Musculoskeletal System
Introduction
In this chapter, we will look at how muscles and bones work together to form the framework for
the body, and the many procedures used to keep this system in shape. Objectives for this chapter
include:
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Understand the components of the musculoskeletal system
Define key terms
Understand the most common pathologies affecting these organs
Understand orthopaedic surgeries and how they relate to pathological conditions
Recognize common eponyms and acronyms
Identify when other sections of CPT or ICD-9-CM should be accessed
Know when HCPCS Level II codes and modifiers are appropriate
Anatomy and Medical Terminology
The musculoskeletal system contains 206 bones, more than 600 muscles, and ligaments, tendons,
and cartilage.
The skeleton is divided into two parts: the axial skeleton and the appendicular skeleton. The axial
skeleton consists of the bones of the skull, the hyoid bone, the chest and the spine. The
appendicular skeleton includes the remaining bones of the upper and lower limbs, shoulders and
pelvis.
Each type of bone has a specific function. Long bones such as the femur, tibia, and fibula in the
legs and the humerus, radius, and ulna in the arms have large surface areas for muscle
attachment. Short bones are found in the wrists and ankles. Flat bones are found covering soft
body parts. These are the shoulder blades, pelvic bones, and ribs. Sesamoid bones are shaped like
sesame seeds and are found near a joint, such as the patella (kneecap). Irregular bones—for
instance, the vertebrae or mandible (jaw bone)—are other various shapes.
The muscles assist with heat production, locomotion, and posture. There are three basic muscle
types: striated (skeletal) muscles, smooth (visceral) muscle, and cardiac muscle. The
musculoskeletal system includes mostly striated (voluntary) muscle. Cardiac muscle is found in
the heart and smooth muscle is involuntary muscle found in the internal organs, such as the
bowel and blood vessels.
Ligaments attach bones to other bones, and tendons attach muscles to bones. Cartilage acts as a
cushion between bones in a joint. Aponeuroses are flattened or ribbon-shaped tendons, of a
pearly white color, iridescent, glistening, and similar in structure to the tendons. They are only
sparingly supplied with blood vessels. The tendons and aponeuroses are connected, on the one
hand, with the movable structures, as the bones, cartilages ligaments, and fibrous membranes
(for instance, the sclera).
1
Skeletal System
http://www.arthursclipart.org/medical/skeletal/page_05.htm
2
Muscle System
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Key Terms and Concepts
Axilla (Mass of Axilla): The armpit. There are numerous lymph nodes in this area, as well as
muscles and tissue. There are times when the axilla may refer to the upper arm, back, or flank
area. It is important to understand the anatomy in the medical record to determine the correct
location for coding. If you are unable to determine the location based on anatomy within the
medical documentation, you will need to query the provider.
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Manipulation: Returning a fracture or dislocation to its normal anatomical position
Reduction: Treatment of a fracture of dislocation by returning the part to its normal position.
Reduction of a fracture can also mean surgical restoration.
Decompression: Removing scar tissue or bone from an area, most commonly the spine, to
relieve pressure on nerves or nerve roots. It is often performed with placement of a bone graft,
screws, plates or rods to maintain the alignment of the bones. Another common decompression is
of the median nerve in the wrist, also known as carpal tunnel.
Internal/External Fixation: Some fractures are treated with fixation, either internal or external,
to maintain the alignment of the bone while it heals, or to reinforce the bone permanently.
Internal fixation can be done with pins, screws, plates or wires placed directly in the bone to
immobilize it. External fixation is primarily on the outside of the body, and can include a cagelike structure, as well as pins and rods.
Approach: When coding orthopaedic surgeries, it is vital first to determine the approach—the
method of and direction the surgeon uses to access the part of the body that needs to be repaired.
An approach can be from the front of the body (anterior), from the back (posterior), or from the
side (lateral). An endoscopic or arthroscopic approach accesses a body area with a scope
instrument.
Instrumentation: Used primarily in the spinal area to permanently align the vertebrae.
Segmental instrumentation is defined as a spinal rod or device placed with three or more areas
anchored by screws or wires. With non-segmental instrumentation, rods or wires are anchored at
the top and bottom of the device only.
