Orthopedics€¦ · B16.2 Acute hepatitis B without delta-agent with hepatic coma B17.0 Acute...

Orthopedics

Volume 2Musculoskeletal System (27680-29999). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1069

Hemic and Lymphatic Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1422

Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1423

Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1440

Pathology and Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1582

Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1587

Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1601

Category III Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1675

HCPCS Codes

• Medical and Surgical Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1687

• Outpatient PPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1688

• Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1689

• Procedures/Professional Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1690

• Drugs Administered Other Than Oral Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1698

• Orthotic Procedures and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1699

• Temporary National Codes (Non-Medicare) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1700

ICD-10 CrossRef Details. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1701

Modifier Descriptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2065

Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2075

Code Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2121

Contents

Volume 1Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Integumentary System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Musculoskeletal System (20100-27676). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

71Modifier: 0 = not allowed, 1 = allowed CPT® is a registered trademark of the American Medical Association. CPT © 2020 American Medical Association. All rights reserved.

Musculoskeletal System Coders’ Specialty Guide 2021: Orthopedicsm

uSCu

loSk

eletal SyStem

+20936 — +20937

+20936 — +20937

959330, 959370, 959380, 959390, 959400, 965230, G04530

ICD-10 CrossRefM25.78, M47.011-M47.019, M47.021-M47.029, M47.11-M47.13, M47.21-M47.23, M47.26, M47.27, M47.28, M47.811-M47.813, M47.816, M47.817, M47.818, M47.891-M47.893, M47.896, M47.897, M47.898, M48.01-M48.03, M48.061, M48.062, M48.07, M48.9, M50.00, M50.01, M50.03, M50.20, M50.21, M50.220-M50.223, M50.23, M54.11-M54.13, M54.2, M79.12, M79.18, M99.20, M99.21, M99.23, M99.30, M99.31, M99.33, M99.40, M99.41, M99.43, M99.50, M99.51, M99.53, M99.60, M99.61, M99.63, M99.70, M99.71, M99.73, Q76.2

+20936Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)

Clinical responsibilityWhen the patient is appropriately prepped and anesthetized for a spinal surgery procedure, the provider fills in bony defects during the surgical procedure with an autograft obtained from the same incision. She extends the incision longitudinally, or lengthwise, upward or downward, as applicable. For a fusion procedure in the cervical spine, or neck, she takes graft material from a rib by extending the incision upward. For a fusion procedure in the lumbar spine, which is the lower back, or in the sacrum, the area at the base of the spine, she takes graft material from an adjacent vertebra, generally the lower vertebra. She localizes the donor site and uses an osteotome or bone shaver to shave and pull the graft. After completing the grafting portion of the procedure, she turns her attention to the remainder of the major operative procedure.

Coding tipsCode 20936 is an add-on code describing grafting from a donor area using the same incision during a major operative procedure and must be reported with an allowable primary spinal procedure code.

You should never append modifier 50, Bilateral procedure, to 20936. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply. If the procedure is performed bilaterally, report the add-on code twice.

Be aware of possible nonpayment. Although neither CPT® nor CMS officially bundle spinal bone grafts to other procedures, Medicare payers and third party payers observing CMS guidelines will effectively bundle spinal bone grafts, such as 20936, along with 20930, Allograft, morselized, or placement of osteopromotive material, for spine surgery only, list separately in addition to code for primary procedure, to any related procedure with which you would report them. Medicare designates these graft procedures as status B codes. CMS policy dictates that Medicare payers always bundle these codes into payment for other services. To reinforce this, the national Physician Fee Schedule Database assigns these codes zero relative value units, or RVUs. In other words, Medicare does not preclude you from reporting these codes, but it will not pay you for them and you cannot charge the patient for the disallowed amounts because Medicare has already paid you for these services as part of the payment for the primary procedure. Your best strategy with Medicare is not to stop reporting these procedures but to simply to write off the codes as disallowed when Medicare does not pay.

Fee Schedulemedicare Fees national Conversion Factor: 36.0896, Facility: $0.00, Non Facility: $0.00, OPPS Facility: $0.00, OPPS Non Facility: $0.00rVu Facility Work RVU: 0.00, PE RVU: 0.00, Malpractice RVU: 0.00, Total RVU: 0.00rVu non-Facility Work RVU: 0.00, PE RVU: 0.00, Malpractice RVU: 0.00, Total RVU: 0.00Indicators Preoperative: 0.00, Intraoperative: 0.00, Postoperative: 0.00, Total RVU: 0, Global Period: XXX, Radiology Diagnostic Test: 99, Code Status: B, PC/TC Indicator: 9, Endoscopic Base Code: None, MUE: 0modifier allowances 22, 52, 53, 59, 63, 76, 77, 79, 99, AR, CR, ET, GA, GC, GJ, GR, GY, GZ, KX, LT, Q5, Q6, QJ, RT, XE, XP, XS, XU

CCI Alerts (version 25.3)365910, 365920, 965230

ICD-10 CrossRefM47.011-M47.019, M47.021-M47.029, M47.11-M47.13, M48.01-M48.03, M48.061, M48.062, M48.07, M50.00, M50.01, M50.03, M50.20, M50.21, M50.220-M50.223, M50.23, M50.30, M50.31, M50.320-M50.323, M50.33, M51.26, M51.27, M51.36, M51.37, M99.20, M99.21, M99.23, M99.30, M99.31, M99.33, M99.40, M99.41, M99.43, M99.50, M99.51, M99.53, M99.60, M99.61, M99.63, M99.70, M99.71, M99.73, T81.41XA-T81.41XS, T81.42XA-T81.42XS, T81.43XA-T81.43XS, T81.49XA-T81.49XS

+20937Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

Clinical responsibilityWhen the patient is appropriately prepped and anesthetized for a spinal surgery procedure, the provider fills in bony defects during the surgical procedure with a morselized autograft obtained through a separate incision. She selects and prepares the donor area, typically the iliac crest, rib, or femoral head. She makes a longitudinal, or lengthwise, incision. She incises and retracts superficial skin, fascia, and muscles to expose the bone for grafting. She localizes the donor site and uses an osteotome or bone shaver to shave and pull the graft. She obtains sufficient bone pieces for the graft and then closes the donor site incision by suturing it in a layered fashion. She then prepares the autograft outside the patient's body. She uses a rongeur and bone shaver to morselize, or crush, the autograft into granules of various shapes and sizes. This allows the bone pieces to confirm to the bony defect and fill in the gap, or cavity, in the bone. After completing the grafting portion of the procedure, she turns her attention to the remainder of the spinal surgery procedure.

72 Modifier: 0 = not allowed, 1 = allowedCPT® is a registered trademark of the American Medical Association. CPT © 2020 American Medical Association. All rights reserved.

Musculoskeletal SystemCoders’ Specialty Guide 2021: Orthopedicsm

uSC

ulo

Skel

eta

l Sy

Stem

+209

38 —

+20

938

+20938 — +20938

Coding tipsCode 20937 is an add-on code describing preparation and application of a morselized autograft through a separate skin incision and must be reported with an allowable primary spinal procedure code.

You should never append modifier 50, Bilateral procedure, to 20937. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply. If the procedure is performed bilaterally, report the code twice.

