Orthopedic Coding Alert

Tactics help you recoup deserved pay for 24357-24359.

Tennis elbow claims faults can wreak your reimbursement for these services. But you can clean up your method if you can spot in the note how the surgeon reached the elbow tendon and whether the tendon was released or repaired. By doing so, you stand to gain your full earned pay for codes 24357, 24358, and 24359, which is $437.27, $514.74, and $647.59, respectively.

Review Structures Treated

When you are confident in your elbow anatomy knowledge, you'll have a better chance of understanding where the operative note is directing you. The codes are simple and can easily be applied if you are reading correct. "Coding these procedures became much easier when CPT condensed the codes from the previous five down to the current three," confirms Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

The bones, --humerus above and the radius and ulna below-- articulate in a manner to allow 180 degrees of movement that helps you use the upper limb for various functions (See Figure 1).

The numerous muscles that originate and insert around the joint allow movement; particularly important is the bundle of extensors including the muscle extensor carpi radialis brevis (ECRB) that originates at the lateral epicondyle which is the lateral prominence of the humerus at the elbow joint. Repeated back movements of the wrist joint, as seen when playing tennis, can cause small micro tears in the tendon of origin and result in inflammation known as lateral epicondylitis or 'tennis elbow.' The term is highly deceptive, though; the condition affects non-athletes as well, and is not solely confined to tennis players. As the pathology progresses, the damaged tendon(s) may rupture and secondary fibrosis and calcification may ensue.

Identify Surgical Approach

For recalcitrant tennis elbow cases which do not respond to NSAIDs for relief from pain and inflammation, steroids (either oral or injections), casting, physiotherapy, home exercises, and 'RICE' (which implies rest, ice, compression, and elevation), surgical intervention may be required. The surgeon's aim is to remove the degenerative tissues and strain on the muscle, and thereby promote healing.

Your surgeon may adopt a percutaneous approach for a tenotomy which involves using a hypodermic needle to fenestrate the tendon at the lateral epicondyle and release the contracture. This is done under local anesthesia. Report code 24357 (Tenotomy, elbow, lateral or medial [eg, epicondylitis, tennis elbow, golfer's elbow]; percutaneous) for a situation like this.

Use code 29999 (Unlisted procedure, arthroscopy) or 29837 (Arthroscopy, elbow, surgical; debridement, limited) or 29838 (Arthroscopy, elbow, surgical; debridement, extensive) when an arthroscopic approach is adopted for treatment. The choice of codes is largely governed by "the extent of debridement," advises Dr. Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C. Done with an arthroscope introduced through a small incision, this approach is favored over open surgery as it enables a closer look at the joint, less post-operative pain, and better grip strength post-operatively as the ECRB tendon can be selectively released without affecting the origins of other extensors. "Though it is yet to be proven that the arthroscopic approach enables a faster return to routine," adds Mallon.

Another common approach may include extracorporeal shock wave treatment (ECSWT), for which you may code 0102T (Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle). This procedure, done as an out-patient procedure, delivers shock waves to the site of damage to instigate healing. Pay particular attention to energy settings when selecting a code. Report code 0019T (Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy) if low energy is being used. "The method of reporting changes when low energy ESWT is the mode of treatment; in that case, you report code 0019T," confirms Stout.

Report Tendon Release

To release the tendon, the surgeon may incise through the skin to expose the tendons and cut through them to release the scar tissue and lengthen to allow easier contraction. In addition, the surgeon may perform debridement on the bone and soft tissue to ease the movements. To report these services, you would use code 24358 (Tenotomy, elbow, lateral or medial [eg, epicondylitis, tennis elbow, golfer's elbow]; debridement, soft tissue and/or bone, open).

Tighten Up Your Repair Scrutiny

Not infrequently, the surgeon may attempt to repair the tendon and even reattach it to the lateral condyle. "An open repair is rather frequent," says Stout. You should discretely code 24359 (Tenotomy, elbow, lateral or medial [eg, epicondylitis, tennis elbow, golfer's elbow]; debridement, soft tissue and/or bone, open with tendon repair or reattachment).

Example: The operative note may state 'A small incision was made over the dorsal lateral aspect of the forearm to show the flat tendon of extensor carpi radialis longus, retraction of which revealed the tendon of the adjacent extensor carpi radialis brevis. This was divided by a step-cut and lengthened by 1 cm following which the ends were sutured in absorbable sutures. In this situation, 24359 is the best code.

Both Elbows Fixed? Append Modifier 50

Although rarely done, if the surgeon performs any of the above procedures on both elbows concurrently, addthe modifier 50 (Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code) to the procedural code. This may be seen in the centers for trauma recovery. "Except for trauma, we rarely do bilateral upper extremity cases," says Mallon.

Example: If the operative note reads that the surgeonperforms an open repair of the ECRB tendon on the left elbow and repeated the same procedure on the right elbow, you code 24359 and append modifier 50 to imply that the same procedure was repeated on the other elbow.

ICD-9/ICD-10 Crosswalk

Add the ICD-9 code 726.32 (Lateral epicondylitis) to 24357 for percutaneous release, 24358 for release, or 24359 for open repair. For ICD-10, use code M77.10 (Lateral epicondylitis, unspecified elbow). "Code 726.32 maps to M77.10-M77.12 in ICD10," says Stout. Depending upon the left or the right side, select codes M77.11 (Lateral epicondylitis, right elbow) or M77.12 (Lateral epicondylitis, left elbow).