Orthopedic Coding Alert

The surgeon's notes will give you a hint about the right codes to report

If your head spins when you-re faced with the various codes for medial and lateral epicondylitis procedures, we-ve got some solid advice for you.

When you have to decide among CPT codes 24350-24356, you may wonder which codes describe each surgical procedure--so many codes, for what seems to be one little problem, right? To understand why it is so important to have all of those codes available to you, you should get to know a little elbow anatomy, and you-ll find the code choice much easier.

Elbow Terminology Translates Into Coding Terms

The elbow is a sophisticated hinged joint involving the ulna, radius and the humerus. The ulno-humeral joint allows flexion and extension. The radio-capitellar (humeral) joint, when combined with the distal radio-ulnar joint in the wrist, allow rotation in the elbow, also known as pronation and supination. The ligaments of the elbow include the medial and lateral collateral ligaments.

Although many muscles originate or insert around the elbow, those involved in tennis elbow and golfers- elbow include the extensor muscles on the radial (lateral) side and the flexors on the ulnar (medial) side of the elbow, respectively.

Know the Differences Between Golfers- Elbow and Tennis Elbow

Lateral epicondylitis, or tennis elbow, is related to chronic repetitive micro trauma to the extensor carpi radialis brevis muscle (ECRB). It was initially described as an injury occurring as the result of poor backhand technique--thus the origin of the term -tennis elbow.- It usually affects patients in the fourth to fifth decades of life.

What happens: Micro tearing occurs at the origin of the ECRB at the lateral epicondyle. This, coupled with a poor blood supply, can lead to poor healing and refractory symptoms.

Lateral epicondylitis is 10 times more common than medial epicondylitis, a similar process affecting the medial side of the elbow, perhaps more easily recognized as -golfers- elbow.- However, any activity involving overuse or abnormal use of the flexor or extensor muscles can cause these conditions. Despite the sporty-sounding names, these conditions occur more frequently in non-athletes than in athletes.

Initial treatment for these conditions typically includes -RICE---Rest, Ice, Compression, and Elevation. Surgeons may also recommend non-steroidal anti-inflammatory medicines, and casting may be helpful acutely.

Surgeons may also recommend local steroid injections, oral steroids, stretching and strengthening of the involved muscles through a home exercise program (HEP) or formal physical therapy, but despite appropriate conservative management, some patients require more aggressive treatment.

Know the Epicondylitis Treatments, Codes

Extracorporeal shock wave treatment (ECSWT) is an FDA-approved treatment for refractory lateral epicondylitis that uses high-frequency sound waves to stimulate healing in soft tissues.

Despite FDA approval, there is no Category I CPT code as of yet for ECSWT. There is, however, a Category III code to describe it (0019T, Extracorporeal shock wave, involving musculoskeletal system, not otherwise specified; low energy).

The Medicare Physician Fee Schedule assigns no RVUs to Category III codes, so there are no guarantees of reimbursement, and you should always seek preapproval for these procedures.

Look for These Clues in the Op Report

After conservative management fails, orthopedists may consider surgical treatment. You can select the right CPT code for your surgeon's work if you look for the following descriptions in his operative report to clue you in to the correct code:

- 24350--Fasciotomy, lateral or medial (e.g., tennis elbow or epicondylitis)

This code selection typically represents a percutaneous release of the extensor origin just distal to the lateral epicondyle.
 
This type of fasciotomy procedure effectively lengthens the extensor tendons, and the ensuing inflammatory response promotes scarring and healing. Care must be taken by the orthopedic surgeon not to injure the lateral collateral ligament.
 
Surgeons may perform this type of fasciotomy in the operating room or under local anesthesia in the office.

Tip: Orthopedic surgeons would not typically perform this procedure on the medial side because the ulnar nerve could be at risk with a percutaneous technique.

- 2435--...with extensor origin detachment

During this surgery, the physician makes a longer incision to expose the extensor muscle origin around the epicondyle. The surgeon retracts the extensor carpi radialis longus (ECRL) to expose the ECRB, and debrides and/or excises the origin of the ECRB.

Surgeons may perform this on the medial side as well with detachment of the flexor muscles.

- 24352--...with annular ligament resection

This procedure involves detachment of the conjoined tendon, common origin of the ECRL, ECRB, extensor digitorum communis (EDC), extensor digiti minimi (EDM), and the extensor carpi ulnaris (ECU) muscles. The surgeon then carries exposure down to the radial head and partially excises the annular ligament. Many think that tennis elbow is an extra-articular process, and this procedure is not frequently performed.

Hint: Surgeons would not perform this procedure on the medial side.

- 24354--...with stripping

The surgeon excises the common extensor attachment (ECRL, ECRB, EDC, EDM, ECU) muscles from the bone and allows them to slide distally about 1 centimeter. This procedure effectively lengthens the tendons and promotes an inflammatory response to promote healing.

Surgeons may perform this procedure on the medial side as well.

- 24356--... with partial ostectomy

Essentially, this procedure code is the same as 24354, except it represents an additional step.

During this procedure, the orthopedic surgeon removes several millimeters of bone from the lateral epicondyle with an osteotome or rongeur. This allows a vigorous healing response. Surgeons may refer to this as  the classic -Nirschl- procedure.

Orthopedic surgeons may perform this procedure on the medial side with detachment of the flexor origin and partial removal of the medial epicondyle.

- 29999--Unlisted procedure, arthroscopy

Surgeons can treat tennis elbow arthroscopically with a release of the extensors performed from within the joint. The orthopedist may perform a partial exostectomy as well.

Some surgeons may select 29837 (Arthroscopy, elbow, surgical; debridement, limited) for this procedure instead. You should ask the surgeon which code choice best reflects the work that he performed.

Surgeons rarely perform this arthroscopic procedure on the medial side, due to the proximity of the ulnar nerve.

It is amazing how many codes are available for such a small area. I hope that this short review can help to clarify any confusion you may have had about the differences in the code descriptors.

--David  V. Janeway, MD, is a practicing orthopedic surgeon at Orthopaedic Specialists of the Carolinas, and is the director of outpatient orthopedic surgery at Forsyth Medical Center in Winston Salem, NC.