Illustration

TrephineBone graft is

harvested from fibula

Fibula

Tibia

Morselized boneis placed over the

removed disc

Morselizesbone

+20937

Fee Schedulemedicare Fees national Conversion Factor: 36.0896, Facility: $175.03, Non Facility: $175.03, OPPS Facility: $100.69, OPPS Non Facility: $100.69rVu Facility Work RVU: 2.79, PE RVU: 1.36, Malpractice RVU: 0.70, Total RVU: 4.85rVu non-Facility Work RVU: 2.79, PE RVU: 1.36, Malpractice RVU: 0.70, Total RVU: 4.85

Indicators Preoperative: 0.00, Intraoperative: 0.00, Postoperative: 0.00, Total RVU: 0, Global Period: ZZZ, Radiology Diagnostic Test: 99, Code Status: A, PC/TC Indicator: 0, Endoscopic Base Code: None, MUE: 1modifier allowances 22, 52, 53, 58, 59, 62, 63, 76, 77, 78, 79, 80, 81, 82, 99, AQ, AR, AS, CR, ET, GA, GC, GJ, GR, KX, Q5, Q6, QJ, XE, XP, XS, XU

CCI Alerts (version 25.3)0333T0, 0464T0, 110101, 365910, 365920, 382200, 382211, 382220, 925850, 958220, 958600, 958610, 958630, 958640, 958650, 958660, 958670, 958680, 958690, 958700, 959070, 959080, 959090, 959100, 959110, 959120, 959130, 959250, 959260, 959270, 959280, 959290, 959300, 959330, 959370, 959380, 959390, 959400, 965230, G04530

ICD-10 CrossRefM48.01-M48.03, M48.061, M48.062, M50.00, M50.01, M50.03, M99.20, M99.21, M99.30, M99.31, M99.40, M99.41, M99.50, M99.51, M99.60, M99.61, M99.70, M99.71, T81.41XA-T81.41XS, T81.42XA-T81.42XS, T81.43XA-T81.43XS, T81.49XA-T81.49XS

+20938Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

Clinical responsibilityWhen the patient is appropriately prepped and anesthetized for a spinal surgery procedure, the provider fills in bony defects during the surgical procedure with autograft material obtained through a separate incision. She selects and prepares the donor area, typically the iliac crest, rib, or femoral head. She makes a longitudinal, or lengthwise, incision. She incises and retracts superficial skin, fascia, and muscles to expose the bone for grafting. She localizes the donor site and uses an osteotome or bone shaver to pull the graft. She obtains sufficient bone pieces for the graft and then closes the donor site incision by suturing it in a layered fashion. She then prepares the autograft outside the patient's body. She uses a rongeur and bone shaver to form the structural

autograft material into small triangular, rectangular, or oval shapes, which allow customized filling of the spinal bone defects. After completing the grafting portion of the procedure, she turns her attention to the remainder of the spinal surgery procedure.

Coding tipsCode 20938 is an add-on code describing preparation and application of structural autograft through a separate skin incision and must be reported with an allowable primary spinal procedure code.

You should never append modifier 50, Bilateral procedure, to 20938. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply. If the procedure is performed bilaterally, report the code number twice.

Illustration

TrephineBone graft is

harvested from fibula

Fibula

Tibia

Reshaped fibulatricortical blockused as spinal

graft

+20938

Fee Schedulemedicare Fees national Conversion Factor: 36.0896, Facility: $192.72, Non Facility:



uSCu

loSk

eletal SyStem

+20939 — 20950

+20939 — 20950

$192.72, OPPS Facility: $108.99, OPPS Non Facility: $108.99rVu Facility Work RVU: 3.02, PE RVU: 1.44, Malpractice RVU: 0.88, Total RVU: 5.34rVu non-Facility Work RVU: 3.02, PE RVU: 1.44, Malpractice RVU: 0.88, Total RVU: 5.34Indicators Preoperative: 0.00, Intraoperative: 0.00, Postoperative: 0.00, Total RVU: 0, Global Period: ZZZ, Radiology Diagnostic Test: 99, Code Status: A, PC/TC Indicator: 0, Endoscopic Base Code: None, MUE: 1modifier allowances 22, 52, 53, 58, 59, 62, 63, 76, 77, 78, 79, 80, 81, 82, 99, AQ, AR, AS, CR, ET, GA, GC, GJ, GR, KX, Q5, Q6, QJ, XE, XP, XS, XU

CCI Alerts (version 25.3)110101, 110111, 110121, 365910, 365920, 382200, 382211, 382220, 965230

ICD-10 CrossRefG95.81, G95.89, M47.21-M47.23, M47.811-M47.813, M47.891-M47.893, M50.20, M50.21, M50.220-M50.223, M50.23, M50.30, M50.31, M50.320-M50.323, M50.33, T81.41XA-T81.41XS, T81.42XA-T81.42XS, T81.43XA-T81.43XS, T81.49XA-T81.49XS

+20939Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)

Clinical responsibilityAfter appropriate preparation and anesthesia and during primary spinal surgery, the provider prepares the separate site from which to aspirate the bone marrow. The provider makes a small incision in the skin or through fascia adjacent to the primary site, through which a bone marrow aspiration needle is inserted. Once the marrow cavity is reached, bone marrow is aspirated (sucked up through the needle). The aspiration needle is removed, and the site checked for bleeding, which is controlled if there is any. The provider continues to perform the primary spinal procedure, transferring the bone marrow graft to fill the defect in the spine. Report this code for bone marrow aspiration (BMA) for bone grafting along with the primary procedure code for the spinal surgery.

Fee Schedulemedicare Fees national Conversion Factor: 36.0896, Facility: $73.26, Non Facility: $73.26, OPPS Facility: $41.86, OPPS Non Facility: $41.86rVu Facility Work RVU: 1.16, PE RVU: 0.56, Malpractice RVU: 0.31, Total RVU: 2.03rVu non-Facility Work RVU: 1.16, PE RVU: 0.56, Malpractice RVU: 0.31, Total RVU: 2.03Indicators Preoperative: 0.00, Intraoperative: 0.00, Postoperative: 0.00, Total RVU: 0, Global Period: ZZZ, Radiology Diagnostic Test: 99, Code Status: A, PC/TC Indicator: 0, Endoscopic Base Code: None, MUE: 1modifier allowances 22, 47, 50, 52, 53, 59, 76, 77, 78, 79, 80, 81, 82, AA, AD, AS, CR, ET, G8, G9, GA, GC, GJ, GR, LT, Q5, Q6, QK, QS, QX, QY, QZ, RT, SC, XE, XP, XS, XU

CCI Alerts (version 25.3)011120, 011200, 0213T0, 0216T0, 0228T0, 0230T0, 0232T1, 0481T1, 120011, 120021, 120041, 120051, 120061, 120071, 120111, 120131, 120141, 120151, 120161, 120171, 120181, 120201, 120211, 120311, 120321, 120341, 120351, 120361, 120371, 120411, 120421, 120441, 120451, 120461, 120471, 120511, 120521, 120531, 120541, 120551, 120561, 120571, 131001, 131011, 131021, 131201, 131211, 131221, 131311, 131321, 131331, 131511, 131521, 131531, 360001, 364001, 364051, 364061, 364101, 364201, 364251, 364301, 364401, 365910, 365920, 366001, 366401, 437521, 517011, 517021, 517031, 616501, 623200, 623210, 623220, 623230, 623240, 623250, 623260, 623270, 644000, 644020, 644050, 644080, 644100, 644130, 644150, 644160, 644170, 644180, 644200, 644210, 644250, 644300, 644350, 644450, 644460, 644470, 644480, 644490, 644501, 644610, 644620, 644630, 644790, 644800, 644830, 644840, 644860, 644870, 644880, 644890, 644900, 644910, 644920, 644930, 644940, 644950, 645050, 645100, 645170, 645200, 645300, 699900, 805001, 805021, 920121, 920141, 930001, 930051, 930101, 930401, 930411, 930421, 933181, 940021, 942001, 942501, 946801, 946811, 946901, 947701, 958121, 958131, 958161, 958191, 958221, 958291, 959551, 963601, 963611, 963651, 963661, 963671, 963681, 963721, 963741, 963751, 963761, 963771, 965230, 991550, 991560, 991570, 992111, 992121, 992131, 992141, 992151, 992171, 992181, 992191, 992201, 992211, 992221, 992231, 992311, 992321, 992331, 992341, 992351, 992361, 992381, 992391, 992411, 992421, 992431, 992441, 992451, 992511, 992521, 992531, 992541, 992551, 992911,

992921, 993041, 993051, 993061, 993071, 993081, 993091, 993101, 993151, 993161, 993341, 993351, 993361, 993371, 993471, 993481, 993491, 993501, 993741, 993751, 993771, 993781, J06701, J20011

ICD-10 CrossRefM43.01-M43.09, M43.11-M43.19,M47.011-M47.019, M47.021-M47.029, M47.11-M47.13, M47.26-M47.28,M47.816-M47.818, M47.896-M47.898, M48.01-M48.03, M48.061, M48.062, M51.14-M51.17, M51.36, M51.37, M54.14-M54.17, M99.20, M99.21, M99.30, M99.31, M99.40, M99.41, M99.50, M99.51, M99.60, M99.61, M99.70, M99.71, Q06.1-Q06.9, T81.41XA-T81.41XS, T81.42XA-T81.42XS, T81.43XA-T81.43XS, T81.49XA-T81.49XS

20950Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome

Clinical responsibilityWhen the patient is appropriately prepped and the area anesthetized, the provider inserts a needle or a wick catheter of a manometer, a pressure monitoring device, through the skin and into the muscle compartment in the affected extremity. She records the pressure reading from the monitoring device. She removes the needle and applies a sterile dressing to the insertion site.

