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Old 10-21-2008, 07:51 AM
kristinab kristinab is offline
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Default LRTI-Thumb CMC Joint Arthorplasty

I need help coding a Thumb CMC Joint Arthroplasty for optimal reimbursement. Procedure includes ligament reconstruction; arthroplasty; trapeziectomy; and tendon harvest. Any help would be greatly appreciated.
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Old 10-21-2008, 08:40 AM
coderguy1939 coderguy1939 is offline
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Check out 25447 for the arthroplasty and 25310 or 26480 for the tendon component depending on how the doctor performed the surgery.
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Old 10-21-2008, 08:55 AM
steps2codes steps2codes is offline
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I was thinking 25445 and totally agree with the other codes for the tendon
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Old 10-21-2008, 09:38 AM
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please see my response to the the post by coderguy from the other day titled "Carpometacarpal Resection Arthroplasty". There is a lot of good info about wrist arthroplasties. Also, this is from the AAOS website and should prove helpful as well:

A helping hand for coding
Wrist, hand, finger codes don’t have to be confusing

By M. Bradford Henley, MD; William R. Beach, MD; Gary K. Frykman, MD; Melvin M. Friedman, MD, and Margie Scalley Vaught, CPC, Cpc-H, CCS-P, ASC-OR

If the questions we’ve received about applying and using common procedure terminology (CPT) codes for wrist/hand/finger procedures are any indication, many orthopaedic surgeons and coders feel “all thumbs” in this area. Therefore, this column covers documentation and coding pertaining to wrist/hand/finger surgery.

Revision CTR

At times, a redo or revision carpal tunnel release (CTR) can require more work than the initial surgery. In some cases, fascial grafting or hypothenar fat grafts must be fashioned to help prevent further recurrence. The AAOS Global Service Data Book (GSD) includes the following procedures in a CTR: division of transverse carpal ligament with or without Z-plasty or other local tissue rearrangement; tenosynovectomy/tenolysis of flexor tendon(s); excision of lipoma of carpal canal; exploration/incidental release of ulnar nerve; release of distal forearm fascia; and use of scope equipment.

Excluded from a CTR are: internal neurolysis of the median nerve with decompression of pathology requiring internal neurolysis with use of an operating scope; neuroplasty of ulnar nerve for documented ulnar neuropathy; and wrist arthrotomy/synovectomy.

The current coding options for a repair/revision CTR are 64721-22 (if there is supporting documentation of more extensive work) or unlisted 64999. The AAOS Coding, Coverage and Reimbursement Committee is evaluating the possibilities for CTR revisions to determine whether additional reporting for the grafting (20926) can be allowed rather than developing a new revision code. The goal is to expand the use of existing resource value unit (RVU)-rated codes instead of adding new codes that could reduce the RVU for existing codes.

Another concern when doing CTR is the ability to report release of the ulnar nerve. To report both median and ulnar nerve release, the supporting documentation must indicate that the patient has ulnar neuropathy. This requires both a separate preoperative diagnosis (establishing medical necessity) and operative notes. Otherwise, the ulnar exploration/release could be considered inherent and thus not separately reportable.

Excision interosseous nerve

Anatomy: The interosseous nerve is divided into anterior and posterior sections. The anterior interosseous nerve is essentially a motor branch of the median nerve. It arises 5 cm-8 cm below the medial epicondyle, under the arch of the flexor digitorum superficialis, after passing between the two heads of the pronator teres. Its branches supply the flexor pollicis longus, the flexor digitorum profundus indicis and, about half the time, the flexor digitorum profundus majus. It then accompanies the anterior interosseous artery as they pass through and below the flexor pollicis longus and the flexor digitorum profundus to reach the pronator quadratus. Finally, it passes deep to the pronator quadratus and ends by sending articular branches to the wrist joint. None of its branches are cutaneous.

The posterior interosseous nerve travels along the posterior aspect of the forearm between the ulna and the radius. The posterior interosseous has its roots in the cervical spine (C6, C7, C8) and arises as a branch from the radial nerve.

Coding: CPT has several codes (64732-64772) relating to the excision or transection of the nerves. The origin of the nerve root must be known to reference the proper CPT code. You must also check to see whether the excision/transection is being performed for postoperative pain control. The Centers for Medicare and Medicaid Services has stated that the global surgical package includes postoperative pain management by the surgeon (see 100-04 Claims Processing Section 40). The documentation must clearly show why the nerve is being excised/transected. The recommended code for these excisions is 64772.

Basal joint arthroplasty

Anatomy: The basal joint of the thumb is also known as the carpometacarpal (CMC) joint. Located at the base of the thumb, the basal joint usually moves quite freely to help position the thumb.

Coding: Arthritis of the basal joint is often treated with an arthroplasty. Years ago, the anchovy procedure, as it was called, was represented by 25447 (Arthroplasty, interposition, intercarpal or carpometacarpal joints), and this code is still used for the treatment of basal joint arthritis. If the tendon graft is harvested from a separate incision, 20924 (tendon graft, from a distance [eg, palmaris, toe extensor, plantaris]) can also be reported. The GSD includes the following procedures under code 25447: arthrotomy/synovectomy of wrist or intercarpal joints; excision of osteophytes, bone fragments and joint debridement; partial or total excision of trapezium or trapezoid; capsular release, repair and/or reconstruction; and internal fixation of implant. The harvesting of tendon graft through separate skin or fascial incision is excluded from code 25447.

