Orthopedic Coding Alert

As if the more than 330 potential new diagnosis codes CMS published for 2009 aren't enough, a few more codes may find their way in by Oct. 1. Here's a peek at what could be in store.

Possible new incidental durotomy code choices would prove useful for those who code spine surgery, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network.

You may see your surgeon use terms such as "incidental durotomy" or "dural tear" for an unintended dura mater tear during spine surgery.

The tear may also occur during other invasive extradural procedures, such as epidural injections.

Now the ICD-9 index points you to 998.2 (Accidental puncture or laceration during a procedure) for a dural tear, says John D. Shaw, president of Albany, N.Y.-based Next Wave, in his March 2008 presentation to the ICD-9 Coordination and Maintenance (C&M) Committee, "Incidental Durotomy/Dural Tear," online at http://www.cdc.gov/nchs/ppt/icd9/att5ShawMar08B_97-03.ppt.

But because dural tears require repair, they should have a unique code, Shaw says.

Watch out: Many surgeons expect dural tears because they are common for certain procedures (such as revision spine surgery), so surgeons don't document the tears as complications. That makes your job tougher because you don't know whether to code the tear. A distinct code and multiple "code also" notes may help change that.

Shaw offered two options, with a preference for the following:

- add new code 349.3 (Dural tear)

- add "use additional code for associated conditions" note, including curvature of spine (737.0-737.9), intervertebral disc disorders (722.0-722.93), and postlaminectomy syndrome (722.83), among others.

The other option would have the same "use additional code" notes, but it would create new accidental puncture codes:

- 998.20 -- Accidental puncture or laceration during a procedure, unspecified site

- 998.21 -- Accidental puncture or laceration of dura during a procedure.

- 998.29 -- Accidental puncture or laceration during a procedure, other specified site.

Nursemaid's elbow -- radial head subluxation commonly seen in children younger than 5 years of age -- also may get its own code in 2009.

Now, ICD-9 directs you to 832.0x (Dislocation of elbow; closed dislocation) for this condition, says Leslie Follebout, CPC-ORTHO, PCS, coding department supervisor at Peninsula Orthopaedic Associates in Salisbury, Md.

This coding option doesn't cause any issues, but "adding the specific category for a nursemaid's elbow will allow separation (for tracking) of a nursemaid's elbow from other types of dislocation of the elbow," Follebout says.

The proposed new code would be 832.2x (Subluxation of radial head), with a note specifying that the code is for nursemaid's elbow. The note is particularly helpful because you-re more likely to see "nursemaid's elbow" in the documentation than "subluxation of radial head." The applicable fifth-digit option would be 0 (Elbow unspecified).

If your surgeon removes a joint prosthesis for infection and completes the joint replacement after the infection heals, you may have a new V code to report in October -- V54.82 (Other orthopedic aftercare; awaiting joint prosthesis).

According to the C&M Committee 2008 summary, you may see the more precise descriptor "joint prosthesis explantation" instead (http://www.cdc.gov/nchs/classifications_of_diseses_and_f.htm).

And because you never replace the prosthesis in some patients (due to complications), you may see an explantation status code and a separate encounter code for patients with an explanted joint admitted for the new prosthetic joint placement.

Now, you report codes for acquired site deformity (such as 736.39, Other acquired deformities of hip) for these patients, but these codes aren't accurate, the C&M Committee says.

Initial prosthesis? Pay attention: For billable visits prior to an initial joint prosthesis, you should report the related medical condition (such as 715.xx, Osteoarthrosis and allied disorders), Follebout says. Once the surgeon makes the decision to operate, and the patient arrives for the preoperative visit, you-ll use V72.8x (Other specified examinations), she says.