Orthopedic Coding Alert

Here’s how your surgeon could diagnose a dislocated elbow.

Patients reporting to your practice with dislocated elbows are going to need several services from your practice.

Why? They’ll be requiring diagnostic and surgical work that your orthopedic surgeon can provide, which means at least two separate coding opportunities.

See how orthopedic practices manage dislocated elbow patients with the advice below, which takes you from initial diagnosis to surgical solution.

E/M & MRI Likely for Dx Services

Before your surgeon treats a dislocated elbow, they have to decide if the patient has a dislocated elbow. The surgeon could use a combination of testing methods to determine the presence of spinal deformity, confirms Jessyka Burke, BSHA, CPC, OSC, CASCC, coding specialist at Cascade Orthopaedics in Auburn Washington.

“In order for a provider to make the decision if an elbow dislocation needed surgery or not, there are some things that definitely need to be done; E/M and X-rays for starters,” she explains. With an X-ray the provider can view the bone for injury — but the diagnostic work might not end there, Burke explains.

“However, after exam and X-ray they may request for an urgent CT [computed tomography] scan to look further at the bony anatomy and/or MRI [magnetic resonance imaging] to get a better look at the ligaments,” says Burke. “Based on these things a provider will be able to determine if the patient needs surgery or not.”

Here’s a list of the codes you might come across on an encounter form where your surgeon is deciding whether an elbow is dislocated and needs surgery:

Evaluation and management (E/M) service: Typically 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) — but there is a chance that the E/M could take place in the hospital, which you’d report with the appropriate E/M code

X-ray: You’ll likely choose from the following codes:

• 73070 (Radiologic examination, elbow; 2 views)
• 73080 (… complete, minimum of 3 views)
• 73085 (Radiologic examination, elbow, arthrography, radiological supervision and interpretation)

MRI: You’ll likely choose from the following codes:

• 73221 (Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s))
• 73222 (… with contrast material(s))
• 73223 (… without contrast material(s), followed by contrast material(s) and further sequences)

CT scan: You’ll likely choose from the following codes:

• 73070 (Radiologic examination, elbow; 2 views)
• 73080 (… complete, minimum of 3 views)
• 73085 (Radiologic examination, elbow, arthrography, radiological supervision and interpretation)

Example: A new patient reports to the orthopedist complaining of severe pain and swelling of the left elbow. The physician performs an office evaluation and management (E/M) service, orders a complete elbow X-ray and an MRI with contrast material, and diagnoses the patient with pathological fracture of the left humerus. Notes indicate that the E/M service lasted 57 minutes and included moderate medical decision making (MDM).

On the claim, you’d report:

• 73080 for the X-ray
• 73222 for the MRI
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) for the E/M
• M84.422A (Pathological fracture, left humerus, initial encounter for fracture) appended to 73080, 73222, and 99214 to indicate the patient’s injury.

Use These Codes for Surgical Treatment

When you are choosing a surgical code, one of the most important aspects is knowing whether the surgery is open or closed. “Closed treatment means there is no open incision made and treatment can be done with manipulation and casting; and open treatment means incision was made and usually internal fixation was needed in order to fix the injury,” according to Burke.

You’ll choose from the following set of codes if your surgeon decides to operate on the patient’s elbow:

• 24586 (Open treatment of periarticular fracture and/ or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius))
• 24587 (… with implant arthroplasty)
• 24600 (Treatment of closed elbow dislocation; without anesthesia)
• 24605 (… requiring anesthesia)
• 24615 (Open treatment of acute or chronic elbow dislocation)
• 24620 (Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation)
• 24635 (Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed)

Look to Code These Services Separately

There are several services that your provider might perform during elbow dislocation surgery that you could code separately for, Burke confirms. However, you should check with your payer before coding services performed during the same session as the elbow procedure.

Per the American Academy of Orthopaedic Surgeons (AAOS), services not included with CPT® 24615 can include:

• Harvesting of graft through separate skin or fascial incision, distant site: 20924 (Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris))
• Application of external fixation: For example, 20690 (Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system), 20692 (Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type))
• Debridement: For example, 29837 (Arthroscopy, elbow, surgical; debridement, limited), 29838 (… debridement, extensive)
• Repair of nerve or artery: For example, 64856 (Suture of major peripheral nerve, arm or leg, except sciatic; including transposition), 64857 (… without transposition).