Coding tipsExperts recommend reporting 20950 per extremity, per session. You should not report this code per compartment.

A provider measures compartment pressures in anterior and posterior compartments of bilateral legs. You should report 20950 RT, right side, followed by 20950 LT, left side.

If a provider repeats pressure measurement later on the same day, such as to test for exercise induced compartment syndrome, you may report those studies separately. Remember to append modifier 76, Repeat procedure or service by same physician or



uSC

ulo

Skel

eta

l Sy

Stem

2095

5 —

209

5520955 — 20955

other qualified health care professional, if the same provider repeats the procedure at a separate session on the same day.

Illustration

Pressure transducerrecorder

Catheter taped toskin

Muscle

Wick catheter inserted to check

interstitial fluid

Needle inserted into muscle

20950

Fee Schedulemedicare Fees national Conversion Factor: 36.0896, Facility: $92.39, Non Facility: $268.15, OPPS Facility: $45.47, OPPS Non Facility: $45.47rVu Facility Work RVU: 1.26, PE RVU: 1.07, Malpractice RVU: 0.23, Total RVU: 2.56rVu non-Facility Work RVU: 1.26, PE RVU: 5.94, Malpractice RVU: 0.23, Total RVU: 7.43Indicators Preoperative: 0.00, Intraoperative: 0.00, Postoperative: 0.00, Total RVU: 0, Global Period: 000, Radiology Diagnostic Test: 99, Code Status: A, PC/TC Indicator: 0, Endoscopic Base Code: None, MUE: 2modifier allowances 22, 47, 51, 52, 53, 58, 59, 63, 76, 77, 78, 79, 80, 81, 82, 99, AQ, AR, AS, CR, ET, GA, GC, GJ, GR, KX, LT, PD, Q5, Q6, QJ, RT, XE, XP, XS, XU

CCI Alerts (version 25.3)0213T0, 0216T0, 0228T0, 0230T0, 110001, 110011, 110041, 110051, 110061, 110101, 110111, 110121, 110421, 110431, 110441, 110451, 110461, 110471, 120011, 120021, 120041, 120051, 120061, 120071, 120111, 120131, 120141, 120151, 120161, 120171, 120181, 120201, 120211, 120311, 120321, 120341, 120351, 120361, 120371, 120411, 120421, 120441, 120451, 120461, 120471, 120511, 120521, 120531, 120541, 120551, 120561, 120571, 131001, 131011, 131021, 131201, 131211, 131221, 131311, 131321, 131331, 131511, 131521, 131531, 360001, 364001, 364051, 364061, 364101, 364201, 364251, 364301, 364401, 365910, 365920, 366001, 366401, 437521, 517011, 517021, 517031, 623200, 623210, 623220, 623230, 623240, 623250, 623260, 623270, 644000, 644020, 644050, 644080, 644100, 644130, 644150, 644160, 644170, 644180, 644200, 644210, 644250, 644300, 644350, 644450, 644460, 644470, 644480, 644490, 644501, 644610, 644620, 644630, 644790, 644800, 644830, 644840, 644860, 644870, 644880, 644890, 644900, 644910, 644920, 644930, 644940, 644950, 645050, 645100, 645170, 645200, 645300, 699900, 920121, 920141, 930001, 930051, 930101, 930401, 930411, 930421, 933181, 933551, 940021, 942001, 942501, 946801, 946811, 946901, 947701, 958121, 958131, 958161, 958191, 958221, 958291, 959071, 959081, 959091, 959101, 959111, 959121, 959131, 959551, 963601, 963611, 963651, 963661, 963671, 963681, 963721, 963741, 963751, 963761, 963771, 965230, 975971, 975981, 976021, 991550, 991560, 991570, 992111, 992121, 992131, 992141, 992151, 992171, 992181, 992191, 992201, 992211, 992221, 992231, 992311, 992321, 992331, 992341, 992351, 992361, 992381, 992391, 992411, 992421, 992431, 992441, 992451, 992511, 992521, 992531, 992541, 992551, 992911, 992921, 993041, 993051, 993061, 993071, 993081, 993091, 993101, 993151, 993161, 993341, 993351, 993361, 993371, 993471, 993481, 993491, 993501, 993741, 993751, 993771, 993781, 994460, 994470, 994480, 994490, 994510, 994520, 994951, 994961, G04631, G04711

ICD-10 CrossRefM62.00, M62.011-M62.019, M62.021-M62.029, M62.031-M62.039, M62.051-M62.059, M62.061-M62.069, M62.08, M62.10, M62.111-M62.119, M62.121-M62.129, M62.131-M62.139, M62.151-M62.159, M62.161-M62.169, M62.18, M62.20, M62.211-M62.219, M62.221-M62.229, M62.231-M62.239,

M62.251-M62.259, M62.261-M62.269, M62.28, M79.10, M79.18, M79.A11-M79.A19, M79.A21-M79.A29, M79.A3, M79.A9, S47.1XXA, S47.2XXA, S47.9XXA, S57.80XA, S57.81XA, S57.82XA, S77.00XA, S77.00XD, S77.01XA, S77.02XA, S77.10XA, S77.10XD, S77.11XA, S77.12XA, S77.20XA-S77.20XS, S77.21XA, S77.22XA, S87.80XA, S87.81XA, S87.82XA, T79.A0XA, T79.A11A, T79.A12A, T79.A19A, T79.A21A, T79.A22A, T79.A29A, T79.A3XA, T79.A9XA

20955Bone graft with microvascular anastomosis; fibula

Clinical responsibilityWhen the patient is appropriately prepped and anesthetized, the provider makes a longitudinal, or lengthwise, incision at the donor graft site over the soleus and the long fibular muscle of the leg. She extends the incision down to the level of fascia and muscle. She incises and retracts muscle tissue to expose the grafting area on the fibula. She localizes fibular bone and then dissects a piece of bone from the fibula in a proximal and distal osteotomy. She takes extra care to preserve and dissect the vascular blood supply along with the dissected bone. She ensures satisfactory preparation of the bone graft along with intact vascular supply and then sutures the donor site in a layered fashion. She then turns her attention to the recipient site. She brings the extracted graft into the operative field of the recipient site. She performs microvascular anastomosis, ligating, or attaching, the vascular supply of the bone graft to the bone of the recipient site. She then fits the bone graft into the defect area of the recipient site. She affixes the bone graft to the site with bone plates, screws, and bone paste. She closes the recipient site using layered sutures.

Coding tipsProviders sometimes combine hip core decompression, 27299, Unlisted procedure, pelvis or hip joint, reported with S2325, Hip core decompression, along with other procedures such as nonvascularized or vascularized bone grafts or electromagnetic treatment in hopes of stimulating formation of new bone tissue. Watch for opportunities to also report 20955, based on the type of bone graft.



uSCu

loSk

eletal SyStem

20956 — 20956

20956 — 20956

Illustration

Fibula bone graft is harvested fromthe donor site

Blood vessels areanastomosed to provide

blood flow to grafted bone

Grafted bone

Fibula bone graftis grafted intorecipient site

20955

Fee Schedulemedicare Fees national Conversion Factor: 36.0896, Facility: $2,562.00, Non Facility: $2,562.00, OPPS Facility: $1,452.97, OPPS Non Facility: $1,452.97rVu Facility Work RVU: 40.26, PE RVU: 24.73, Malpractice RVU: 6.00, Total RVU: 70.99rVu non-Facility Work RVU: 40.26, PE RVU: 24.73, Malpractice RVU: 6.00, Total RVU: 70.99Indicators Preoperative: 10.00, Intraoperative: 69.00, Postoperative: 21.00, Total RVU: 100, Global Period: 090, Radiology Diagnostic Test: 99, Code Status: A, PC/TC Indicator: 0, Endoscopic Base Code: None, MUE: 1modifier allowances 22, 51, 52, 53, 54, 55, 56, 58, 59, 62, 63, 76, 77, 78, 79, 80, 81, 82, 99, AQ, AR, AS, CR, CS, ET, GA, GC, GJ, GR, KX, LT, Q5, Q6, QJ, RT, XE, XP, XS, XU