A variation of this procedure adds a sling or suspension aspect. The first metacarpal is suspended to the second metacarpal to inhibit the proximal migration of the first metacarpal that often occurs after the excisional arthroplasty of the first CMC joint. Typically, one half (or all) of the flexor carpi radialis (FCR) is used to create the new intercarpal ligament between the first and second metacarpals.

The transfer of the FCR to the base of the first metacarpal is not a part of the basic CMC arthroplasty and must be coded separately. Use either 26480 (transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon) or 25310 (tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon, as appropriate). Modifier 51 would be appended to the secondary procedure in either the 25447 + 26480 or 25310 code pairs, according to the January 2005 CPT Assistant.

Now let’s look at some recent questions about coding hand, wrist and finger procedures.

Implant removal

What is the difference between 20680 and 26320?

Although 20680 covers the removal of a deep implant (buried wire, pin, screw, metal band, nail, rod or plate), the AAOS Coding, Coverage and Reimbursement Committee says that code 26320 (removal of implant from finger or hand) should be used for removal of a carpal prosthesis, carpal screws, or other material inside the wrist capsule/joint. This procedure would require capsular or retinacular closure plus skin closure.

IM rodding of metacarpal bones

What CPT code would be used to report intramedullary (IM) rodding of the metacarpal bones?

If the fracture is opened, then the AAOS Coding, Coverage and Reimbusement Committee recommends using 22615, the code for open treatment with internal fixation. Technically, the IM rod is considered as internal fixation in the revised CPT guidelines (at the beginning of the musculoskeletal section). If, however, the technique is performed percutaneously and the fracture site is not opened, then codes such as 26607 or 26727 may be more appropriate.

Manipulation codes

How should the manipulation of joint codes be applied?

According to the National Correct Coding Initiative (chapter 1) as well as the AAOS GSD, manipulation of a joint is normally performed during the course of another (major) procedure and requires no additional reporting because it is considered inherent. Problems occur, however, when manipulation is performed as the only procedure, such as outlined in the CPT code 26340 (manipulation, finger joint, under anesthesia, each joint). This and other codes were added in 2002. The January 1999 CPT Assistant noted that the phrase ‘with or under anesthesia’ in a code description meant under general anesthesia. But by 2002, this information was outdated and the terms ‘under anesthesia’ or ‘with anesthesia’ are now understood to reflect the appropriate anesthesia for a given patient and/or given situation.

M. Bradford Henley, MD, is professor of orthopaedic surgery at the University of Washington and chairman of the AAOS Coding, Coverage and Reimbursement Committee. He can be reached at bhenley@u.washington.edu. William R. Beach, MD; Gary K. Frykman, MD; and Melvin M. Friedman, MD, are also members of the committee.

Margie Scalley Vaught, CPC, CCS-P, CPC-H, ACS-OR, is an independent coding specialist in Ellensburg, Wash. A BONES member, she has served on the National Advisory Board for the American Academy of Professional Coders. She can be reached at vaught@kvalley.com

Using the new revision TJA codes

By Kevin J. Bozic, MD, MBA

Currently, the ICD-9-CM diagnosis and procedure codes related to revision total joint arthroplasty (TJA) are inadequate to detect relevant differences in patient characteristics, cause of failure, type and complexity of the revision procedure, and resource utilization among TJA procedures. But this is about to change.

The most commonly used ICD-9 diagnosis codes now being used with failed TJA are 996.4 (complication of an orthopaedic device) and 996.66 (infection associated with an orthopaedic joint). Furthermore, all revision TJA procedures are grouped under one of two ICD-9 procedure codes: 81.53 (revision total hip arthroplasty [THA]) and 81.55 (revision total knee arthroplasty [TKA]).

As reported in the June 2005 Bulletin, the National Center for Health Statistics and the Center for Medicare and Medicaid Services recently adopted new ICD-9-CM diagnosis and procedure codes for revision TJA. These new codes will go into effect in October 2005. The addition of these codes will significantly enhance the understanding of failure mechanisms in TJA and will ultimately facilitate quality improvement and better outcomes for TJA patients.

In addition, the new codes will provide more accurate data for the American Joint Replacement Registry Project. Use of these codes will provide more accurate and relevant data inputs for risk adjustment models that are used by payers to predict resource utilization related to specific diagnoses and surgical procedures.

However, these benefits will be realized only if TJA surgeons improve their documentation so that hospital coders can abstract the appropriate diagnosis and procedure codes from the hospital record (office notes, admission notes, operative notes, discharge summaries). The following case examples can be used as guidelines in applying the new codes.

