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We all know about the opportunities that exist when you bill HCPCS Level II codes for implants or devices that are inserted during surgery. But the CPT code book also contains specific guidelines that require a code for both the procedure and the device or implant when you apply an external fixator, pelvic floor defect mesh/prosthesis or GraftJacket during surgery. Here's a review.
External fixator
External fixation is based on the principle of "load transference." Forces normally transmitted through the fracture site are bypassed through the external fixator frame and pin/bone interface at an early stage of treatment. As the fracture callus (formation of new bone around a fracture site) begins to consolidate, more load will be shared by the bone fragments. When the fracture is stable or healed, all forces are borne by the bone. The external fixation is then no longer needed and can be safely removed.
Use codes for external fixation only when external fixation is not already listed as part of the basic procedure.
20690: Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
20692: Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (e.g., Ilizarov, Monticelli type)
Use code 20690 when you apply pins or wires in 1 plane, unilaterally, as an external fixation device. Use code 20692 when you apply a multiplane external fixation system. There are 3 directions of planes, assuming the person being examined is standing and facing the examiner: vertical anterior to posterior (sagittal), vertical side to side (coronal or longitudinal) and horizontal (transverse).
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External Fixator Case Study |
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DIAGNOSIS: Left comminuted impacted distal radius fracture PROCEDURE: Under general anesthesia, 2 distal pins were placed on the second metacarpal shaft under direct visualization with care to dissect down to the bone. Under fluoroscopic guidance, proximal pins were then placed in the usual fashion at about the mid level of the radius, again using the same sequence. The Synthes external fixator set was used for this procedure. The wrist was visually reduced and good reduction was verified on both AP and lateral X-rays. The fixator was then fixed in place using the bar and more X-rays were taken. 25605-LT Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation 20690 Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system |
Pelvic floor defect mesh/prosthesis
Next we discuss reconstructive procedures performed for the anterior and posterior compartments of the vagina. It's not uncommon for the native tissues to be weak and inadequate for repair, especially in patients who have had previous attempts at repair. In such cases, the surgeon will insert an intervening prosthetic material (autograft, allograft, xenograft or synthetic), which involves attachment of the graft to the surrounding tissues in addition to the routine vaginal repair(s).
Use 57267: in conjunction with 45560, 57240-57265, 57285.
57267: Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (list separately in addition to code for primary procedure)
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Pelvic Floor Defect Mesh/Prosthesis Case Study |
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DIAGNOSIS: Symptomatic rectocele PROCEDURE: Under general anesthesia, a midline vaginal wall incision was made into the posterior aspect using a 15 blade scalpel. The rectocele was then carefully dissected from the vaginal wall tissue using Metze scissors. The Denonvilliers fascia was then reapproximated to the perineal body using 20 PDS suture. A strip of Vicryl mesh was then tacked down over Denonvilliers fascia using a 20 Vicryl suture. 57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy 57267 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) |
GraftJacket
GraftJacket is a skin replacement product made from human donor skin, which undergoes a process that removes the epidermis and dermal cells, thereby creating an acellular dermis.
Q4107: GraftJacket, per square centimeter
15330: Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children
15331: Acellular dermal allograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)
15335: Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children
15336: Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)
See codes 15330 to 15336 for application of the GraftJacket. Use the units field on the claim form to report the total square centimeters of GraftJacket product (code Q4107) applied during the surgery.
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GraftJacket Case Study |
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DIAGNOSIS: Left first toe degenerative arthritis and recurrent hallux rigidus PROCEDURE: This 57-year-old woman has had hallux rigidus in the past treated with an interposition arthroplasty that gave her some relief, but recently she has noted toe stiffness and recurrent deformity. The old incision on the left foot was re-incised and full thickness flaps were carried dorsally and plantarly. A thorough debridement of the metatarsal head was performed, and osteophytes were removed from around the head, and it was tapered to a small size. A drill hole was passed from medial to lateral and from proximal to distal for passage of the graft. Osteophytes were also removed from around the base of the phalanx. A GraftJacket was molded to the shape of a condom and sutured with 3-0 Vicryl. 28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint 15335 Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children Q4107 GraftJacket, per square centimeter |
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