CCI Alerts (version 25.3)0213T0, 0216T0, 0228T0, 0230T0, 120011, 120021, 120041, 120051, 120061, 120071, 120111, 120131, 120141, 120151, 120161, 120171, 120181, 120201, 120211, 120311, 120321, 120341, 120351, 120361, 120371, 120411, 120421, 120441, 120451, 120461, 120471, 120511, 120521, 120531, 120541, 120551, 120561, 120571, 131001, 131011, 131021, 131201, 131211, 131221, 131311,

131321, 131331, 131511, 131521, 131531, 209331, 352011, 352061, 352071, 352261, 360001, 364001, 364051, 364061, 364101, 364201, 364251, 364301, 364401, 365910, 365920, 366001, 366401, 437521, 517011, 517021, 517031, 623200, 623210, 623220, 623230, 623240, 623250, 623260, 623270, 644000, 644020, 644050, 644080, 644100, 644130, 644150, 644160, 644170, 644180, 644200, 644210, 644250, 644300, 644350, 644450, 644460, 644470, 644480, 644490, 644501, 644610, 644620, 644630, 644790, 644800, 644830, 644840, 644860, 644870, 644880, 644890, 644900, 644910, 644920, 644930, 644940, 644950, 645050, 645100, 645170, 645200, 645300, 699900, 920121, 920141, 930001, 930051, 930101, 930401, 930411, 930421, 933181, 933551, 940021, 942001, 942501, 946801, 946811, 946901, 947701, 958121, 958131, 958161, 958191, 958221, 958291, 959551, 963601, 963611, 963651, 963661, 963671, 963681, 963721, 963741, 963751, 963761, 963771, 965230, 991550, 991560, 991570, 992111, 992121, 992131, 992141, 992151, 992171, 992181, 992191, 992201, 992211, 992221, 992231, 992311, 992321, 992331, 992341, 992351, 992361, 992381, 992391, 992411, 992421, 992431, 992441, 992451, 992511, 992521, 992531, 992541, 992551, 992911, 992921, 993041, 993051, 993061, 993071, 993081, 993091, 993101, 993151, 993161, 993341, 993351, 993361, 993371, 993471, 993481, 993491, 993501, 993741, 993751, 993771, 993781, 994460, 994470, 994480, 994490, 994510, 994520, 994950, 994960, G04631, G04711

ICD-10 CrossRefC40.00-C40.02, C41.1, C41.2, C79.51, C79.52, D16.4, D16.5, D49.2, K09.0, M26.00-M26.02, M26.04, M26.05, M26.06, M26.07, M26.09, M26.11, M26.12, M26.19, M26.69, M26.71-M26.74, M26.74, M27.1, M27.2, M27.40, M27.49, M27.8, M46.30, M84.369S, M84.376S, M84.40XS, M84.453S, M84.469S, M84.48XS, M84.750S, M86.38, M86.39, M86.48, M86.49, M86.58, M86.59, M86.68, M86.69, M86.8X0, M86.8X8, M86.9, M87.08, M87.180, M89.70-M89.79, M89.711-M89.719, M89.721-M89.729, M89.731-M89.739, M89.741-M89.749, M89.751-M89.759, M89.761-M89.769, M89.771-M89.779, M90.80, M90.89, M97.21XA, M97.22XA, S02.0XXS, S02.101S, S02.102S, S02.109S, S02.110S, S02.111S, S02.112S, S02.113S, S02.118S, S02.119S, S02.11AS, S02.11BS, S02.11CS, S02.11DS, S02.11ES, S02.11FS, S02.11GS, S02.11HS, S02.19XS, S02.2XXS, S02.30XS, S02.31XS, S02.32XS, S02.400S, S02.401S, S02.402S,

S02.40AS, S02.40BS, S02.40CS, S02.40DS, S02.40ES, S02.40FS, S02.411S, S02.412S, S02.413S, S02.42XS, S02.5XXS, S02.600S, S02.601S, S02.602S, S02.609S, S02.610S, S02.611S, S02.612S, S02.620S, S02.621S, S02.622S, S02.630S, S02.631S, S02.632S, S02.640S, S02.641S, S02.642S, S02.650S, S02.651S, S02.652S, S02.66XS, S02.670S, S02.671S, S02.672S, S02.69XS, S02.80XS, S02.81XS, S02.82XS, S02.91XK, S02.91XS, S02.92XK, S02.92XS, S07.0XXA, S07.1XXA, S07.8XXA, S07.9XXA, S12.000K, S12.001K, S12.100K, S12.101K, S12.200K, S12.201K, S12.300K, S12.301K, S12.400K, S12.401K, S12.500K, S12.501K, S12.600K, S12.601K, S12.9XXS, S22.009S, S22.9XXK, S22.9XXS, S32.9XXK, S32.9XXS, S42.009K, S42.009P, S42.209K, S42.209P, S42.90XK, S42.90XP, S52.90XK-S52.90XM, S52.90XN, S52.90XP, S52.90XQ, S52.90XR, S62.90XK, S62.90XP, S72.90XK-S72.90XM, S72.90XN, S72.90XP, S72.90XQ, S72.90XR, S79.009S, S82.009P-S82.009Q, S82.009R, S82.009S, S82.90XK-S82.90XM, S82.90XN, S82.90XP, S82.90XQ, S82.90XR, S82.90XS, S92.819K-S92.819P, S92.819S, S92.909K-S92.909P, S92.909S, S92.919K-S92.919P, S92.919S, S99.209K-S99.209P, S99.209S, S99.219K-S99.219P, S99.219S, S99.229K-S99.229P, S99.229S, S99.239K-S99.239P, S99.239S, S99.249K-S99.249P, S99.249S, S99.299K-S99.299P, S99.299S

20956Bone graft with microvascular anastomosis; iliac crest

Clinical responsibilityWhen the patient is appropriately prepped and anesthetized, the provider makes an incision in the skin of the hip over the iliac crest. He extends the incision down to bone. He excises a piece of bone, taking care to dissect and preserve the vascular supply along with the dissected bone graft. He then makes an incision at the recipient site, dissecting down to bone, while preserving the vascular supply in the area. He places the graft in position and uses an operating microscope to view the site as he joins the small arteries and veins in the graft to the local vessels. He closes both the donor and recipient sites with layered sutures following successful placement of the graft.



uSC

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2095

7 —

209

5720957 — 20957

Illustration

Blood vessels areanastomosed to

provide blood flow tografted bone

Grafted bone

Iliac crestbone graft is

harvested fromthe donor site

Iliac crest bone graft is grafted into recipient site

20956

Fee Schedulemedicare Fees national Conversion Factor: 36.0896, Facility: $2,761.58, Non Facility: $2,761.58, OPPS Facility: $1,486.17, OPPS Non Facility: $1,486.17rVu Facility Work RVU: 41.18, PE RVU: 27.18, Malpractice RVU: 8.16, Total RVU: 76.52rVu non-Facility Work RVU: 41.18, PE RVU: 27.18, Malpractice RVU: 8.16, Total RVU: 76.52Indicators Preoperative: 10.00, Intraoperative: 69.00, Postoperative: 21.00, Total RVU: 100, Global Period: 090, Radiology Diagnostic Test: 99, Code Status: A, PC/TC Indicator: 0, Endoscopic Base Code: None, MUE: 1modifier allowances 22, 51, 52, 53, 54, 55, 56, 58, 59, 62, 63, 76, 77, 78, 79, 80, 81, 82, 99, AQ, AR, AS, CR, CS, ET, GA, GC, GJ, GR, KX, LT, Q5, Q6, QJ, RT, XE, XP, XS, XU

CCI Alerts (version 25.3)0213T0, 0216T0, 0228T0, 0230T0, 0424T1, 0427T1, 0428T1, 0431T1, 119001, 119011, 120011, 120021, 120041, 120051, 120061, 120071, 120111, 120131, 120141, 120151, 120161, 120171, 120181, 120201, 120211, 120311, 120321, 120341, 120351, 120361, 120371, 120411, 120421, 120441, 120451, 120461, 120471, 120511, 120521, 120531, 120541, 120551, 120561, 120571, 131001, 131011, 131021, 131201, 131211, 131221, 131311, 131321, 131331, 131511, 131521, 131531, 158510, 158521, 158601, 205001, 205011, 209001, 209021, 209331, 209700, 290001, 290100, 290151, 290350, 290400, 290440, 290460, 293051, 293251, 297001, 297051, 297101, 297200, 297301, 352011,