Sprain Nomenclature: A sprain or strain is the twisting or stretching of a joint in a way that
causes pain and damage to a ligament. A sprain involves the non-contractile tissue (the
ligament), and a strain involves the contractile tissue (muscle or tendon).
Scapula: The scapula is a flat, triangular-shaped bone on the dorsal thorax or back. The
acromion is an extension of this bone that joins with the clavicle at the shoulder to form the
acromioclavicular joint.
Fracture Eponyms: These often are named after the physician who first documented or
described the fracture or the treatment. Common eponyms are:
Colles fracture: A fracture of the wrist at the distal radius. Sometimes the ulnar styloid
also is involved.
Smith’s fracture: Similar to a Colles fracture except the bones are displaced toward the
palm.
Jones fracture: A stress fracture of the fifth metatarsal of the foot.
Salter-Harris fracture: An epiphyseal plate fracture; a common injury seen in children.
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Dupuytren’s fracture: Fracture of the distal fibula with rupture of the distal tibiofibular
ligaments and lateral displacement of the talus.
Monteggia fracture: Fracture of the proximal third of the ulna with associated dislocation
of the radial head.
Osteomyelitis: An inflammation of the bone and/or bone marrow caused by infection.
Curettage: Use of a curette to remove tissue by scraping.
Curette: A spoon-shaped instrument used to cut or scoop away (curettage) tissue.
Bunion Terms: A bunion, or hallux valgus, is the swelling and deformity of the
metatarsophalangeal joint, usually at the base of the big toe. There are numerous ways to repair a
bunion.
A Silver type procedure is a simple resection of the medial eminence of the metatarsal
bone.
A Keller, McBride, or Mayo type of procedure is a removal of the medial eminence of
the metatarsal bone and the base of the proximal phalanx. Sometimes a wire holder or
implant is used to stabilize the joint.
A Joplin procedure includes the transplant of the extensor tendon to the head of the
metatarsal bone.
The Mitchell procedure is a double step-cut, biplanar osteotomy through the metatarsal
bone.
The Lapidus type procedure is a fusion of the first metatarsal and first cuneiform joint,
and the first and second metatarsal bases.
No Man’s Land: The term for the fibrous sheath of the flexor tendons of the hand, specifically
in the zone from the distal palmar crease to the proximal interphalangeal joint. Stiffness
following injury is a common problem in this area.
Flexor: A muscle that causes flexion or bending of a limb or body part.
Extensor: A muscle that causes straightening of a limb or body part.
Adductor: A muscle that moves a part of the body towards the midline of the body.
Abductor: A muscle that moves a part of the body away from the midline of the body.
Polydactylous Digit: A extra digit on the hand or the foot. This digit may be soft tissue, or may
contain bones and tendons.
Cheilectomy: Removal of a large portion of the dorsal metatarsal head and associated bone
spurs.
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ICD-9-CM Coding
Many of the codes in ICD-9-CM used for the musculoskeletal system are found in chapter 13:
Diseases of the Musculoskeletal system and Connective Tissue. There are also numerous codes
used from other chapters, including chapter 16: Symptoms Signs, and Ill-Defined Conditions,
and chapter 17: Injury and Poisoning. Many codes in this section require a fifth digit.
The first conditions listed under Diseases of the Musculoskeletal System and Connective Tissue
(710-719) are arthropathies and related disorders.
Systemic lupus erythematosus (710.0), or “lupus,” is an autoimmune inflammatory connective
tissue disease. It is most common in women, and the cause is unknown.
An arthropathy is a pathology or abnormality of a joint; arthritic conditions are classified in this
section. Many of the arthropathy codes require use of another code first to specify an underlying
disease. Rheumatoid arthritis (714.x) and osteoarthritis (715.xx) are listed here.
Also found in this classification are joint derangement codes, which include tears or damage to to
cartilage and ligaments. A common example is chronic bucket handle tear of the lateral
meniscus, 717.41.
Dorsopathies (720-724) are disorders affecting the spinal column. The fourth digit classifies the
type of disorder, and the fifth classifies the area of the spine. It is also important to note if the
disorder is affecting the vertebrae or the intervertebral discs, because these are listed separately.
