Orthopedic Coding Alert

CPT and the AMA may have just made the orthopedic coder's life a little easier. CPT 2002 includes 89 changes to codes in the musculoskeletal system chapter, 31 of which are new codes. Eight of these new codes deal with arthroscopic surgery and will in many cases eliminate the need for submitting unlisted-procedure codes for surgeries that up until now had no CPT code.
 
The 2002 changes go into effect Jan. 1, 2002. Practices should plan changes to super bills, encounter forms, charge tickets, etc., but hold off on implementation until after Jan. 1.
 
According to Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., many carriers do not update their fee schedules until February or March, so poll your major payers to determine when they will activate new CPT codes. Jumping the gun can result in a rash of denied claims" " Stout says.
   
Note: New codes appear here in bold type and revised codes are in plain type. As in past issues all new revised and deleted codes are listed in Appendix B of CPT 2002.

Dotting I's and Crossing T's

Many of the changes to existing codes involve the slightest grammatical or even punctuation changes but even those slight revisions can change the nature of the code. For instance 20225 now reads: biopsy bone trocar or needle; deep (e.g. vertebral body femur). The only change in the code definition is the addition of "e.g." But the change means that a deep bone biopsy includes but is not limited to the vertebral body or the femur.
 
The most minor changes appear in the 21182-21184 code group (reconstruction of orbital walls rims forehead nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone [e.g. fibrous dysplasia] with multiple autografts [includes obtaining grafts]; total area of bone grafting ). The choice of code depends on the size of area of bone grafting e.g. 40 square centimeters. That measurement used to be shown as 40cm but the term for the measurement is now 40 sq. cm.

New and Revised Injection Codes

The 20000 series of injection codes includes a number of new entries. These new codes offer options for reporting injection of the carpal canal for carpal tunnel syndrome as well as a range of codes for reporting those troublesome trigger-point injections. Expansion of this section of codes will allow for more accurate reporting and less confusion about location purpose and number of injections rendered.
 

20526 injection therapeutic (e.g. local  anesthetic corticosteroid) carpal tunnel.
 

20550 injection; tendon sheath ligament ganglion cyst.

20551 injection; tendon origin/insertion.

20552 injection; single or multiple trigger point(s) one or two muscle group(s).
 

20553 injection; single or multiple trigger point(s) three or more muscle groups.

Miscellaneous Changes

Several other codes have been rewritten with slight additions or deletions of terms to make them clearer or more consistent with current medical terminology.
 

21750 closure of median sternotomy separation with or without debridement (separate procedure).
 

23000 removal of subdeltoid calcareous deposits open.
 

23350 injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography.
 

27447 arthroplasty knee condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty).
 
The term "soft tissue" was added to a number of codes for the excision of subcutaneous and deep tumors (24075 24076 25075 25076 26115 and 26116) to solidify their use for soft tissue masses only and not bony tumors.

More Elbow Room

Important additions were made to the humerus (upper arm) and elbow section which has remained essentially untouched for years providing coders with a wider more specific range of codes for identifying surgeries to the arm. Stout says the big plus with these new codes is that for many common surgeries they eliminate the need for an unlisted-procedure code (24999 unlisted procedure humerus or elbow) and the accompanying reimbursement hassles. Physicians who perform ulnar collateral ligament repairs will be especially pleased with the new codes for reporting this service.
 

24075 excision tumor soft tissue of upper arm or elbow area; subcutaneous.
 

24076 excision tumor soft tissue of upper arm or elbow area; deep (subfascial or intramuscular).
 

24300 manipulation elbow under anesthesia.

24332 tenolysis triceps.

24343 repair lateral collateral ligament elbow  with local tissue.

24344 reconstruction lateral collateral ligament  elbow with tendon graft (includes harvesting of graft).
 

24345 repair medial collateral ligament elbow  with local tissue.
 

24346 reconstruction medial collateral ligament  elbow with tendon graft (includes harvesting of graft).

Clarifications for Wrist and Forearm Surgeries

A range of new and revised codes will offer more accurate coding options for surgery to the wrist and forearm. The code changes offer greater specificity as evidenced by the expanded range of codes for decompressive fasciotomies.
 
Many of the changes are minor giving more clarification as to what is and isn't included in surgeries of the wrist and forearm. Some of the most notable new codes here are 25001 for release of flexor carpi radialis tunnel syndrome 25259 for manipulation of the wrist joint and 25651 and 25652 for treatment of ulnar styloid fracture. Again the need to report an unlisted-procedure code (25999 unlisted procedure forearm or wrist) has been eliminated by the addition of these new codes.
 