352071, 352261, 357001, 357411, 357611, 360001, 364001, 364051, 364061, 364101, 364201, 364251, 364301, 364401, 365910, 365920, 366001, 366401, 376171, 376181, 437521, 517011, 517021, 517031, 623200, 623210, 623220, 623230, 623240, 623250, 623260, 623270, 644000, 644020, 644050, 644080, 644100, 644130, 644150, 644160, 644170, 644180, 644200, 644210, 644250, 644300, 644350, 644450, 644460, 644470, 644480, 644490, 644501, 644610, 644620, 644630, 644790, 644800, 644830, 644840, 644860, 644870, 644880, 644890, 644900, 644910, 644920, 644930, 644940, 644950, 645050, 645100, 645170, 645200, 645300, 645531, 645551, 645751, 645801, 645851, 645901, 645951, 647021, 647041, 647081, 647121, 647131, 647141, 647161, 647181, 647191, 647211, 647221, 647261, 699900, 757101, 757161, 758201, 758221, 760001, 770011, 770021, 870700, 870760, 870770, 871020, 920121, 920141, 930001, 930051, 930101, 930401, 930411, 930421, 933181, 933551, 940021, 942001, 942501, 946801, 946811, 946901, 947701, 958121, 958131, 958161, 958191, 958221, 958291, 958601, 959071, 959081, 959091, 959101, 959111, 959121, 959131, 959551, 963601, 963611, 963651, 963661, 963671, 963681, 963721, 963741, 963751, 963761, 963771, 965230, 991550, 991560, 991570, 992111, 992121, 992131, 992141, 992151, 992171, 992181, 992191, 992201, 992211, 992221, 992231, 992311, 992321, 992331, 992341, 992351, 992361, 992381, 992391, 992411, 992421, 992431, 992441, 992451, 992511, 992521, 992531, 992541, 992551, 992911, 992921, 993041, 993051, 993061, 993071, 993081, 993091, 993101, 993151, 993161, 993341, 993351, 993361, 993371, 993471, 993481, 993491, 993501, 993741, 993751, 993771, 993781, 994460, 994470, 994480, 994490, 994510, 994520, 994950, 994960, G01681, G04631, G04711

ICD-10 CrossRefA18.01, A18.03, C05.0-C05.9, C40.00-C40.02, C40.10-C40.12, C40.20-C40.22, C40.30-C40.32, C41.0-C41.4, C79.51, C79.52, C7B.03, D16.00-D16.02, D16.10-D16.12, D16.20-D16.22, D16.30-D16.32, D16.4-D16.8, D48.0, D49.2, K09.0, M26.00-M26.02, M26.04, M26.05, M26.06, M26.07, M26.09, M26.11, M26.12, M26.19, M26.69, M26.73, M26.74, M27.1, M27.2, M27.40, M27.49, M27.8, M48.50XA, M48.51XA, M48.52XA, M48.53XA, M48.54XA, M48.55XA, M48.56XA, M48.57XA, M48.58XA, M80.08XA, M80.88XA, M84.48XA, M84.58XA, M84.68XA, M86.311-M86.319, M86.321-M86.329,

M86.331-M86.339, M86.341-M86.349, M86.351-M86.359, M86.361-M86.369, M86.371-M86.379, M86.38, M86.39, M86.411-M86.419, M86.421-M86.429, M86.431-M86.439, M86.441-M86.449, M86.451-M86.459, M86.461-M86.469, M86.471-M86.479, M86.48, M86.49, M86.511-M86.519, M86.521-M86.529, M86.531-M86.539, M86.541-M86.549, M86.551-M86.559, M86.561-M86.569, M86.571-M86.579, M86.58, M86.59, M86.611-M86.619, M86.621-M86.629, M86.631-M86.639, M86.641-M86.649, M86.651-M86.659, M86.661-M86.669, M86.671-M86.679, M86.68, M86.69, M86.8X0-M86.8X8, M86.8X3, M86.8X4, M86.8X5, M86.8X6, M86.8X7, M86.8X8, M86.9, M87.08, M87.180, M89.70-M89.79, M89.711-M89.719, M89.721-M89.729, M89.731-M89.739, M89.741-M89.749, M89.751-M89.759, M89.761-M89.769, M89.771-M89.779, M90.811-M90.819, M90.821-M90.829, M90.831-M90.839, M90.841-M90.849, M90.851-M90.859, M90.861-M90.869, M90.871-M90.879, M90.88, M90.89, Q68.8, Q75.0-Q75.9, Q76.0-Q76.2, Q76.411-Q76.419, Q76.49, Q76.6, Q76.7, Q76.8, Q76.9, Q77.0-Q77.2, Q77.4, Q77.5, Q77.6, Q77.7, Q77.8, Q77.9, Q78.0-Q78.4, Q78.8, Q79.8, Q79.9, Q87.0, S01.421A, S01.422A, S01.429A, S01.441A, S01.442A, S01.449A, S01.522A, S01.542A, S07.0XXA, S07.1XXA, S07.8XXA, S07.9XXA, Z85.830

20957Bone graft with microvascular anastomosis; metatarsal

Clinical responsibilityWhen the patient is appropriately prepped and anesthetized, the provider makes a longitudinal, or lengthwise, incision at the donor graft site over the metatarsal area of the foot. She extends the incision down to the level of fascia and muscle. She incises and retracts muscle tissue to expose the grafting area on a metatarsal bone. She localizes the metatarsal bone and then dissects a piece of bone from the metatarsal in a proximal and distal osteotomy. She takes extra care to preserve and dissect the vascular blood supply along with the dissected bone. She ensures satisfactory preparation of the bone graft along with intact vascular supply and then sutures the donor site in a layered fashion. She then turns her attention to the recipient site. She

1701

ICD-10 Cro

ssref Deta

Ilsa

01.04 — a

52.05

ICD-10 CrossRef Detailsa01.04 Typhoid arthritisa01.05 Typhoid osteomyelitisa01.09 Typhoid fever with other complicationsa02.21 Salmonella meningitisa02.22 Salmonella pneumoniaa06.5 Amebic lung abscessa06.6 Amebic brain abscessa15.0 Tuberculosis of lunga15.4 Tuberculosis of intrathoracic lymph nodesa15.5 Tuberculosis of larynx, trachea and bronchusa15.6 Tuberculous pleurisya15.7 Primary respiratory tuberculosisa15.8 Other respiratory tuberculosisa15.9 Respiratory tuberculosis unspecifieda17.0 Tuberculous meningitisa17.1 Meningeal tuberculomaa17.81 Tuberculoma of brain and spinal corda17.82 Tuberculous meningoencephalitisa17.83 Tuberculous neuritisa17.89 Other tuberculosis of nervous systema17.9 Tuberculosis of nervous system, unspecifieda18.01 Tuberculosis of spinea18.02 Tuberculous arthritis of other jointsa18.03 Tuberculosis of other bonesa18.09 Other musculoskeletal tuberculosisa18.10 Tuberculosis of genitourinary system, unspecifieda18.11 Tuberculosis of kidney and uretera18.12 Tuberculosis of bladdera18.13 Tuberculosis of other urinary organsa18.14 Tuberculosis of prostatea18.15 Tuberculosis of other male genital organsa18.16 Tuberculosis of cervixa18.17 Tuberculous female pelvic inflammatory diseasea18.18 Tuberculosis of other female genital organsa18.2 Tuberculous peripheral lymphadenopathya18.31 Tuberculous peritonitisa18.32 Tuberculous enteritisa18.39 Retroperitoneal tuberculosisa18.50 Tuberculosis of eye, unspecifieda18.51 Tuberculous episcleritisa18.52 Tuberculous keratitisa18.53 Tuberculous chorioretinitisa18.54 Tuberculous iridocyclitisa18.59 Other tuberculosis of eyea18.6 Tuberculosis of (inner) (middle) eara18.81 Tuberculosis of thyroid glanda18.84 Tuberculosis of hearta18.89 Tuberculosis of other sitesa19.2 Acute miliary tuberculosis, unspecifieda19.8 Other miliary tuberculosisa19.9 Miliary tuberculosis, unspecifieda20.0 Bubonic plaguea20.2 Pneumonic plaguea20.7 Septicemic plaguea21.1 Oculoglandular tularemiaa21.2 Pulmonary tularemiaa22.1 Pulmonary anthraxa22.9 Anthrax, unspecifieda23.0 Brucellosis due to Brucella melitensisa23.1 Brucellosis due to Brucella abortusa23.2 Brucellosis due to Brucella suisa23.3 Brucellosis due to Brucella canisa27.0 Leptospirosis icterohemorrhagicaa27.81 Aseptic meningitis in leptospirosisa27.89 Other forms of leptospirosisa28.0 Pasteurellosisa28.8 Other specified zoonotic bacterial diseases, not elsewhere classifieda28.9 Zoonotic bacterial disease, unspecifieda30.0 Indeterminate leprosya31.0 Pulmonary mycobacterial infectiona31.8 Other mycobacterial infectionsa32.0 Cutaneous listeriosisa32.11 Listerial meningitisa32.12 Listerial meningoencephalitisa32.7 Listerial sepsisa32.81 Oculoglandular listeriosisa32.82 Listerial endocarditisa32.89 Other forms of listeriosisa32.9 Listeriosis, unspecified

