Orthopedic Coding Alert

How well do you know the elbow anatomy?

When the surgeon performs work on an ulnar collateral ligament (UCL), you need to ask these questions to make code selection easier: Lateral or medial collateral ligaments? Repair or reconstruction?

You’ll also have to know the correct ICD-10 code to help the payers understand why the patient had a UCL repair.

Once you’ve answered these questions, you’re ready to code your UCL repair claim. Read on for more information on coding these surgeries.

Understand the Collateral Ligament Anatomy

The first element you’ll need to identify on the claim is the type of collateral ligament your surgeon is treating.

Radial/lateral: If the documentation states torn RCL (radial collateral ligament) or LCL (lateral collateral ligament), this refers to a torn lateral collateral ligament. This ligament is located on the lateral side connecting the humerus to the radius.

Ulnar/medial: Most often the surgeon will refer to the MCL (medial collateral ligament) as the UCL (ulnar collateral ligament). This is extremely important, as CPT® code descriptors do not have “UCL” in the terminology. This ligament is located on the inside of the elbow, and is attached on one side to the humerus and on the other side to the ulna.

Strains/sprains of the corresponding collateral ligament are likely diagnosis codes to link with the CPT^® code selected. Be sure to bill the diagnosis based on the surgeon’s documentation; if dislocation or instability of elbow are documented, use correct diagnosis to reflect that.

Distinguish Between Repair and Reconstruction

When it comes to proper code choice for your UCL repair, remember the documentation will key you in on the answer. Repair involves use of local tissue for repair of the ligament while reconstruction involves using a tendon graft, which may require a graft harvest.

Some keywords that might indicate UCL repair include “small incision” and “reinforcing the ligament with tape-like suture.” Keywords that might indicate UCL reconstruction include “complex surgical approach” and “replacing damaged ligament with a tendon graft.”

Tip: When billing the reconstruction, the graft harvest is not separately billable as it is already included in the reconstruction code.

Know Your Repair Codes

Once you’ve gotten the information above, you’re ready to code your collateral ligament repair/reconstruction.

If the surgeon performs repair/reconstruction on a lateral collateral ligament, you will choose 24343 (Repair lateral collateral ligament, elbow, with local tissue) or 24344 (Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft)), depending on encounter specifics.

Example: A 44-year-old passenger of a car was involved in a motor vehicle accident where their right elbow was dislocated. Upon meeting the surgeon in the office, they complain of instability and pain. The surgeon performs a physical exam and confirms laxity. The surgeon orders a magnetic resonance imaging (MRI) without contrast materials and findings are consistent with LCL tear. The surgeon performs an LCL reconstruction to restore stability and function.

For this claim, you would report:

• 24344 for the UCL repair
• 73221 (Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)) for the MRI
• Modifier RT (Right side) appended to 24344 and 73221 to indicate laterality

The appropriate-level evaluation and management (E/M) code from the 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 total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) 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 total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) code set

• Modifier 57 (Decision for surgery) appended to the E/M code to show that the E/M and surgery were separate, significantly identifiable services
• S53.21XA (Traumatic rupture of right radial collateral ligament, initial encounter) appended to 24344, 73221, and the E/M code to represent the patient’s injury

If the surgeon performs repair/reconstruction on an ulnar/ medial ligament, you will choose from 24345 (Repair medial collateral ligament, elbow, with local tissue) or 24346 (Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft)), depending on encounter specifics.

Know What Post-Op Care Looks Like

After the repair, patients will be placed in a splint for protection and later switched to a brace. Physical therapy starts within a week of surgery to help regain mobility. The surgeon will follow up closely and advise activity modifications for usually four to six months, or whenever the patient is rehabilitated enough to resume regular activity without restrictions.

Misty Smith, CPC, COSC, Contributing Writer