Rheumatism is a non-specific term for any painful disorder of the joints, muscles, or connective
tissues.
Enthesopathies are disorders of peripheral ligamentous or muscular attachments. Synovitis and
tenosynovitis (disorders of the synovium and/or tendons) are also listed here.
Bursitis is inflammation of the bursae, which are small fluid-filled sacs located between movable
parts of the body, especially at the joints.
Osteopathies, chondropathies, and acquired musculoskeletal deformities (730-739) include codes
for osteomyelitis (730.xx), osteoporosis (733.0x) and pathologic fractures (733.1x) (bone
fractures caused by disease, not accident or injury).
The codes for hallux valgus, or bunion, can be found here (735.0). A congenital bunion would be
coded from chapter 14: Congenital Anomalies (740-759).
How to Code Acute Vs. Chronic, Acute and Chronic
An acute condition is one of rapid onset with severe symptoms, and usually is of brief duration.
A chronic condition develops and worsens over time. The acute condition is always listed first.
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When a condition is documented as acute and chronic, select both codes if the sub terms in the
ICD-9-CM index exist. If a sub term for “acute and chronic” is available, review that code in the
Tabular List instead of reporting acute and chronic codes separately.
Coding Injuries
Closed fractures can be treated open and open fractures can be treated closed.
Fracture types are classified differently than fracture treatments. It is important to distinguish
between the fracture type and the treatment type.
A closed fracture is one that has not broken the skin. The treatment for a closed fracture can be
“closed,” for example placing a cast, manipulating the bone without surgery, or applying traction
to reduce the fracture. The treatment for a closed fracture can be “open,” in which the fracture
site is opened surgically to reduce the fracture, and pins, wires, screws, or plates are applied to
stabilize the fracture.
An open fracture is one where the bone is protruding through the skin. The treatment for an open
fracture may be an “open” treatment, in which surgery is required to re-align the bones, or
“closed,” in which traction is applied to re-align the bones and the wound is sutured.
Injuries are Usually the Cause of Compartment Syndrome
Compartment syndrome is the compression of nerves and blood vessels within an enclosed
space. This leads to muscle and nerve damage, and problems with blood flow. To find
compartment syndrome in ICD-9-CM Index to Diseases, look for Syndrome/compartment.
Codes are grouped by cause (whether non-traumatic, post-surgical, or traumatic) and anatomical
site.
Rotator Cuff Tears in Sports
The four muscles of the rotator cuff (supraspinatus, infraspinatus, subscapularis, and teres minor
muscles) are attached to the scapula on the back through a single tendon unit. The rotator cuff
holds the head of the humerus into the scapula at the shoulder. Chronic inflammation or injury
can cause the tendons of the rotator cuff to tear.
If the rotator cuff is torn, surgery may be necessary. Arthroscopic surgery can remove bone spurs
and inflamed tissue around the area. Small tears can be treated with arthroscopic surgery. Larger
tears require open surgery to repair the torn tendon.
Physical therapy can help strengthen the muscles of the rotator cuff. If therapy is not possible
because of pain, a steroid injection may reduce pain and inflammation enough to allow effective
therapy.
Rotator cuff problems are indexed in ICD-9-CM by the type of problem: sprain, tear, or injury.
Toddlers Who Present with Nursemaid’s Elbow
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Nursemaid’s elbow is a partial dislocation of the elbow, or proximal radial head dislocation. It is
most common in small children, caused by a sudden pull on the child’s are or hand. It is found in
ICD-9-CM under Nursemaid’s/elbow.
Bone Fractures and Their Classification
A fracture is the traumatic or pathologic breaking of a bone or cartilage. ICD-9-CM usually
classifies fractures as either open or closed.
Comminuted Fracture—The bone is crushed or splintered into several pieces.
Impacted Fracture—One part of a bone is forcefully driven into another.
Simple Fracture—The bone is broken in only one place.
Greenstick Fracture—The bone is broken on one surface and bent on the other (think of the
way a “green” twig will break when bent too far); this fracture occurs in children before the
bones have hardened.
Pathologic Fracture—Caused by disease, such as an infection or a tumor.
Compression Fracture—The bone is compressed onto another bone; caused by trauma or
osteoporosis, and common in vertebrae.
