous directing you to code 24538. Modifier LT is appended to indicate the procedure is performed on the left side.

Question 15

A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT® code is reported for this service?

Answer 15

c. 20206

Rationale: In the CPT® Index, look for Biopsy/Muscle. You are referred to 20200-20206. The biopsy is taken through the skin, or percutaneously, with a needle. Although the biopsy is deep, it is performed by percutaneous technique, which is reported with 20206.

Question 16

The patient has a torn medial meniscus. An arthroscope was placed through the anterolateral portal for the diagnostic procedure. The patellofemoral joint showed grade 2 chondromalacia on the patellar side of the joint only, this was debrided with a 4.0-mm shaver. The medial compartment was also entered and a complex posterior horn tear of the medial meniscus was noted. It was probed to define its borders. A meniscectomy was carried out to a stable rim. What CPT® code(s) is/are reported?

Answer 16

b.
29881

Rationale: In the CPT® Index look for Arthroscopy/Surgical/Knee. You are referred to 29866-29868, 29871-29889. Review the codes to choose appropriate service. 29881 is the correct code because the tear was in the medial meniscus. A meniscectomy as well as debridement with a shaver (or chondroplasty) were performed. 29877 is not reported as this is included in 29881. 29880 is not appropriate because a meniscectomy was not performed in both the medial and lateral compartments. The surgery started out as a diagnostic procedure, but changed when the physician decided to perform surgical procedures on the knee.

Question 17

A 74 year-old male presented with ankle avascular necrosis of the talus with collapse of the body. After general anesthesia and sterile prep, the patient was placed prone. A lateral incision was made. The fibula was dissected and approximately 6 cm of the fibula was removed for the autograft. There were a lot of free fragments of bone around the subtalar joint and the talus itself. The bone fragments were removed and a large defect consistent with avascular necrosis of the body of the talus was noted. An egg-shaped burr was introduced and the articulating cartilage of the ankle joint was excised and debrided. The subtalar joint was approached and resection of the articulating surface of the subtalar joint was completed. Bone graft from the fibula was prepared on the back table. We made two large blocks to fill the defect in the talus and then additional small fragments of cortical cancellous bone to fill in smaller defects around the talus and ankle. Fixation was performed in the calcaneocuboid. The talar screw was inserted, followed by fixation of the talonavicular, tibiotalar and additional compression. The ankle screws were inserted proximally and the wound was irrigated and closed in layers. What CPT® codes are reported?

Answer 17

d.
28705, 20902-51

Rationale: The physician fused the tibiotalar, talonavicular, the calcaneocuboid and subtalar joints making this a pantalar arthrodesis. Look in the CPT® Index for Arthrodesis/Talus/Pantalar referring you to 28705. A pantalar arthrodesis is the fusion of the tibiotalar, subtalar, talonavicular and calcaneocuboid joints. Autograft was taken from the fibula (bone graft) for the arthrodesis, 20902. In the CPT® Index, look for Bone Graft/Any Donor Area referring you to 20900, 20902. Modifier 51 is required to indicate multiple procedures during the same session.

Question 18

This 56 year-old female presented with a degenerative posteromedial meniscal flap tear of the right knee. After appropriate preoperative evaluation, the patient was taken to the operating room where general anesthesia was instituted. The patient was placed supine on the operating table. The right lower extremity was sterilely prepped and draped for arthroscopic surgery. The leg was exsanguinated and the tourniquet inflated. The arthroscope was introduced first through the anterolateral portal with medial suprapatellar portal utilized. The lateral compartment looked fairly good. There were some minimal medial degenerative changes. In the medial compartment there was a full-thickness area of osteochondral degeneration with a flap of cartilage noted. It was possible to remove this with a bleeding bony bed with beveled edges of cartilage. The ligament itself was intact. The retropatellar area was normal with Grade I chondromalacia changes noted. The medial joint was inspected and there was a tear at the junction of the middle and posterior portions of the meniscus, a flap tear was based more anteriorly. This was shaved with a combination of small baskets and punches, and the meniscus debrided back to a smooth stable rim. There was additional synovitis in the medial aspect of the intercondylar notch and this was removed with the curved automated meniscal incisor. What CPT® code(s) should be reported?

Answer 18

c.
29881

Rationale: This was a surgical arthroscopy of the knee. In the CPT® Index look for Arthroscopy/Surgical/Knee, directing you to 29866-29868, 29871-29889. The medial meniscectomy and debridement are reported with 29881. In this case the synovectomy, code 29875, is a separate procedure and bundled with 29881; it is not reported separately.

Question 19

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. 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?

Answer 19

a. 23350, 73040-26

Rationale: Contrast material is being injected into the shoulder joint for a radiographic look of the joint and internal structures (arthrogram). Look in the CPT® Index for Arthrography/Shoulder/Injection referring you to 23350. In the Musculoskeletal section, there is a parenthetical note under code 23350 that indicates to use code 73040 for radiographic arthrography. Modifier 26 is required to indicate the radiologic professional service.

Question 20

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- saline solution. Skin was closed in a layered fashion and sterile dressing applied. What CPT® code(s) should be reported?

Answer 20

d. 20680-LT

Rationale: When reporting the removal of hardware (pins, screws, nails, rods), the code is selected by fracture site, not the number of items removed or the number of incisions made. To report 20670 or 20680 more than once, there must be more than one fracture. In this case, there is only one fracture site requiring two incisions. We know the removal is deep because the screws were in the bone. In the CPT® Index look for Removal/Implantation and you are referred to 20670-20680. Verify the correct code is 20680. Modifier LT is appended to indicate the procedure is performed on the left side.