a34 Obstetrical tetanusa36.0 Pharyngeal diphtheriaa36.1 Nasopharyngeal diphtheriaa36.2 Laryngeal diphtheriaa36.89 Other diphtheritic complicationsa37.00 Whooping cough due to Bordetella pertussis without pneumoniaa37.01 Whooping cough due to Bordetella pertussis with pneumoniaa37.10 Whooping cough due to Bordetella parapertussis without pneumoniaa37.11 Whooping cough due to Bordetella parapertussis with pneumoniaa37.80 Whooping cough due to other Bordetella species without pneumoniaa37.81 Whooping cough due to other Bordetella species with pneumoniaa37.90 Whooping cough, unspecified species without pneumoniaa37.91 Whooping cough, unspecified species with pneumoniaa38.8 Scarlet fever with other complicationsa39.0 Meningococcal meningitisa39.1 Waterhouse-Friderichsen syndromea39.2 Acute meningococcemiaa39.3 Chronic meningococcemiaa39.4 Meningococcemia, unspecifieda39.50 Meningococcal carditis, unspecifieda39.51 Meningococcal endocarditisa39.52 Meningococcal myocarditisa39.53 Meningococcal pericarditisa39.81 Meningococcal encephalitisa39.82 Meningococcal retrobulbar neuritisa39.83 Meningococcal arthritisa39.84 Postmeningococcal arthritisa39.89 Other meningococcal infectionsa39.9 Meningococcal infection, unspecifieda40.3 Sepsis due to Streptococcus pneumoniaea40.9 Streptococcal sepsis, unspecifieda41.01 Sepsis due to Methicillin susceptible Staphylococcus aureusa41.02 Sepsis due to Methicillin resistant Staphylococcus aureusa41.1 Sepsis due to other specified staphylococcusa41.2 Sepsis due to unspecified staphylococcusa41.3 Sepsis due to Hemophilus influenzaea41.4 Sepsis due to anaerobesa41.50 Gram-negative sepsis, unspecifieda41.51 Sepsis due to Escherichia coli [E. coli]a41.52 Sepsis due to Pseudomonasa41.53 Sepsis due to Serratiaa41.59 Other Gram-negative sepsisa41.89 Other specified sepsisa41.9 Sepsis, unspecified organisma42.0 Pulmonary actinomycosisa42.2 Cervicofacial actinomycosisa42.82 Actinomycotic encephalitisa42.89 Other forms of actinomycosisa43.0 Pulmonary nocardiosisa43.8 Other forms of nocardiosisa48.1 Legionnaires' diseasea50.30 Late congenital syphilitic oculopathy, unspecifieda50.32 Late congenital syphilitic chorioretinitisa50.40 Late congenital neurosyphilis, unspecifieda50.41 Late congenital syphilitic meningitisa50.42 Late congenital syphilitic encephalitisa50.43 Late congenital syphilitic polyneuropathya50.44 Late congenital syphilitic optic nerve atrophya50.45 Juvenile general paresisa50.49 Other late congenital neurosyphilisa50.51 Clutton's jointsa50.52 Hutchinson's teetha50.53 Hutchinson's triada50.54 Late congenital cardiovascular syphilisa50.55 Late congenital syphilitic arthropathya50.56 Late congenital syphilitic osteochondropathya50.57 Syphilitic saddle nosea50.59 Other late congenital syphilis, symptomatica51.41 Secondary syphilitic meningitisa51.44 Secondary syphilitic nephritisa51.45 Secondary syphilitic hepatitisa51.46 Secondary syphilitic osteopathya51.49 Other secondary syphilitic conditionsa52.00 Cardiovascular syphilis, unspecifieda52.01 Syphilitic aneurysm of aortaa52.02 Syphilitic aortitisa52.03 Syphilitic endocarditisa52.04 Syphilitic cerebral arteritisa52.05 Other cerebrovascular syphilis

1702

ICD-10 CrossRef DetailsCoders’ Specialty Guide 2021: OrthopedicsIC

D-1

0 Cr

oss

ref

Det

aIl

sa

52.0

6 —

B40

.2a52.06 — B40.2

a52.06 Other syphilitic heart involvementa52.09 Other cardiovascular syphilisa52.10 Symptomatic neurosyphilis, unspecifieda52.11 Tabes dorsalisa52.12 Other cerebrospinal syphilisa52.13 Late syphilitic meningitisa52.14 Late syphilitic encephalitisa52.15 Late syphilitic neuropathya52.16 Charcot's arthropathy (tabetic)a52.17 General paresisa52.19 Other symptomatic neurosyphilisa52.2 Asymptomatic neurosyphilisa52.3 Neurosyphilis, unspecifieda52.72 Syphilis of lung and bronchusa52.78 Syphilis of other musculoskeletal tissuea54.41 Gonococcal spondylopathya54.49 Gonococcal infection of other musculoskeletal tissuea54.81 Gonococcal meningitisa54.82 Gonococcal brain abscessa54.83 Gonococcal heart infectiona54.89 Other gonococcal infectionsa69.0 Necrotizing ulcerative stomatitisa80.0 Acute paralytic poliomyelitis, vaccine-associateda80.1 Acute paralytic poliomyelitis, wild virus, importeda80.2 Acute paralytic poliomyelitis, wild virus, indigenousa80.30 Acute paralytic poliomyelitis, unspecifieda80.39 Other acute paralytic poliomyelitisa80.4 Acute nonparalytic poliomyelitisa80.9 Acute poliomyelitis, unspecifieda81.00 Creutzfeldt-Jakob disease, unspecifieda81.01 Variant Creutzfeldt-Jakob diseasea81.09 Other Creutzfeldt-Jakob diseasea81.1 Subacute sclerosing panencephalitisa81.2 Progressive multifocal leukoencephalopathya81.81 Kurua81.82 Gerstmann-Straussler-Scheinker syndromea81.83 Fatal familial insomniaa81.89 Other atypical virus infections of central nervous systema81.9 Atypical virus infection of central nervous system, unspecifieda82.0 Sylvatic rabiesa82.1 Urban rabiesa82.9 Rabies, unspecifieda83.0 Japanese encephalitisa83.1 Western equine encephalitisa83.2 Eastern equine encephalitisa83.3 St Louis encephalitisa83.4 Australian encephalitisa83.5 California encephalitisa83.6 Rocio virus diseasea83.8 Other mosquito-borne viral encephalitisa83.9 Mosquito-borne viral encephalitis, unspecifieda84.0 Far Eastern tick-borne encephalitis [Russian spring-summer

encephalitis]a84.1 Central European tick-borne encephalitisa84.8 Other tick-borne viral encephalitisa84.9 Tick-borne viral encephalitis, unspecifieda85.0 Enteroviral encephalitisa85.1 Adenoviral encephalitisa85.2 Arthropod-borne viral encephalitis, unspecifieda85.8 Other specified viral encephalitisa86 Unspecified viral encephalitisa87.0 Enteroviral meningitisa87.1 Adenoviral meningitisa87.2 Lymphocytic choriomeningitisa87.8 Other viral meningitisa87.9 Viral meningitis, unspecifieda88.0 Enteroviral exanthematous fever [Boston exanthem]a88.1 Epidemic vertigoa88.8 Other specified viral infections of central nervous systema89 Unspecified viral infection of central nervous systema92.2 Venezuelan equine fevera92.30 West Nile virus infection, unspecifieda92.31 West Nile virus infection with encephalitisa92.32 West Nile virus infection with other neurologic manifestationa92.39 West Nile virus infection with other complicationsB00.3 Herpesviral meningitisB00.4 Herpesviral encephalitisB00.50 Herpesviral ocular disease, unspecifiedB00.51 Herpesviral iridocyclitisB00.52 Herpesviral keratitisB00.53 Herpesviral conjunctivitisB00.59 Other herpesviral disease of eyeB00.7 Disseminated herpesviral diseaseB00.82 Herpes simplex myelitisB01.11 Varicella encephalitis and encephalomyelitis