Torus or Incomplete Fracture—One side of the bone buckles; mostly common in children
because of their softer bones.
Further documentation in the medical record will aid code selection for the fracture (eg,
pathological, compression, the site, etc.). Many fractures are listed as eponyms: Smith’s fracture,
deQuervain’s fracture, Bennett’s fracture, etc.
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Types of Fractures
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Depression Skull fracture
Colles Fracture
http://www.thirdage.com/hc/c/colles-fracture-photos
E Codes
E codes are used for supplementary classification of external causes of injury and poisoning.
Many payers require E codes to explain how the patient was injured.
An index of the E codes is listed after the Table of Drugs and Chemicals. It is important to be as
specific as possible when using these codes. Look carefully for the cause of the injury. Never
select an E code as the first-listed diagnosis. E codes help payers determine liability. For
example, if the injury is work related, the claim is paid by the worker’s compensation carrier.
Without an E code identifying a work-related injury, the claim may be denied inappropriately.
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CPT Coding
Codes 20005 to 29999 are specific to the musculoskeletal system; you also may select codes
from the Radiology and Medicine sections to describe musculoskeletal services and procedures.
Wound exploration is listed first in the CPT chapter on the Musculoskeletal System. Penetrating
gunshot or stab wound trauma has its own category. The codes in this category are selected
based on the anatomic site explored. Treatment includes the exploration and enlargement of the
wound.
The next section covers excision and biopsy of muscle and bone. When coding excision
procedures in the musculoskeletal system, carefully read the medical report to determine the
depth of the wound or tissue excised. A muscle biopsy is considered superficial, for example, if
it involves a muscle close to the surface of the skin; a deep biopsy involves underlying muscle.
Introduction or removal includes codes for injections, foreign body removal, and placement of
catheters for radioelement application. Surgical injections involve direct insertion of a needle
into a tendon, muscle, or joint for the aspiration of fluid and/or the administration of medication.
When coding injections, watch for bundled procedures. For example, trigger point injections
(20552-20553) are selected based on the number of muscles injected, not the number of
injections performed.
Testing Technique
Highlight the number of muscles in the code descriptions for 20552 and 20553. Write a note that
states “Select code according to the number of muscles, not the number of injections.”
____________________________________________________________________________
An arthrocentesis of a joint includes the aspiration of fluid and/or the injection of an anesthetic
agent and/or steroid. The codes are selected based on the size of the joint. When a joint
aspiration and injection are performed on the same joint, only report the procedure once. If the
procedures are performed on more than one joint, list each procedure separately.
Injection of a substance does not include the drug itself; the drug supply may be billed separately
using a HCPCS Level II code.
Example:
_____________________________________________________________________________
The provider removes 3 cc of fluid from the left knee. He injects 40 mg of Kenalog into the right
knee. The knee is a major joint. The proper codes are 20610-LT and 20610-RT for the
procedures. The Kenalog is reported with HCPCS Level II code J3301 with four units because
the code is for 10 mg.
_____________________________________________________________________________
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Removal of foreign body procedures are coded by the depth of tissue the surgeon must incise to
reach the foreign body.
External fixation codes are used when coding the stabilization of a fracture or protecting the
skull, as in the application of a halo. Uniplane fixation is defined as pins, wires, rods or screws
applied in one plane or direction, and multiplane fixation is the application of “hardware” in two
or more planes or directions.
Replantation codes are used when the surgeon is replanting a digit or a limb after a complete
amputation. If the digit or limb is amputated partially, use specific codes for repair of bones,
ligaments, tendons, nerves, or blood vessels.
Grafts (or implant) codes are used when obtaining bone, cartilage, tendon or fascia lata grafts, or
other tissue.
An autograft is a graft of tissue or bone harvested from the patient In coding orthopaedic surgery,
an autograft can be bone, cartilage, muscle or tendon. If the material being grafted is from a
donor, it is known as an allograft. Bone grafting to stabilize the spine is common. Codes 2093020938 report the grafting procedures, and usually are coded separately.
Testing Technique
If the procedure code description includes the harvesting of the graft, do not report the graft
code separately. Add a notation in this section to indicate graft is only reported if not include in
the procedure note description. For example 21194 includes obtaining the graft.
