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Musculoskeletal System Case 1 Operative Report Preoperative diagnosis: Comminuted left proximal humerus fracture Postoperative diagnosis: Comminuted left proximal humerus fracture Operative procedure: Open treatment of left proximal humerus. Anesthesia: General. Implants: DePuy Global fracture stem size 10 with a 48 x 15 humeral head. Indications: The patient is a 66-year-old female who sustained a severely comminuted proximal humerus fracture. The risk and benefits of the surgical procedure were discussed. She stated understanding and desired to proceed. Description of procedure: On the day of the procedure after obtaining informed consent, the patient was taken to the main operating room where she was prepped and draped in the usual sterile fashion in beach chair position after administering general anesthesia. Standard deltopectoral approach was used; the cephalic vein was taken laterally with the deltoid. Dissection carried out down to the fracture site. The fracture site was identified. The fragments were mobilized and the humeral head fragments removed. Once this was done, the stem was prepared up to a size 10. A trial reduction was carried out with the DePuy trial stem and implant head. This gave good range of motion with good stability. Sutures were placed in key positions for closure of the tuberosities down to the shaft including sutures through the shaft. The shaft was then prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and then reduced. A bone graft was placed around the area where the tuberosities were being brought down. The tuberosities were then tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with Vicryl over a drain and also staples in the epidermis. A sterile dressing and sling was applied. The patient was taken to recovery in stable condition. No immediate complications. What are the CPT® and ICD-10-CM codes reported? 23616-LT, S42.202A RATIONALE: CPT® code: In the CPT® Index, look for Fracture/Humerus/Open Treatment, and you are directed 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. Case 2 Preoperative diagnosis: Painful L2 vertebral compression fracture. Postoperative diagnosis: Painful L2 vertebral compression fracture. Name of operation: L2 kyphoplasty. Findings preoperatively: She had compression fractures at T 11 and L1, which underwent kyphoplasty and she initially had very good results, but then developed back pain once again. Repeat MRI a couple of weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalping of the superior end plate consistent with a compression fracture at L2. After some preoperative discussion and some patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she was not getting better. At surgery, L2 had some scalloping of the superior end plate. Most of the softness was in the back part of the vertebral body. Procedure: The patient was taken to the operating room and placed under general endotracheal anesthesia in a supine position. She was placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. Using biplane image intensifiers, the skin incision sites were marked out. 0.5 Marcaine with epinephrine was injected. Initially on the left side, a Xyphon trocar was passed down to the superior lateral edge of the pedicle and then passed down through the pedicle and into the vertebral body— uneventfully in the usual fashion. The drill was then placed into the vertebral body and then the Kyphon bone tamp. In a similar fashion, the same thing was done on the other side. Balloons were then inflated uneventfully. The balloons were then deflated and removed and the cement when it was in the doughy state was then injected into the 2 sides in the usual fashion. This was done carefully and sequentially to make sure that there were no cement extrusions and in fact there were none, there was a good fill to the edges of vertebral body up towards the superior end plate and across the midline. The bone filling devices were then removed and the trocars removed. Pressure was applied after which the skin was sutured with 4-0 nylon. Band-Aids were applied and she was taken to recovery in stable condition. Complications: There were no complications. Blood loss: Minimal blood loss. Counts: Sponge and needle counts were correct. What are the CPT® and ICD-10-CM codes reported? 22514, M48.56XA RATIONALE: CPT® code: In the CPT® Index look, for Kyphoplasty, you are directed to the range of codes 22513–22515. 22514 is the correct code based on the location. Radiologic supervision and interpretation is 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, and you are directed 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. Case 3 Preoperative diagnosis: Comminuted intraarticular distal radial Colles’ fracture left wrist. Postoperative diagnosis: Comminuted intraarticular distal radial Colles’ fracture left wrist. Procedure: Application uniplane external fixation and closed reduction of left distal radial fracture under fluoroscopy. Anesthesia: General endotracheal. Description of the procedure: After induction of adequate general endotracheal anesthesia, the patient’s left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 millimeters of mercury. We first placed two half pins distally over the dorsoradial aspect of the second metacarpal first placing first pin in freehand technique making an incision, spreading with hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius. We then connected these 2 pins with clamps and then under C-arm control we reduced the fracture. All pins are now attached to the external fixation. This fracture at both dorsal and volar comminution and intraarticular fractures and was significantly shortened and telescoped. We obtained the best reduction possible and then tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications. What are the CPT® and ICD-10-CM codes reported? 20690-LT, 25605-51-LT, S52.532A RATIONALE: CPT® code: This is a repair of a Colles’ fracture. Look in the CPT® Index for Fracture/Radius/Colles and you are directed to code range 25600–25605. In the numeric section, code 25605 is correct because a reduction (manipulation) was performed. This code does not include the external fixation. Look in the CPT® Index for External Fixation/Application/Uniplane,