Chapter 8-Practical Application
CASE 1
PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.
POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The
postoperative diagnosis is used for coding.)
NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.)
FINDINGS PREOPERATIVELY:
She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty.
She initially had very good results, but then developed back pain once again. The repeat MRI
two weeks later showed that she had fresh high intensity signal changes in the body of L2 and
some scalloping of the superior end plate, consistent with a compression fracture at L2.(The
diagnosis is confirmed in the body of the report.) After some preoperative discussions and
patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty
when she did not improve. At surgery, - Answer 22514
M48.56XA
CPT® code: In the CPT® Index look, for Kyphoplasty, directing you to 22513-22515. 22514 is the
correct code based on the location. Radiologic supervision and interpretation are included in
codes 22513-22515 and is not reported separately.
ICD-10-CM Code: In the ICD-10-CM Alphabetic Index, look for Fracture,
pathological/compression (not due to trauma). You are instructed to see also Collapse, vertebra.
Look for Collapse/vertebra/lumbar region directing you to M48.56-. In the Tabular List, a 7th
character is required. This is an initial encounter for the fracture treatment. A placeholder X is
reported as the 6th character, followed by the 7th character A for initial treatment.
Operative Report
PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture.
POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative
diagnosis is used for coding.)
OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure
until the report is read.)
ANESTHESIA: General.(General anesthesia is used.)
IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication
that a prosthesis was introduced into the joint.)
INDICATIONS: The patient is a 66-year-old female who sustained a traumatic severe
comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal
end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were
discussed. She stated that she understood and desired to proceed.
, DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consen -
Answer 23616-LT
S42.202A
CPT® code: In the CPT® Index, look for Fracture/Humerus/Open Treatment directing you to
codes 23615, 23616 in the numeric section. A humeral prosthesis was inserted to repair the
fracture, which is reported with 23616. Modifier LT is appended to indicate the left humerus.
ICD-10-CM Code: The diagnosis is listed as a traumatic comminuted left proximal humerus
fracture. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/humerus/proximal
end, which directs you to see Fracture, humerus, upper end, then you will be directed to
S42.20-. In the Tabular List, the 6th character 2 is reported for the left side and 7th character A
indicates initial encounter for closed fracture. There is no mention if the fracture is closed or
open, and according to ICD-10-CM guidelines we are instructed to choose the closed fracture
code. There is no documentation of the circumstances surrounding the injury, so the external
cause codes are not reported.
OPERATIVE REPORT
Preoperative Diagnosis: Plantar fasciitis, left
Postoperative Diagnosis: Same as preoperative diagnosis.(The postoperative diagnosis is used
for coding.)
Procedures: Plantar fasciotomy, left heel.(This is the working procedure until the report is read.)
For informed consent, the more common risks, benefits, and alternatives to the procedure were
thoroughly discussed with the patient. An appropriate consent form was signed, indicating the
patient understands the procedure and its possible complications.
This 61-year-old male was brought to the operating room and placed on the surgical table in a
supine position. Following anesthesia, the surgical site was prepped and draped in the normal
sterile fashion. Attention was directed to the left heel where, utilizing a 61 blade, a stab incision
was made, taking care to identify and retract all vital structures. The incision was deepened to
the medial band in - Answer 28008-LT
M72.2
CPT® code: Look in the CPT® Index under Fasciotomy/Foot directing you to 28008. Append
modifier LT to reflect the laterality as left.
ICD-10-CM code: Look for Fasciitis/plantar in the ICD-10-CM Alphabetic Index directing you to
M72.2. Verification in the Tabular List confirms this is the correct code.
PREOPERATIVE DIAGNOSIS: Painful hardware, left foot.
POSTOPERATIVE DIAGNOSIS: Painful hardware, left foot.(The postoperative diagnosis is used for
coding.)
CASE 1
PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.
POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The
postoperative diagnosis is used for coding.)
NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.)
FINDINGS PREOPERATIVELY:
She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty.
She initially had very good results, but then developed back pain once again. The repeat MRI
two weeks later showed that she had fresh high intensity signal changes in the body of L2 and
some scalloping of the superior end plate, consistent with a compression fracture at L2.(The
diagnosis is confirmed in the body of the report.) After some preoperative discussions and
patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty
when she did not improve. At surgery, - Answer 22514
M48.56XA
CPT® code: In the CPT® Index look, for Kyphoplasty, directing you to 22513-22515. 22514 is the
correct code based on the location. Radiologic supervision and interpretation are included in
codes 22513-22515 and is not reported separately.
ICD-10-CM Code: In the ICD-10-CM Alphabetic Index, look for Fracture,
pathological/compression (not due to trauma). You are instructed to see also Collapse, vertebra.
Look for Collapse/vertebra/lumbar region directing you to M48.56-. In the Tabular List, a 7th
character is required. This is an initial encounter for the fracture treatment. A placeholder X is
reported as the 6th character, followed by the 7th character A for initial treatment.
Operative Report
PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture.
POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative
diagnosis is used for coding.)
OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure
until the report is read.)
ANESTHESIA: General.(General anesthesia is used.)
IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication
that a prosthesis was introduced into the joint.)
INDICATIONS: The patient is a 66-year-old female who sustained a traumatic severe
comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal
end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were
discussed. She stated that she understood and desired to proceed.
, DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consen -
Answer 23616-LT
S42.202A
CPT® code: In the CPT® Index, look for Fracture/Humerus/Open Treatment directing you to
codes 23615, 23616 in the numeric section. A humeral prosthesis was inserted to repair the
fracture, which is reported with 23616. Modifier LT is appended to indicate the left humerus.
ICD-10-CM Code: The diagnosis is listed as a traumatic comminuted left proximal humerus
fracture. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/humerus/proximal
end, which directs you to see Fracture, humerus, upper end, then you will be directed to
S42.20-. In the Tabular List, the 6th character 2 is reported for the left side and 7th character A
indicates initial encounter for closed fracture. There is no mention if the fracture is closed or
open, and according to ICD-10-CM guidelines we are instructed to choose the closed fracture
code. There is no documentation of the circumstances surrounding the injury, so the external
cause codes are not reported.
OPERATIVE REPORT
Preoperative Diagnosis: Plantar fasciitis, left
Postoperative Diagnosis: Same as preoperative diagnosis.(The postoperative diagnosis is used
for coding.)
Procedures: Plantar fasciotomy, left heel.(This is the working procedure until the report is read.)
For informed consent, the more common risks, benefits, and alternatives to the procedure were
thoroughly discussed with the patient. An appropriate consent form was signed, indicating the
patient understands the procedure and its possible complications.
This 61-year-old male was brought to the operating room and placed on the surgical table in a
supine position. Following anesthesia, the surgical site was prepped and draped in the normal
sterile fashion. Attention was directed to the left heel where, utilizing a 61 blade, a stab incision
was made, taking care to identify and retract all vital structures. The incision was deepened to
the medial band in - Answer 28008-LT
M72.2
CPT® code: Look in the CPT® Index under Fasciotomy/Foot directing you to 28008. Append
modifier LT to reflect the laterality as left.
ICD-10-CM code: Look for Fasciitis/plantar in the ICD-10-CM Alphabetic Index directing you to
M72.2. Verification in the Tabular List confirms this is the correct code.
PREOPERATIVE DIAGNOSIS: Painful hardware, left foot.
POSTOPERATIVE DIAGNOSIS: Painful hardware, left foot.(The postoperative diagnosis is used for
coding.)