Question 21

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 1 st metatarsal. Using a double action rongeur, 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?

Answer 21

a.
28122-LT, 28090-51-LT

Rationale: Look in the CPT® Index for Excision/Metatarsal/Head, and you are referred to 28110-28114, 28122, 28140, 28288. Code 28122 reports a partial excision or sequestrectomy of metatarsal bone. OR, another way to look this up is with Metatarsal/Sequestrectomy.

Next in the CPT® Index look for Lesion/Foot/Excision referring you to 28080, 28090. Code 28090 reports the excision of the ganglion of the foot. Modifier 51 is appended to indicate multiple procedures performed during the same session. Modifier LT is appended to indicate the procedure is performed on the left side.

Question 22

A 27 year-old triathlete is thrown from his bike on a steep downhill ride. He suffered a severely fractured vertebra at C5. An anterior approach is used to dissect out the bony fragments and strengthen the spine with titanium cages and arthrodesis. The surgeon places the patient supine on the OR table and proceeds with an anterior corpectomy at C5 with discectomy above and below. Titanium cages are placed in the resulting defect and morselized allograft bone is placed in and around the cages. Anterior Synthes plates are placed across C2-C3, C4-C5, and C5-C6. What CPT® codes should be reported?

Answer 22

c.
63081, 22554-51, 22846, 22854, 20930

Rationale: Anterior approach is used to perform several procedures on the cervical spine. The corpectomy has the highest RVUs and is listed first. Code 63081 is the removal of one single cervical segment by anterior approach. In the CPT® Index look for Vertebral/Body/Excision/Decompression directing you to 63081-63103. Arthrodesis, anterior interbody technique is coded with 22554. In the CPT® Index, look for Arthrodesis/Cervical/below C2 referring you to several codes including 22551-22554. Plates are used for anterior instrumentation and placed over a total of five segments (C2, C3, C4, C5, and C6), 22846. In the CPT® Index, look for Instrumentation/Spinal/Insertion or Spinal Instrumentation/Anterior. Report only one unit of 22846, regardless of how many devices placed at one level. Modifier 51 is appended to 22554 to indicate multiple procedures. The application of the titanium cages is described by add-on code 22854. In the CPT® Index look for Application/Intervertebral Device. The morselized allograft is described by 20930. In the CPT® Index look for Allograft/Bone/Spine Surgery/Morselized.

Question 23

A 68 year-old female with long-standing degenerative arthritis in her right knee presented. Risks and benefits were discussed. She was agreeable to surgery. After adequate anesthesia, the patient was prepped and draped in usual sterile fashion with DuraPrep1 and Betadine scrub. The leg was exsanguinated and tourniquet inflated. An anterior incision was made and carried through the skin and bursa, cauterizing all bleeders. The bursa was elevated medially and a medial parapatellar incision was made. The proximal tibia was cleaned. The knee had an 18-degree flexion contracture. The cruciate ligaments were debrided along with the menisci. The proximal tibial cutting guide was placed and the proximal tibial cut made. The femoral canal was entered and a 6 degree cut was made for the anterior jig. The distal cut was made at 6 degrees. The femur measured a size 2. The 2 cutting block was placed and the anterior, posterior and chamfer cuts were made. The notch cut was made and the trial component was placed with a size 2 tibia and 12 mm spacer and was found to fit beautifully and it tracked well. The patella was cut and measured to be a 32. The holes were drilled and the proximal tibial cuts were made. All the excess meniscal tissue and hypertrophic synovium were debrided. The wound was thoroughly irrigated and the bone dried. The cement was mixed; the size 2 tibia with a 12 mm tibial tray, size 2 femur and a size 32 patella were all cemented in place removing all excess cement. After the cement was hard, the tourniquet was released. The knee was placed through a range of motion and was found to track beautifully. The knee was thoroughly irrigated. The retinaculum was closed with interrupted figure-of-eight 1 Vicryl. The bursa was closed with 1 and 0. The subcutaneous layers were closed with 0 and 2-0 and the skin with staples. Sterile dressing was applied. The patient was taken to the recovery room in stable condition. What CPT® code is reported?

Answer 23

c. 27447-RT

Rationale: The procedure performed was an arthroplasty of the knee found in the CPT® Index by looking for Arthroplasty/Knee referring you to 27437-27447. This was a total knee arthroplasty with patella resurfacing reported with 27447. Modifier RT is appended to indicate the procedure is performed on the right side.

Question 24

A patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced 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® and ICD-10-CM codes are reported?

Answer 24

a.
24579-RT, S42.451A

Rationale: In the CPT® Index look for Fracture/Humerus/Condyle/Open Treatment which refers to 24579. The manipulation and internal fixation is included in 24579. The application of the first cast is always bundled with the initial surgical service and not reported separately.

In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/humerus/lower end/condyle/lateral (displaced) referring you to S42.45-. In the Tabular List seven characters are required to report the code. The 6 th character is specific to left or right. Documentation supports this as the right elbow, and the 7 th character A is supported as this is the initial surgical procedure. The complete code is S42.451A. This is the open treatment of a closed fracture, so the 7 th character B is not reported.

Question 25

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) is/are reported?

Answer 25

b.
29847

Rationale: The wrist arthroscopy and stabilization was surgically performed to provide stabilization. Look in the CPT® Index for Arthroscopy/Surgical/Wrist referring you to 29843-29847. Check the numeric section and 29847 reports arthroscopy of the wrist with internal fixation for fracture or instability. Although several K-wires were passed, 29847 is reported only once. The diagnostic arthroscopy is included in the procedure code and is not coded separately.