B01.2 Varicella pneumoniaB01.89 Other varicella complicationsB01.9 Varicella without complicationB02.0 Zoster encephalitisB02.1 Zoster meningitisB02.21 Postherpetic geniculate ganglionitisB02.22 Postherpetic trigeminal neuralgiaB02.23 Postherpetic polyneuropathyB02.24 Postherpetic myelitisB02.29 Other postherpetic nervous system involvementB02.30 Zoster ocular disease, unspecifiedB02.31 Zoster conjunctivitisB02.32 Zoster iridocyclitisB02.33 Zoster keratitisB02.34 Zoster scleritisB02.39 Other herpes zoster eye diseaseB02.7 Disseminated zosterB02.8 Zoster with other complicationsB02.9 Zoster without complicationsB05.0 Measles complicated by encephalitisB05.2 Measles complicated by pneumoniaB05.3 Measles complicated by otitis mediaB05.4 Measles with intestinal complicationsB05.89 Other measles complicationsB05.9 Measles without complicationB06.00 Rubella with neurological complication, unspecifiedB06.01 Rubella encephalitisB06.02 Rubella meningitisB06.09 Other neurological complications of rubellaB06.81 Rubella pneumoniaB06.89 Other rubella complicationsB06.9 Rubella without complicationB15.0 Hepatitis A with hepatic comaB16.0 Acute hepatitis B with delta-agent with hepatic comaB16.2 Acute hepatitis B without delta-agent with hepatic comaB17.0 Acute delta-(super) infection of hepatitis B carrierB17.11 Acute hepatitis C with hepatic comaB17.2 Acute hepatitis EB18.0 Chronic viral hepatitis B with delta-agentB18.1 Chronic viral hepatitis B without delta-agentB19.0 Unspecified viral hepatitis with hepatic comaB19.11 Unspecified viral hepatitis B with hepatic comaB19.20 Unspecified viral hepatitis C without hepatic comaB19.21 Unspecified viral hepatitis C with hepatic comaB20 Human immunodeficiency virus [HIV] diseaseB25.0 Cytomegaloviral pneumonitisB25.1 Cytomegaloviral hepatitisB25.2 Cytomegaloviral pancreatitisB25.9 Cytomegaloviral disease, unspecifiedB26.1 Mumps meningitisB26.2 Mumps encephalitisB26.84 Mumps polyneuropathyB26.89 Other mumps complicationsB26.9 Mumps without complicationB27.00 Gammaherpesviral mononucleosis without complicationB27.09 Gammaherpesviral mononucleosis with other complicationsB27.10 Cytomegaloviral mononucleosis without complicationsB27.19 Cytomegaloviral mononucleosis with other complicationB27.80 Other infectious mononucleosis without complicationB27.89 Other infectious mononucleosis with other complicationB27.90 Infectious mononucleosis, unspecified without complicationB27.99 Infectious mononucleosis, unspecified with other complicationB33.20 Viral carditis, unspecifiedB33.21 Viral endocarditisB33.22 Viral myocarditisB33.23 Viral pericarditisB37.1 Pulmonary candidiasisB37.5 Candidal meningitisB37.6 Candidal endocarditisB37.7 Candidal sepsisB38.0 Acute pulmonary coccidioidomycosisB38.1 Chronic pulmonary coccidioidomycosisB38.2 Pulmonary coccidioidomycosis, unspecifiedB38.3 Cutaneous coccidioidomycosisB38.4 Coccidioidomycosis meningitisB39.0 Acute pulmonary histoplasmosis capsulatiB39.1 Chronic pulmonary histoplasmosis capsulatiB39.2 Pulmonary histoplasmosis capsulati, unspecifiedB39.3 Disseminated histoplasmosis capsulatiB39.4 Histoplasmosis capsulati, unspecifiedB39.5 Histoplasmosis duboisiiB39.9 Histoplasmosis, unspecifiedB40.0 Acute pulmonary blastomycosisB40.1 Chronic pulmonary blastomycosisB40.2 Pulmonary blastomycosis, unspecified

2065

Mo

difier d

escriptors

22 — A

i

CPT® is a registered trademark of the American Medical Association. All rights reserved. CPT © 2020 American Medical Association. All rights reserved.

Modifier DescriptorsModifier description

cpt® Modifiers

22 Increased Procedural Services

23 Unusual Anesthesia

24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

26 Professional Component

27 Multiple Outpatient Hospital E/M Encounters on the Same Date

32 Mandated Services

33 Preventive Services

47 Anesthesia by Surgeon

50 Bilateral Procedure

51 Multiple Procedures

52 Reduced Services

53 Discontinued Procedure

54 Surgical Care Only

55 Postoperative Management Only

56 Preoperative Management Only

57 Decision for Surgery

58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

59 Distinct Procedural Service

62 Two Surgeons

63 Procedure Performed on Infants less than 4 kg

66 Surgical Team

73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia

74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia

76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional

77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional

78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

Modifier description

79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

80 Assistant Surgeon

81 Minimum Assistant Surgeon

82 Assistant Surgeon (when qualified resident surgeon not available)

90 Reference (Outside) Laboratory

91 Repeat Clinical Diagnostic Laboratory Test

92 Alternative Laboratory Platform Testing

95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System

96 Habilitative Services

97 Rehabilitative Services

99 Multiple Modifiers

category ii Modifiers

1p Performance Measure Exclusion Modifier due to Medical Reasons

2p Performance Measure Exclusion Modifier due to Patient Reasons

3p Performance Measure Exclusion Modifier due to System Reasons

8p Performance Measure Reporting Modifier - Action Not Performed, Reason Not Otherwise Specified

Hcpcs Modifiers

A1 Dressing for one wound

A2 Dressing for two wounds

A3 Dressing for three wounds

A4 Dressing for four wounds

A5 Dressing for five wounds

A6 Dressing for six wounds

A7 Dressing for seven wounds

A8 Dressing for eight wounds

A9 Dressing for nine or more wounds

AA Anesthesia services performed personally by anesthesiologist

Ad Medical supervision by a physician: more than four concurrent anesthesia procedures

Ae Registered dietician

Af Specialty physician

AG Primary physician

AH Clinical psychologist

Ai Principal physician of record

2066

Modifier DescriptorsCoders’ Specialty Guide 2021: OrthopedicsM

od

ifie

r d

escr

ipto

rsA

J — e

dAJ — ed

CPT® is a registered trademark of the American Medical Association. All rights reserved. CPT © 2020 American Medical Association. All rights reserved.


AJ Clinical social worker

AK Non participating physician

AM Physician, team member service

Ao Alternate payment method declined by provider of service

Ap Determination of refractive state was not performed in the course of diagnostic ophthalmological examination

AQ Physician providing a service in an unlisted health professional shortage area (HPSA)

Ar Physician provider services in a physician scarcity area

As Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery

At Acute treatment (this modifier should be used when reporting service 98940, 98941, 98942)

AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply

AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic

AW Item furnished in conjunction with a surgical dressing

AX Item furnished in conjunction with dialysis services

AY Item or service furnished to an ESRD patient that is not for the treatment of ESRD

AZ Physician providing a service in a dental health professional shortage area for the purpose of an electronic health record incentive payment

BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services

BL Special acquisition of blood and blood products

Bo Orally administered nutrition, not by feeding tube

Bp The beneficiary has been informed of the purchase and rental options and has elected to purchase the item

Br The beneficiary has been informed of the purchase and rental options and has elected to rent the item

BU The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier of his/her decision

cA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission

cB Service ordered by a renal dialysis facility (RDF) physician as part of the ESRD beneficiary’s dialysis benefit, is not part of the composite rate, and is separately reimbursable

cc Procedure code change (use ‘CC’ when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)

cd AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable


ce AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity

cf AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable

cG Policy criteria applied

cH 0 percent impaired, limited or restricted

ci At least 1 percent but less than 20 percent impaired, limited or restricted

cJ At least 20 percent but less than 40 percent impaired, limited or restricted

cK At least 40 percent but less than 60 percent impaired, limited or restricted

cL At least 60 percent but less than 80 percent impaired, limited or restricted

cM At least 80 percent but less than 100 percent impaired, limited or restricted

cN 100 percent impaired, limited or restricted

co Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

cQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant

cr Catastrophe/disaster related

cs Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean-up activities

ct Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard

dA Oral health assessment by a licensed health professional other than a dentist

e1 Upper left, eyelid

e2 Lower left, eyelid

e3 Upper right, eyelid

e4 Lower right, eyelid

eA Erythropoietic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy

eB Erythropoietic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy

ec Erythropoietic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy

ed Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 G/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle

2075

Termin

olo

gy

Abduction —

Alveolar bone

Terminology Terminology explanation

Abduction Movement of the body part away from the medial line of the body.

