Outpatient Facility Coding Alert

Tip: Knowing the surgeon’s preferred terminology can point you in the right direction.

When an elbow sprain needs surgery, you need to comb through the physician’s documentation in search of two important details:

1) whether he performed a repair or a reconstruction

2) whether the procedure focused on the lateral or medial collateral ligaments.

Use Graft as Repair/Reconstruction Guide

CPT^® offers two repair codes for elbow collateral ligaments, and two for reconstruction:

• 24343 -- Repair lateral collateral ligament, elbow, with local tissue
• 24345 -- Repair medial collateral ligament, elbow, with local tissue.
• 24344 -- Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft)
• 24346 -- Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft).

If the surgeon doesn’t specify whether he performed a repair or reconstruction, check the documentation for evidence of a graft. As the descriptors indicate, repair involves local tissue, and reconstruction involves a graft.

Tip: The graft harvest is included in the reconstruction codes, so you should not charge a graft harvest separately.

Protect yourself: Reconstruction is more common for chronic tears than for acute tears.  However, in throwing athletes, such as the classic Tommy John procedure, even in acute tears, reconstruction is usually performed for greater strength of the repair. So reconstruction is possible for an acute tear, so if you aren’t certain, ask the surgeon whether he performed a repair or reconstruction.

Learn Ligaments to Ace Diagnosis Choice

Two likely ICD-9 codes for lateral and medial collateral ligament repair and reconstruction are 841.0 (Sprains and strains of elbow and forearm; radial collateral ligament) and 841.1 (… ulnar collateral ligament). So you need to know how CPT^®’s “lateral” (24343, 24344) and “medial” (24345, 24346) match up with ICD-9’s “radial” (841.0) and “ulnar” (841.1) collateral ligaments.

Radial/lateral: If the surgeon documents a torn “RCL” (radial collateral ligament) or-”LCL,” he is referring to a torn lateral collateral ligament. That means you should pair 841.0 (radial) with 24343 and 24344 (lateral).

Ulnar/medial: Surgeons often refer to the medial collateral ligament as the “MCL” or “UCL” (ulnar collateral ligament). So 841.1 (ulnar) pairs with 24345 and 24346 (medial).

Tip: The surgeon may also refer to a “Tommy John” procedure. This is a nickname for UCL reconstruction created by Frank Jobe, MD, who invented and first performed the procedure on major- league pitcher Tommy John.

Remember: Don’t report 841.0 and 841.1 if they don’t match the patient’s documented diagnosis. For example, if the surgeon documents chronic instability, you should look to 718.82 (Other joint derangement, not elsewhere classified; upper arm).