______________________________________________________________________________
The next few sections of the CPT book are listed anatomically. The first of these anatomical
sections is the head. This area includes procedures on the skull, facial bones, and the
temporomandibular joint (TMJ).
TMJ is the “hinge” of the jaw between the mandible and temporal bones. There are many
procedures listed in CPT for repair, reconstruction, and manipulation of this joint. The most
common problem is displacement of the articular disc, which can require manipulation or
reconstruction. An arthrotomy of the TMJ is coded with 21010; codes 21050-21070 and 2124021243 are other reconstructive surgical procedures. Treatment of a TMJ dislocation is coded with
21480, 21485 or 21490, depending on whether the surgery is open or closed.
The vertical part of the lower jaw extends from the TMJ to the angle where it curves into the
mandibular body, called the mandibular rami. Surgery on the mandibular rami is performed for
reconstruction after a fracture, or to move the lower part of the jaw forward or back to correct an
orthognathic defect. CPT codes for reconstruction of the mandibular rami are 21193-21196. If a
bone graft is performed, it is included with 21194.
The spine is divided into three main sections: the cervical spine, the thoracic spine, and the
lumbar spine.
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A vertebral segment describes the basic constituent part into which the spine may be divided. It
represents a single complete vertebral bone with its associated articular processes and laminae. A
vertebral interspace is the non-bony compartment between two adjacent vertebral bodies that
contains the intervertebral disc, and includes the nucleus pulposus, annulus fibrosus, and two
cartilaginous endplates.
Spinal surgery often requires the skills of more than one surgeon. When these surgeons work
together as primary surgeons performing a portion of the same procedure, modifier 62 should be
appended to report the services. Each surgeon dictates an operative report for his or her portion
of the surgery, and each surgeon reports the same code with modifier 62.
Spinal instrumentation codes are add-on codes; they are to be coded in addition to the primary
surgery (eg, arthrodesis 22800-22812).
Diagnostic arthroscopy is always included in therapeutic or surgical arthroscopy.
When coding an injection of contrast material for an X-ray of a joint (arthrography), use the code
for the injection in addition to the code for the radiologic service itself.
During mosaicplasty, cylindrical osteochondral (bone and cartilage) grafts are removed from a
donor site and transplanted to holes prepared at the recipient site. A mosaicplasty is coded with
CPT 27416 if performed via an open incision; if performed via arthroscopy, use 29866 or 29867.
Mosaicplasty includes harvesting of the bone and cartilage.
Arthrodesis is the surgical immobilization of a joint, which is intended to result in bone fusion.
This procedure is often documented in the operative note as a fusion. A physician may implant
pins, plates, screws, wires, or rods to position the bones together until they fuse. Bone grafts may
be needed if there is significant bone loss. When selecting codes for spinal arthrodesis, you need
to know the approach (anterior, posterior, posterolateral or lateral transverse). You also need to
know the vertebral segment (cervical, thoracic or lumbar).
Disarticulation is the separation of two bones at the joint, either traumatically or by surgical
amputation. CPT has codes for disarticulation of the ankle, hip, knee, and wrist. Shoulder
disarticulation is coded with 23920 or 23921, depending on whether it is the initial surgery, or a
secondary closure or scar revision.
There are three compartments in the knee: medial, lateral, and patellofemoral. When coding
surgeries on the knee joint, each compartment is considered a separate area.
CPT usually defines compartments in the shoulder as anterior or posterior. The American
Academy of Orthopaedic Surgeons (AAOS) recognizes three “areas” or “regions” of the
shoulder: the glenohumeral joint, the acromioclavicular joint, and the subacromial bursal space.
These “areas” are clearly separate; procedures performed in one area should not influence coding
in a different area.
Fracture code selection is based on type of treatment (open or closed), whether manipulation is
performed and, in some cases, the use of internal fixation.
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Test Technique
Highlight key words in the fracture care codes, such as “with manipulation,” “without
manipulation” and “with internal fixation.”