Abduction pillow or splint A medical device used to immobilize an extremity after a surgical procedure to help decrease the risk of a dislocation.

Abductor Muscle that draws a body part away from the midline of the body.

Abductor hallucis muscle Muscle of the great toe which draws it away from the body.

Abductor muscle of hip A group of muscles in the buttock that lifts the thigh out to the side.

Ablation Removal of tissue, a body part, or an organ or destruction of its function.

Abrasion arthroplasty Refinishing the surfaces of a joint through a grinding process.

Abscess A collection of pus in a walled off sac or pocket, caused by infection.

Abscess cavity Pocket formed due to the accumulation of purulent material, pus.

Accessory navicular bone An extra bone on the inner side of the foot that can cause irritation and require removal.

Acetabular rim Margin of the acetabulum.

Acetabulum A hollow cavity or socket within the hip bone that receives the ball at the top end of the femur, or thighbone.

Achilles Tendon at the heel, or calcaneal tendon.

Achilles tendon Large tendon at the back the heel that connects the muscles of the calf to the calcaneal bone, or heel; also called tendo calcaneus.

Acromioclavicular joint A joint between the acromion process of the scapula, or shoulder blade, and the clavicle, or collar bone.

Acromioclavicular, or AC, joint

Union of the acromion, a bony projection on the shoulder blade, and the clavicle, or collar bone.

Acromion A bony process, or projection, on the scapula, or shoulder blade, that extends over the joint.

Acromionectomy Surgical excision of the acromion, a bony projection on scapula, or shoulder blade, that extends over the joint.

Acromioplasty Surgical revision of the acromion, a bony projection on the end of the shoulder blade, to relieve compression on the rotator cuff.

Acute A medical condition or injury of sudden onset, sometimes severe in nature, and typically lasts a short period of time; opposite of chronic.

Adductor A muscle that helps a body part to move toward the centerline of the body or limb.

Adductor aponeurosis A thin band of tissue that separates the two ends of ulnar collateral ligaments.

Adductor muscle Group of muscles that pulls the body part towards the midline of the body.

Adductors A group of muscles of the thigh that moves the thigh toward the midline of the body.

Adductors of hip Group of muscles that moves the thigh toward the midline of the body.

Adhesiolysis Freeing up adhesions by cutting and dividing, typically with a combination of sharp and blunt dissection.

Adhesions Fibrous bands, which typically result from inflammation or injury during surgery, that form between tissues and organs; they may be thought of as internal scar tissue.

Advance directive A document which enables a person to make provision for his health care decisions in case if in the future, he becomes unable to make those decisions; include documents such as a living will and a medical power of attorney.

Algorithm A specific set of step-by-step calculations using defined inputs at each step to produce a useful output.

Allograft A tissue graft harvested from one person for another; donors include cadavers and living individuals related or unrelated to the recipient; also called allogeneic graft and homograft.

Alveolar bone The alveolar bone contains the tooth sockets; also called the alveolar ridge or alveolar process.

2076

TerminologyCoders’ Specialty Guide 2021: OrthopedicsTe

rmin

olo

gy

Alv

eola

r cle

ft —

Ant

iinfla

mm

ator

yAlveolar cleft — Antiinflammatory

Terminology explanation

Alveolar cleft Congenital defect in which a cleft, or gap, occurs in the alveolar arch, the tooth bearing portion of the jaw bone.

Ambulatory The ability to walk or suitability for walking.

Ambulatory care Medical care rendered in an outpatient setting, i.e., not requiring an overnight stay in a hospital.

Amputate Removal of a limb or digit.

Amputation Surgical removal of a body extremity, commonly to control pain or progression of a disease in the affected limb.

Analgesic Medicines that give relief from pain.

Anastomosis Connection between two structures, anatomical or surgically created, such as between two blood vessels or the colon after resection of a part; types of anastomoses include end to side and side to side.

Anatomic alignment Normal position; refers primarily to skeletal structures; malalignment refers to skeletal structures that are out of their normal position.

Anatomical neck humerus The portion of the humerus that separates the greater and lesser tubercles from the humeral head, or the forearm muscles.

Anatomical position The position of human body taken as a reference while explaining the orientation of body parts amongst themselves, the position includes the person standing with neck and spine erect, looking in front, square shoulders, arms by the side, and palms rotated to face forwards.

Anconeus A small muscle near the elbow.

Anesthesia A medication induced state that reduces or eliminates sensitivity to pain, depending upon the type of anesthesia administered; general anesthesia renders the patient completely unconscious, while local or regional anesthesia reduces sensation to pain in specific areas of the body.

Anesthetic Substance that reduces sensitivity to pain.

Aneurysm Weakness in the wall of a blood vessel or wall of a ventricle of the heart, typically the left ventricle, causing the wall to balloon out; sometimes requiring surgical excision or repair to prevent rupture.

Ankle joint Joint composed by the tibia, the fibula, and the talus.

Ankylosis A condition following an injury, surgery, or infection, which leads to stiffness or fusion, or permanent fixation, of a joint.

Annulus fibrosus Fibrous outer ring of the intervertebral disk, the cartilage cushion between the interlocking bones in the spine; also known as the annular ring.

Anterior Closer to the front part of the body or a structure.

Anterior approach Surgical approach from the front, in this case from the front of the spine.

Anterior capsule The front part of the joint capsule that envelopes the elbow joint.

Anterior cruciate ligament, or ACl

Strong fibrous tissue that connects the upper tibia, one of the lower leg bones, to the base of the femur, or thigh bone, holding the patella, or knee cap, in place and ensuring stability of the knee joint; the ACL passes diagonally in front of the posterior cruciate ligament, or PCL.

Anterior inferior iliac spine Bony projection in the front border of the hip bone.

Anterior instrumentation Spinal fixation device that attaches to the front of the spine.

Anterior interbody technique

Spinal fusion through an anterior, or front, approach, through the neck for cervical vertebrae, the chest for thoracic vertebrae, the abdomen for lumbar vertebrae.

Anterior intrusion Abnormal projection of a structure in a frontward direction.

Anterior superior iliac spine Front projection of the iliac crest in the hip.

Anterior technique Spinal fusion from the anterior, or front, portion of the vertebrae.

Anterior tibial extensors Muscle of anterior part of leg.

Anteroposterior view The X-ray projection travels from front to back, abbreviated as AP.

Anterosuperior iliac spine Front projection of the iliac crest in the hip.

Antibiotic A substance that inhibits infection.

Anticoagulant A drug that prevents clot formation within the blood vessels and dissolves any blood clot formed previously.

Antiinflammatory Substance that reduces pain, swelling, and inflammation.

2121

Cod

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21268

Codes Page no.0274T 1675

0275T 1675

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21181 139

21182 139

21183 140

21184 141

21188 142

21193 143

21194 144

21195 145

21196 145

21198 146

21199 147

21206 148

21208 148

21209 149

21210 150

21215 151

21230 152

21235 153

21240 154

21242 154

21243 155

21244 156

21245 157

21246 158

21247 159

21248 160

21249 160

21255 161

21256 162

21260 163

21261 164

21263 164

21267 165

21268 166

Code Index

ISBN: 978-1-635277-715eBook ISBN: 978-1-635277-937

CSG: Orthopedics 2021

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