Diagnosis codes: Revision TJA

The new, more specific ICD-9-CM diagnosis codes related to revision TJA include: 996.41 (mechanical loosening of prosthetic joint); 996.42 (dislocation of prosthetic joint); 996.43 (prosthetic joint implant failure/breakage); 996.44 (peri-prosthetic fracture around prosthetic joint); 996.45 (peri-prosthetic osteolysis); 996.46 (articular bearing surface wear of a prosthetic joint); 996.47 (other mechanical complication of prosthetic joint implant); and 996.48 (bone graft failure).

Surgeons should specify the cause of failure in their documentation, including office notes, admission notes, operative notes and discharge summaries, as indicated in the following examples.

Case 1. A 79-year-old woman, who received a right hybrid THA 13 years ago, presents with radiographic evidence of eccentric wear of the polyethylene acetabular liner and expansile osteolysis in Charnley-DeLee zones 1 and 2.

Use diagnosis codes 996.45 (peri-prosthetic osteolysis) and 996.46 (articular bearing surface wear of a prosthetic joint).

Case 2. Same patient as above now presents with migration of the acetabular component secondary to retroacetabular osteolysis.

In this case, use diagnosis codes 996.41 (mechanical loosening of prosthetic joint); 996.45 (periprosthetic osteolysis); and 996.46 (articular bearing surface wear of a prosthetic joint).

Case 3. Same patient as above now presents with a periprosthetic femur fracture through an osteolytic lesion in Gruen zone 3.

This case would require diagnosis codes 996.41 (mechanical loosening of prosthetic joint); 996.44 (peri-prosthetic fracture around prosthetic joint); 996.45 (periprosthetic osteolysis); and 996.46 (articular bearing surface wear of a prosthetic joint).

Procedure Codes: Revision THA

More specific ICD-9-CM procedure codes related to revision THA have also been added and will be effective in October. These include: 00.70 (revision of both acetabular and femoral components); 00.71 (revision of acetabular component; includes femoral head); 00.72 (revision of femoral component; includes acetabular liner); 00.73 (isolated revision of head, liner); 84.56 (insertion of cement spacer); and 84.57 (removal of cement spacer).

Again, it is important that surgeons specify the exact cause of failure and the specific type of revision procedure that is performed, as illustrated in the following examples.

Case 1. A 68-year-old man who had a left THA 15 years ago undergoes acetabular liner and femoral head exchange for eccentric wear of the acetabular liner.

This case calls for diagnosis code 996.46 (articular bearing surface wear of a prosthetic joint) and procedure code 00.73 (isolated revision of head, liner).

Case 2. A 72-year-old woman who had a right THA 11 years ago undergoes acetabular revision with exchange of the femoral head for mechanical loosening of the acetabular component associated with retroacetabular osteolysis.

This case would require diagnosis codes 996.41 (mechanical loosening of prosthetic joint), 996.45 (periprosthetic osteolysis), and 996.46 (articular bearing surface wear of a prosthetic joint), as well as procedure code 00.71 (revision of acetabular component; includes femoral head).

Procedure Codes: Revision TKA

CMS also added the following, more specific ICD-9-CM procedure codes for revision TKA: 00.80 (revision of all components); 00.81 (revision of tibial component; includes tibial insert); 00.82 (revision of femoral component); 00.83 (revision of patellar component); 00.84 (isolated revision of tibial insert); 84.56 (insertion of cement spacer); and 84.57 (removal of cement spacer).

As with revision THA, surgeons performing a revision TKA should specify the exact cause of failure and the specific type of revision procedure that is performed. The following cases illustrate the use of these codes.

Case 1. A 67-year-old man who underwent right TKA nine years ago is now scheduled for exchange of the tibial insert due to eccentric wear of the polyethylene insert.

This case calls for diagnosis code 996.46 (articular bearing surface wear of a prosthetic joint) and procedure code 00.84 (isolated revision of tibial insert).

Case 2. A 78-year-old woman who underwent a left posterior cruciate-retaining TKA 11 years ago undergoes conversion to a semi-constrained TKA due to mechanical loosening and collapse of the femoral component secondary to osteolysis. The patellar component is retained.

In this situation, the following diagnosis codes should be used: 996.41 (mechanical loosening of prosthetic joint), 996.45 (periprosthetic osteolysis) and 996.46 (articular bearing surface wear of a prosthetic joint). The procedure codes are: 00.81 (revision of tibial component, includes tibial insert) and 00.82 (revision of femoral component).

Kevin J. Bozic, MD, MBA, is assistant professor in residence, University of California – San Francisco Department of Orthopaedic Surgery, and a member of the AAOS Coding, Coverage and Reimbursement Committee. He can be reached at bozick@orthosurg.ucsf.edu
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Old 10-21-2008, 11:53 AM
coderguy1939 coderguy1939 is offline
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Also, the lay description of 25447 states that this procedure is often referred to as LRTI or Burton LRTI procedure.
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Old 10-26-2008, 09:21 AM
jdmatcoder jdmatcoder is offline
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Would 25447 also be appropriate if the CMC joint arthroplasty was done using Dr. Meals' method, where the base of the thumb metacarpal is pinned to the base of the index finger metacarpal?
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Old 10-27-2008, 09:55 AM
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jdm, I would have to see the op report to answer that question
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