Advice on selecting the correct code
Answers to frequently asked questions
By Margie Scalley Vaught, CPC, CCS-P, ACS-OR, MCS-P
The AAOS Coding Corner frequently gets questions about which ICD-9 or CPT code to use in specific situations. Because selecting the correct code—whether ICD-9 or CPT—can be difficult at times, we’re addressing some frequently asked questions in this month’s column. Answers are based on the American Hospital Association’s official coding publication, The Coding Clinic, and on discussions by the AAOS ICD-9 and CPT Coding Committee.
Q: When a patient has degenerative joint disease of both knees, what is the correct code assignment? We assigned code 715.96 (Osteoarthrosis, unspecified whether generalized or localized, knee). Should we have utilized a code that identifies multiple sites, e.g., code 715.06 (Osteoarthrosis, generalized, knee [involving multiple joints])?
A: Assign code 715.36 (Osteoarthrosis, localized, not specified whether primary or secondary, for bilateral degenerative joint disease, knee). In the Tabular List (Volume 1), under category 715 (Osteoarthrosis and allied disorders), an instructional note can be found:
“Note: Localized, in the subcategories below, includes bilateral involvement of the same site.”
This note should be interpreted to mean that bilateral involvement is included in the fifth digit for that site. Furthermore, when the degenerative joint disease affects only one site, but is not identified as primary or secondary, it is coded to 715.3x (Osteoarthrosis, localized, not specified whether primary or secondary). If it involves more than one site but is not specified as generalized, assign code 715.8x (Osteoarthrosis involving, or with mention of, more than one site but not specified as generalized).1
Q: The patient, a 34-year-old woman, has had problems with her left ankle since 1993, when she injured it. As a result of the injury, the patient developed an osteochondral lesion of the left talus. She had previously undergone two open curettages and bone grafting for the talar defect. However, the left ankle has remained symptomatic. The patient now presents to the physician with talar osteonecrosis and degenerative changes of the talar dome. Would this situation be coded as a late effect?
A. Yes. Assign code 732.7 (Osteochondritis dessicans) as the principal diagnosis. Also assign code 733.4 (Osteonecrosis of the talus) as an additional diagnosis, and then the late effects code 908.9 (Late effect of unspecified injury) as additional diagnoses. A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes; the condition or nature of the late effect is sequenced first.(2)
Q: At what point in the patient’s progress should we stop using the fracture code and begin using the aftercare V58.x codes?
A: Aftercare codes came out in 2002 and have been confusing. Here is supporting information from The Coding Clinic:
“Three new subcategories and many new codes have been created to greatly expand the detail in the aftercare codes. Major changes were made to the orthopedic aftercare codes. Coding guidelines for the ICD-9-CM require that a fracture code be used only for an initial encounter for treatment. Subsequent encounters require the use of an orthopedic aftercare code. The problem was that the aftercare code provided very little detail. To remedy this, subcategories V54.1 (Aftercare for healing traumatic fracture) and V54.2 (Aftercare for healing pathologic fracture) were created. The codes under these subcategories identify the site of the fracture. It is not necessary to assign code V54.19 (Aftercare for healing traumatic fracture of other bone), or code V54.29 (Aftercare for healing pathologic fracture of other bone), more than once if several bones in the same subcategory are involved. A new code has also been created for aftercare following joint replacement, V54.81.
“Broad new codes were created for aftercare following surgery for neoplasms, V58.42; for injury and trauma, V58.43; and for specific body systems, V58.71-V58.78. These codes should be used in conjunction with any other aftercare codes or other diagnosis codes to provide better detail on the specifics of an aftercare visit. The sequencing of multiple aftercare codes is discretionary.
“Codes identifying aftercare following surgery of specified body systems (V58.71-V58.78), for neoplasm (V58.42), and for injury and trauma (V58.43) should also be used in conjunction with the V codes for post-operative wound dressing care, ostomy care, or other similar V codes, so that the wound dressing care or ostomy device is identified.
“Code V58.43 should not be reported with one of the V54.1 codes if the aftercare is for treatment of a healing traumatic fracture. Only code V54.1 is necessary. Should a patient be receiving aftercare for both a healing traumatic fracture and for other injuries it is acceptable to use both codes V58.43 and V54.1. Similarly, it is not necessary to use both a code from subcategory V58.7 with a code from subcategory V58.4. If a patient is receiving surgical aftercare for an injury or trauma or neoplasm only a code from subcategory V58.4 is necessary.”4
Q: The patient had a bimalleolar ORIF and, for whatever reason, a year or two later the physician removes the hardware. There are two plates and eight screws (four screws in each plate). Do you report:
• 20680x10 for the two plates and eight screws?
• 20680 just once because it is considered one internal device that was placed?
• 20680x2 because you made two incisions to remove?
A: Based on a discussion by the AAOS ICD-9 and CPT Coding Committee, removal of hardware used for a specific fracture type—regardless of the number of screws, plates, rods or incisions—would only be coded once. If there was an extraordinary of work involved (e.g., bone-buried screws, exceptional scar), then modifier -22 would be added with the usual accompanying note.
Multiple use of 20680 would only be appropriate when the hardware removal was for another fracture unrelated to the first fracture (e.g.,ankle and humerus). Then modifier -59 would be used.
Q: Does the following documentation support CPT 29540? “We taped and Ace bandaged the right ankle” for a diagnosis of a right ankle sprain.
If someone is placed in a sling or a velcro wrist splint, could you use a cast application code or the dynamic splinting code?
A: The answer to this question can be found in the December, 1998 issue of the CPT Assistant:
“Application of a cast or strapping device (listed in the 29000 series) is intended to be used when the desired effect is to provide total immobilization or restriction of movement. Strapping refers to the application of overlapping strips of adhesive plaster or tape to a body part to exert pressure on it and hold a structure in place. Strapping may be used to treat strains, sprains, dislocations, and some fractures.
“Orthosis application differs from the purpose of an application of a cast or strapping device. Orthotics are used to support a weak or ineffective joint or muscle. They are generally used to provide support while the patient transitions through treatment (i.e., provides mobility with support). Some examples of orthotic devices include shoe inserts and braces.
“When code 97504 was added to CPT, a cross-reference was added at the end of the Application of Casts and Strapping Section Notes to refer the reader to code 97504 to report orthotics fitting and training ‘(For orthotics fitting and training, see 97504).’ This cross-reference and the addition of the new code (97504) was to make it clear that casting and strapping codes should not be reported for orthotics fitting and training. Also, the cross reference is intended to make clear that the casting and strapping codes should not be reported in addition to code 97504. When describing orthotic procedures, dynamic splints are considered orthotics and therefore the dynamic splint application service should be identified by code 97504.”5
Margie S. Vaught, CPC, CCS-P, MCS-P, ACS-OR is an independent coding specialist in Ellensburg, Wash. She has served as a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at firstname.lastname@example.org