25001 incision flexor tendon sheath wrist (e.g.  flexor carpi radialis).
 

25020 decompression fasciotomy forearm and/or wrist flexor or extensor compartment; without debridement of nonviable muscle and/or nerve.
 

25024 decompression fasciotomy forearm and/or wrist flexor and extensor compartment; without debridement of nonviable muscle and/or nerve.
 

25025 decompression fasciotomy forearm and/or wrist flexor and extensor compartment; with debridement of nonviable muscle and/or nerve.
 

25075 excision tumor soft tissue of forearm and/or wrist area; subcutaneous.
 

25076 excision tumor soft tissue of forearm and/or wrist area; deep (subfascial or intramuscular).
 

25259 manipulation wrist under anesthesia.
 

25274 repair tendon or muscle extensor forearm and/or wrist; secondary with free graft (includes obtaining graft) each tendon or muscle.
 

25275 repair tendon sheath extensor forearm and/or wrist with free graft (includes obtaining graft) (e.g. for extensor carpi ulnaris subluxation).
 

25394 osteoplasty carpal bone shortening.
 

25405 repair of nonunion or malunion radius or ulna; with autograft (includes obtaining graft).
 

25420 repair of nonunion or malunion radius and ulna; with autograft (includes obtaining graft).
 

25430 insertion of vascular pedicle into carpal bone (e.g. Harii procedure).
 

25431 repair of nonunion of carpal bone (excluding carpal scaphoid [navicular[ (includes obtaining graft and necessary fixation) each bone.
 

25440  repair of nonunion scaphoid carpal (navicular) bone with or without radial styloidecto my (includes obtaining graft and necessary fixation).
 

25443 arthroplasty with prosthetic replacement; scaphoid carpal (navicular).
 

25520 closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation).
 

25526 open treatment of radial shaft fracture  with internal and/or external fixation and open treatment with or without internal or external fixation of distal radioulnar joint (Galeazzi fracture/dislocation) includes repair of triangular fibrocartilage complex.
 

25645 open treatment of carpal bone fracture (other than carpal scaphoid [navicular]) each bone.
 

25651 percutaneous skeletal fixation of ulnar styloid fracture.
 

25652 open treatment of ulnar styloid fracture.
 

25671 percutaneous skeletal fixation of distal radioulnar dislocation.

A Fist Full of Changes in Terminology

There is only one new code (26340) in the hands and fingers section but numerous terminology changes were made that clarified codes and removed obsolete terms. For example the term "zone 2" replaces "digital flexor tendon sheath" in CPT codes 26350 and 26356; "synthetic" replaces "prosthetic" in 26390 26392 26415 and 26416; and "polydactylous" replaces "supernumerary" in CPT code 26587.
 
The addition of the word "each" to the codes for treatment of carpometacarpal joint (CMC) dislocations (26670 26676 and 26685) and arthrodesis of the CMC joint (26843) invites coders to report these codes as multiples when this is appropriate. Code 26340 again offers a viable alternative to the unlisted-procedure code for finger manipulation.
 

26115 excision tumor or vascular malformation  soft tissue of hand or finger; subcutaneous.
 

26116 excision tumor or vascular malformation  soft tissue of hand or finger; deep (subfascial or intramuscular).
 

26160 excision of lesion of tendon sheath or joint capsule (e.g. cyst mucous cyst or ganglion) hand or finger.
 

26340 manipulation finger joint under anesthesia each joint.
 

26350 repair or advancement flexor tendon not in zone 2 digital flexor tendon sheath (e.g. no man's land); primary or secondary without free graft each    tendon.

26356 repair or advancement flexor tendon in zone 2 digital flexor tendon sheath (e.g. no man's land); primary or secondary without free graft each  tendon.
 

26390 excision flexor tendon with implantation of synthetic rod for delayed tendon graft hand or finger each rod.
 

26392 removal of synthetic rod and insertion of flexor tendon graft hand or finger (includes obtaining graft) each rod.
 

26415 excision of extensor tendon with implantation of synthetic rod for delayed tendon graft hand or finger each rod.
 

26416 removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft)  hand or finger each rod.
 

26426 repair of extensor tendon central slip  secondary (e.g. boutonniere deformity); using local tissue(s) including lateral band(s) each finger.
 