____________________________________________________________________________
“Articular” refers to a moveable joint. When a code refers to a fracture that is “extra-articular,”
the fracture does not extend into the joint. “Intra-articular” refers to a fracture that extends into
the joint. In certain fracture coding subsections, these key words are important for proper code
selection. For example, one of the differences between codes 25607 and 25608 is whether the
distal radial fracture is extra-articular or intra-articular.
Non-union or malunion of a fracture occurs when a fracture does not heal properly. Surgery to
correct this problem is not coded with fracture codes; use codes for Repair, Revision, and/or
Reconstruction. For a nonunion/Malunion of the femur, there are codes for repairing the defect
with a graft (27472) or without a graft (27470).
The term “radical,” when referring to surgery of the musculoskeletal system, is used to describe
removal of an extensive area of tissue surrounding an area of infection or malignancy. For
example, 21620 Ostectomy of sternum, partial reports the removal of a portion of the sternum,
and 21630 Radical resection of sternum is reported for excision of most or all of the sternum and
some of the surrounding tissue.
When a physician reports a treatment of a fracture and then applies a cast or strapping,
the cast or strapping is included in the procedure. A physician may code for a cast or
strapping when the cast or strapping is the only treatment given at the first visit and no
surgical treatment is planned. Each replacement castor or strapping can be reported.
Modifier 58 is reported with a cast or strapping procedure performed in the post-operative
period. The removal of a cast or strapping is not reported separately unless the service is
provided by a physician who did not apply the cast.
A bunion is also known as a hallux valgus deformity. There are many types of surgeries
described in CPT for repair of a bunion. Pins, rods, wires, and/or screws are used to stabilize the
bones of the foot. Removal of the pins after the bones have healed is coded separately.
HCPCS Level II
HCPCS Level II L codes are for orthotic and prosthetic procedures and supplies. Many HCPCS
Level II E codes are also used with musculoskeletal and orthopaedic services, such as canes,
crutches, walkers, traction devices, wheelchairs, and other orthopaedic devices. Some physicians
will provide basic orthopaedic supplies, but most of them are supplied by a durable medical
equipment (DME) provider fulfilling the physician’s order. J codes are used to report the supply
of medications given by injection, IV, or intrathecally.
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Modifiers
Modifiers often are used in orthopaedic surgery to indicate on which side of the body the surgery
was performed; which finger or toe was repaired; or to show identical procedures were
performed on both sides of the body. These modifiers are critical in indicate a procedure was
performed twice, or to a certain part of the body, so the payer won’t inappropriately deny the
claim as a duplicate or bundled procedure.
The most common modifiers used in orthopaedic surgery are:
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Modifier
50
54
57
Description
Bilateral procedure
Surgical care only
Decision for surgery
Additional Explanation
Before using this modifier, consult with the payer. Some payers
prefer RT and LT instead of modifier 50.
staged or related procedure or
service by the same physician
during the postoperative period
This modifier is used when a physician performs an additional
procedure(s) that was planned or related to the initial procedure.
This often happens in the case of staged, reconstructive surgeries,
and a second or third surgery must be performed (eg, cleft lip and
palate surgery or removal of hardware after stabilization of a
fracture).
Distinct procedural service
This modifier is used to indicate a service should not be considered
a bundled service when it normally might be bundled (eg, service
performed on a repair of a laceration in the foot and a treatment of
a fracture of the distal radius).
Two surgeons
This modifier is used when two surgeons work together to perform
distinct portions of the same service (using the same CPT code), this
modifier is appended.
66
Surgical team
This modifier is used when a surgical team (three or more surgeons)
is required for complex procedures (for example, some spine
surgeries or complicated repairs).
78
Unplanned return to the
operating/procedure room by the
same physician following initial
procedure for a related procedure
during the postoperative period
(complication).
