Bone Up on Orthopaedic Changes

Long-due Adjustments Ease Coding

By Mary Brown, CPC

The majority of the 2008 changes to the surgery chapter of CPT® can be found in the orthopaedic section. We saw 96 revisions, 24 new codes, and five deleted codes. There are new orthopaedic codes in surgical navigation, spinal osteotomy, elbow tendon repair, femoral fracture repair, treatment of ankle joint, and arthroscopies of the shoulder and subtalar joint.

Most of the revisions are in the “Fracture and/or Dislocation” subsections. In 2008, the words “with or without internal or external fixation” are replaced to say “includes internal fixation, when performed” and the words “external fixation” were removed. If your physician places an external fixation device along with an open treatment of a fracture, CPT® 20690-51 Application of a uniplane (pins or wires in one plane), unilateral, external fixation; or CPT® 20692-51 Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type), would be coded in addition to the open treatment of the fracture code. Note that modifier 51 Multiple procedures has been appended to the codes. For an extensive list of revised codes please refer to Appendix B in your CPT® book.

Modifier 51 Use

Other code revisions stemmed from removing the 51 exempt symbols from several grafting (implant) codes. These codes are no longer modifier 51 exempt, meaning they are free to be reported to the primary procedure if modifer 51 Multiple procedures is appended.

  • 20660 Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)
  • 20690 Application of a uniplane (pins or wires in one plane), unilateral, external fixation system
  • 20692 Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)
  • 20900 Bone graft, any donor area; minor or small (eg, dowel or button)
  • 20902 …major or large
  • 20910 …Cartilage graft; costochondral
  • 20912 …nasal septum
  • 20920 Fascia lata graft; by stripper
  • 20922 …by incision and area exposure, complex or sheet
  • 20924 Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris)
  • 20926 Tissue grafts, other (eg, paratenon, fat, dermis)

Some codes that were previously modifier 51 exempt have been revised and are now considered Add-On codes with the (+) symbol attached to them.

  • +20930 Allograft for spine surgery only; morselized (List separately in addition to code for primary procedure)
  • +20931 …structural (List separately in addition to code for primary procedure)
  • +20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)
  • +20937
  • morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
  • +20938 …structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
  • +22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
  • +22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)
  • +22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
  • +22843 …7 to 12 vertebral segments (List separately in addition to code for primary procedure)
  • +22844 …13 or more vertebral segments (List separately in addition to code for primary procedure)
  • +22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
  • +22846 …4 to 7 vertebral segments (List separately in addition to code for primary procedure)
  • +22847 …8 or more vertebral segments (List separately in addition to code for primary procedure)
  • +22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)
  • +22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

New and Deleted Codes

  • +20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures; image-less (List separately in addition to code for primary procedure)
  • 20986 …with image guidance based on intraoperatively obtained images (eg, fluoroscopy, ultrasound) (List separately in addition to code for primary procedure)
  • 20987 …with image guidance based on preoperative images (List separately in addition to code for primary procedure)

These three new Add-On codes describe surgical navigation procedures. They are subdivided into whether they are without image guidance; with image guidance based on intraoperatively obtained images; or based on preoperative images.

  • 21073 Manipulation of temporomandibular joint(s) (TMJ) therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)

Remember that there are other codes for manipulation of the TMJ in the 90000s when not using general or monitored anesthesia care. I’d recommend writing a note next to the others if you use this code a lot.

  • 22206 Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); thoracic
  • 22207 …lumbar
  • 22208 …each additional vertebral segment (List separately in addition to code for primary procedure)

These new spinal osteotomy codes describe an osteotomy of three columns. This new osteotomy is used in reconstructive surgery to correct deformities in the sagittal plane, using three columns of bone. This is a different osteotomy than described in CPT® 22210-22214.

  • 24357 Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer’s elbow); percutaneous
  • 24358 …debridement, soft tissue and/or bone, open
  • 24359 …debridement, soft tissue and/or bone, open with tendon repair or reattachment

These three codes replace five codes, 24350–24356, and they provide more clarity than the deleted codes.

  • 27267 Closed treatment of femoral fracture, proximal end, head; without manipulation
  • 27268 …with manipulation
  • 27269 Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performed

There have always been codes for proximal end fracture of the femoral neck (27230-27236) but not for the proximal end of the femoral head. Now coders can be specific on proximal end fractures. Beware that these codes are at the end of the section rather than with the other proximal end codes. It is a good idea to make a note in your CPT® book to “See also codes 27267-27269 for femoral head fractures” by the 27230-27236 codes.

  • 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]

This code was created to provide physicians a CPT® code for osteochondral autograft(s) done through an open incision rather than arthroscopically. Physicians have had an arthroscopic code for the last few years but now have an open procedure code. Remember if the procedure begins arthroscopically and turns into an open procedure, you would only code the open code, not both. CPT® guidelines state not to report 27415, 29871, 29875, 29884 when performed at the same session and/or 29874, 29877, 29879, 29885-29887 when performed in the same compartment.

  • 27726 Repair of fibula nonunion and/or malunion with internal fixation

We now have one code for the repair of a nonunion fibula with internal fixation. CPT® does not give us choices on the types of repair as it does for the repair of a non union of a tibia (27220-27725).

  • 27767 Closed treatment of posterior malleolus fracture; without manipulation
  • 27768 …with manipulation
  • 27769 Open treatment of posterior malleolus fracture, includes internal fixation, when performed

The posterior malleolus is considered one of the three parts of a trimalleolar fracture. We have not had a code for repair of just the posterior malleolus. Remember if your physician repairs the lateral and/or medial malleolus along with the posterior malleolus, you would code a bimalleolar or trimalleolar repair instead.

  • 28446 Open osteochondral autograft, talus (includes obtaining graft[s])

Open osteochondral autograft of talus is a new technology code that foot and ankle surgeons have been waiting for. This procedure takes osteochondral grafts from the non weight-bearing part of the talus or other area and grafts them to the damaged area of the talus.

  • 29828 Arthroscopy, shoulder, surgical; biceps tenodesis

This procedure has been long awaited by orthopaedic surgeons who have performed biceps tendonodesis through the arthroscope for years but the only code they could report was for a procedure done through an open incision. They were forced to report 29999. Unlisted procedure, arthroscopy. We all know what a nightmare it is to use unlisted procedure codes.

  • 29904 Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body
  • 29905 …with synovectomy
  • 29906 …with debridement
  • 29907 …with subtalar arthrodesis

Foot and ankle surgeons are very happy about having an arthroscopic procedure code for the subtalar joint. The first three codes (29904-29906) are the basic arthroscopic procedure codes with removal of loose/foreign body; with synovectomy; with debridement, where 29907 describes subtalar arthrodesis.

2008 brought orthopedic coders a little of everything. There are new technology codes, revised codes (tennis elbow), and new codes for surgeries that have been preformed for years without codes (nonunion of fibula, femoral head, and posterior malleolar fracture, etc.). The variety of revisions are difficult to grasp because the changes are related to each other but are also different from each other (grafting codes no longer being modifier 51 exempt and spine codes that used to be modifier 51 exempt are now Add-On codes).

Don’t forget to talk to your physicians about the changes and update your surgery charge tickets.

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