26428 repair of extensor tendon central slip  secondary (e.g. boutonniere deformity); with free graft (includes obtaining graft) each finger.
 

26510 cross intrinsic transfer each tendon.
 

26585 deleted use 26587.
 

26587 reconstruction of polydactylous digit soft tissue and bone.
 

26590 repair macrodactylia each digit.
 

26597 deleted use 11041-11042 14040-14041  15120 15240.
 

26607 closed treatment of metacarpal fracture  with manipulation with external fixation each bone.
 

26607 closed treatment of carpometacarpal dislocation other than thumb with manipulation  each joint; without anesthesia.

26676 percutaneous skeletal fixation of carpometacarpal dislocation other than thumb with manipulation each joint.
 

26685 open treatment of carpometacarpal dislocation other than thumb; with or without internal or external fixation each joint.
 

26843 arthrodesis carpometacarpal joint digit  other than thumb each.

Pelvis and Hips Feet and Toes Revisions

The pelvis and hip joint section of CPT has several code revisions but no additions. As with the other changes they are more specific but offer little substantive difference from the past edition of CPT.
 

27110 transfer iliopsoas; to greater trochanter of femur.
 

27130 arthroplasty acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft.
 

27132 conversion of previous hip surgery to total hip arthroplasty with or without autograft or allograft.
 

27140 osteotomy and transfer of greater trochanter of femur (separate procedure).
 

27185 epiphyseal arrest by epiphysiodesis or stapling greater trochanter of femur.

There are a few changes to nomenclature in the foot and toes section but no new codes. The narrative for CPT code 28299 was tightened up a bit by replacing "other methods" with "by double osteotomy."
 

28104 excision or curettage of bone cyst or benign tumor tarsal or metatarsal except talus or calcaneus.
 

28238 reconstruction (advancement) posterior tibial tendon with excision of accessory tarsal navicular bone (e.g. Kidner type procedure).
  

28299 correction hallux valgus (bunion) with or without sesamoidectomy; by double osteotomy.
 

28737 arthrodesis with tendon lengthening and advancement midtarsal tarsal navicular-cuneiform (e.g. Miller type procedure).

Casts and Strapping

One new code was added to the section on casts and strapping and one was revised.
 

29049 application cast; figure-of-eight.

29086 application cast; finger (e.g. contracture).

Arthroscopy Codes Added

  
The most meaningful changes to CPT 2002 for orthopedics are the addition of several new codes for arthroscopy. Sports medicine orthopedists should be pleased since they now have a means for reporting arthroscopic Bankart repairs (capsulorrhaphy) SLAP lesion repairs and distal clavicle resections.
 
The addition of 29806 29807 and 29824 alone means there are now codes to describe common arthroscopic shoulder surgeries that formerly had to be reported using 29909 (unlisted procedure arthroscopy). Orthopedic coders are painfully familiar with the denials extra documentation reimbursement reductions and other pitfalls that came with submitting this code. And as if to put those headaches to bed permanently CPT has eliminated 29909 replacing it with 29999. The change is largely symbolic as the language for 29999 remains just as it was for 29909 (unlisted procedure arthroscopy).
 

29805 arthroscopy shoulder diagnostic with or without synovial biopsy (separate procedure).
 

29806 arthroscopy shoulder surgical; capsulorrhaphy.
 

29807 arthroscopy shoulder surgical; repair of SLAP lesion.
 

29815 deleted use 29805.

29824 arthroscopy shoulder surgical; distal claviculectomy including distal articular surface (Mumford procedure).
 

29900 arthroscopy metacarpophalangeal joint  diagnostic includes synovial biopsy.
 

29901 arthroscopy metacarpophalangeal joint  surgical; with debridement.
 

29902 arthroscopy metacarpophalangeal joint surgical; with reduction of displaced ulnar collateral ligament (e.g. stenar lesion).

29909 deleted use 29999.
 

29999 unlisted procedure arthroscopy.

The downside to the new arthroscopy codes is that they may present bundling issues in 2002. According to Terry Fletcher BS CPC CCS-P CCS a healthcare coding consultant based in Laguna Beach Calif. bundling was less of an issue when unlisted-procedure codes were reported with other surgeries performed at the same setting. "Now with the new codes " she says "coders should be aware of all of the new bundling issues that come with them and reimbursements will definitely be affected. It's a good idea to start negotiating contracts with payers as soon as possible."