80
Assistant surgeon
58
59
62
Modifier AS is used for a surgical assistant who is a physician
assistant
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Modifier
Description
LT
RT
FA
F1
F2
F3
F4
F5
F6
F7
F8
F9
TA
T1
T2
T3
T4
T5
T6
T7
T8
T9
left side of the body
Right side of the body
Left hand, thumb
Left hand, second digit
Left hand, third digit
Left hand, fourth digit
Left hand, fifth digit
Right hand, thumb
Right hand, second digit
Right hand, third digit
Right hand, fourth digit
Right hand, fifth digit
Left foot, great toe
Left foot, second digit
Left foot, third digit
Left foot, fourth digit
Left foot, fifth digit
Right foot, great toe
Right foot, second digit
Right foot, third digit
Right foot, fourth digit
Right foot, fifth digit
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Chapter Review Questions
1. Muscle is attached to bone by what method?
a. Tendons, ligaments, and directly to bone
b. Tendons and aponeuroses
c. Tendons, aponeuroses and directly to bone
d. Tendons, ligaments, aponeuroses, and directly to bone
2. What is affected by myasthenia gravis?
a. Neuromuscular junction
b. Muscle belly
c. Muscle/bone connection
d. Bone
3. A patient is given Xylocaine, a local anesthetic, by injection into the thigh above the site to be
biopsied. A small bore needle is then introduced through the skin into the muscle, about 3
inches deep, and a muscle biopsy is taken. What is the CPT code for this service?
a. 20205
b. 20206
c. 20225
d. 27324
4. This 45-year-old male presents to the operating room with a painful mass of the right upper
arm. General anesthesia is induced. Soft tissue dissection is carried down through the
proximal aspect of the teres minor. Upon further dissection a large mass is noted just distal of
the IGHL, which appears to be benign in nature. With blunt dissection and electrocautery, the
4 cm mass is removed en bloc and sent to pathology. Wound is irrigated; repair of the teres
minor with subcutaneous tissue is then closed with triple-0 Vicryl. Skin is closed with double-0
Prolene in a subcuticular fashion. What is the correct CPT code for this service?
a. 23076-RT
b. 23066-RT
c. 23075-RT
d. 11406-RT
5. The patient has a torn medical meniscus. An arthroscope was placed through the anterolateral
portal for the diagnostic procedure. The patellofemoral joint showed some grade 2
chondromalacia on the patella side of the joint only, and this was debrided with the 4.0 mm
shaver. The medial compartment was also entered and a complex posterior horn tear of the
medical meniscus was noted. It was probed to define its borders. A meniscectomy was carried
out back to a stable rim. Select the appropriate CPT code(s) for this service.
a. 29880, 29879-59
c. 29880
b. 29881, 29877-59
d. 29881
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6. A 3-year-old is brought into the ER crying. He cannot bend his left arm after his older brother
pulled it. The physician looks at the X-ray and makes a diagnosis of dislocated nursemaid’s
elbow. The ER physician reduces the elbow successfully. The patient is able to move his arm
again. The patient is referred to an orthopaedist for follow-up care. What CPT and ICD-9-CM
codes should be reported?
a. 24640-54, 832.2, E927.0
b. 24565-54, 832.2, E929.8
c. 24640-54, 832.10, E927.0
d. 24600-54, 832.00, E928.8
7. A 50-year-old male had surgery on his upper leg one day ago and is presenting with serous
drainage from the wound. He is scheduled back to the operating room for an evaluation of the
hematoma. His wound is explored and there is a hematoma at the base of the wound, which is
very carefully evacuated, and the wound irrigated with antibacterial solution. The correct
CPT and ICD-9-CM codes are?
a. 10140-79, 998.12
b. 27603-78, 998.59
c. 10140-76, 998.9
d. 27301-78, 998.12
8. A 45-year-old presents to the operating room with a right index trigger finger and left
shoulder bursitis. The left shoulder is injected with 1cc of Xylocaine, 1cc of Celestone, and 1 cc
of Marcaine. An incision was made over the A1 pulley in the right distal transverse palmar
crease, about an inch in length. This is taken through skin and subcutaneous tissue. The A1
pulley is identified and released in its entirety. The wound is irrigated with antibiotic saline
solution. The subcutaneous tissue is injected with Marcaine without epinephrine. The skin is
closed with 4-0 Ethilon suture. Clean dressing is applied. What are the codes for these
procedures?
a. 26055-F6, 20610-76-LT
b. 20552-F6, 20605-52-LT
c. 26055-F6, 20610-51-LT
d. 20553-F6, 20610-59-LT
20
21
Answers:
1. C
2. A 3. B 4. A
5. D 6. A 7. D 8. C