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OP Orthopaedics

OP Orthopaedics. Lamon Willis. Aspirations/Injections. 20526 Injection, therapeutic ( eg , local anesthetic, corticosteroid), carpal tunnel 20550 Injection(s); single tendon sheath, or ligament, aponeurosis ( eg , plantar “fascia”) 20551 Injection(s); single tendon origin/insertion

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OP Orthopaedics

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  1. OP Orthopaedics Lamon Willis

  2. Aspirations/Injections

  3. 20526 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”) 20551 Injection(s); single tendon origin/insertion 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s) Aspirations & Injections

  4. Cross Section of Wrist Joint Carpal tunnel syndrome (CTS) is divided into: Early Intermediate Advanced, and Acute stages. Patients with early CTS without thinner atrophy and mild symptoms respond well to steroid injection & splinting.

  5. Aspirations & Injections

  6. Aspirations & Injections • What is a trigger point? • A tender and painful area of a muscle. • Hyperirritable spots in muscle associated with palpable nodules in taut bands of muscle fibers. • They may also manifest as tension headaches, tinnitus, temporomandibular joint pain (TMJ), decreased range of motion in the legs, and low back pain. • Palpation of the trigger will illicit pain directly over the affected area and/or cause radiation of pain.

  7. Aspirations & Injections • Trigger Point Injection Info • Outpatient injection given into the trigger point • May be dry needling, an anesthetic, and also a steroid • Does not require imaging guidance • Needle does not go very deep

  8. Aspirations & Injections • These injections can be provided in various muscles throughout the body

  9. Joint injection are coded by joint size as follow: 20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) without ultrasound guidance 20604 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting 20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) without ultrasound guidance Aspirations & Injections

  10. 20606 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder hip, knee joint, subacromial bursa) 20611 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa); with ultrasound guidance, with permanent recording and reporting Aspirations & Injections

  11. Aspirations & Injections • Arthrocentesis of a joint would occur to remove fluid which has built up due to an injury or illness that has caused swelling and discoloration of the area

  12. The synovial fluid analysis provides details to the physician related to current and future treatment Aspirations & Injections

  13. Dupuytren’s Contracture

  14. The Relevant Anatomy • Dupuytren’s contracture is a progressive disease of the palmar fascia which results in shortening, thickening and fibrosis of the fascia and aponeurosis of the palm. • The palmar fascia is continuous with the antebrachial fascia, the deep fascia of the forearm, and the layer of fascia that covers the dorsum of the hand.

  15. The Relevant Anatomy • The palmar fascia is thicker in the center of the palm and fingers where it forms the palmar aponeurosis and digital sheaths. • The palmar aponeurosis covers the soft tissues of the palm and long flexor tendons. As the longitudinal bands of the palmar aponeurosis undergo fibrosis, the metacarpophalangeal and proximal interphalangeal joints get pulled into flexion.

  16. The Relevant Anatomy • The fourth metacarpal is most commonly affected, followed by the fifth, third, and second. • Recently, Dupuytren’s disease has become a more widely adopted term than Dupuytren’s contracture to name this condition, as the fingers are not always held in a fixed flexion deformity.

  17. The Relevant Anatomy

  18. Mechanism of the Injury/Illness • The exact origin of Dupuytren disease is unknown; however, researchers have identified a number of risk factors: • Genetic • Human leukocyte antigen (HLA) type • Family linkage • Zf9 genetic binding protein • Mitochondrial mutation

  19. Mechanism of the Injury/Illness • Environmental • Trauma and exposure to continuous vibrations • Alcohol consumption • Smoking • Age • These all provide oxidative stresses on the body, which is an imbalance between the production of reactive oxygen and body’s ability to detoxify and repair damaged tissue.

  20. Mechanism of the Injury/Illness • Associated Diseases • Diabetes • Epilepsy • HIV • Cancer • When there are multiple disease processes working in the body, these simply compound the impact of the problem of this disease.

  21. Clinical Presentation • Dupuytren contracture occurs slowly and typically progresses over the course of several years, but can also develop more rapidly over weeks or months. • It typically affects older men of European decent. • This condition most commonly begins with thickening of the skin on the palm, resulting in a puckering or dimpled appearance. • As the condition progresses, bands of fibrotic tissue form in the palmar area and may travel distal toward the fingers.

  22. Clinical Presentation • This tightening and shortening eventually leads to the affected fingers being pulled into flexion. • Dupuytren’s contracture typically occurs bilaterally, with one hand being more severely affected than the other.

  23. Diagnostic Procedures • Several features of Dupuytren’s disease can be noted upon examination: • sites of nodules and bands or contracted cords, • skin pitting, • degree of skin involvement, • measurement of the angle between the metacarpophalangeal and proximal interphalangeal joints, • presence of any surgical scarring and • sensation in the palm and digits.

  24. Diagnostic Procedures • ICD-10 Dx code M72.0: Palmar fascial fibromatosis [Dupuytren]

  25. Diagnostic Procedures • The degree of flexion contracture in the affected digit or digits can be measured with a goniometer. • A Staging System has been created and used by some to measure the flexion contracture of an affected digit to determine the severity of Dupuytren’s disease; stage 1 indicates the least severe flexion contracture deformity while stage 4 indicates the most severe flexion contracture deformity.

  26. Diagnostic Procedures

  27. Diagnostic Procedures

  28. Diagnostic Procedures Stage 2 Stage 1 Stage 3 Stage 4

  29. Management / Interventions • Most common: • Surgical • Enzyme Injection • Less common and unproven or clinically ineffective: • Splinting • Hyperbaric Oxygen • Radiation • Ultrasound Therapy • Vitamin E • Physical Therapy • Interferon

  30. Management / Interventions • Simple Fasciotomy • Performed percutaneously or through small incisions, • The surgeon dividing the contracted tissue cord to release the flexion contracture. • The contracted cord is simply cut, but is not surgically removed from the digit. • Fasciectomy • Removal of the diseased palmar fascia, including the contracted tissue cord and nodule. • Partial or total depending on the severity of the disease.

  31. Management / Interventions • A partial fasciectomy involves removal of the diseased palmar fascia. • A total fasciectomy is more invasive, involving the removal of the entire palmar fascia; both areas affected by disease and areas not affected by disease.

  32. Management / Interventions • Dermofasciectomy is the most invasive surgical procedure for Dupuytren’s disease. • Removal of the diseased palmar fascia, the contracted tissue cord and nodule included, and all overlying affected skin and subcutaneous fat. • A full-thickness skin graft is required to cover the surgical site. • In cases of chronic advanced proximal interphalangeal joint contracture, external fixators may be indicated in addition to the dermofasciectomy procedure to keep the contracture from recurring.

  33. Management / Interventions • Fasciotomy - Percutaneous • CPT-4 code 26040 Fasciotomy, palmar (eg, Dupuytren’s Contracture); percutaneous is for the percutaneous procedure called needle fasciotomy or needle aponeurotomy. • Modifier -50 should be reported if the procedure is performed bilaterally. • This code is reported once per hand, and not based upon the fingers involved.

  34. Management / Interventions • Fasciotomy - Open • CPT-4 code 26045 Fasciotomy, palmar (eg, Dupuytren’s Contracture); open, partial is for the invasive incisional service.

  35. Management / Interventions • Dermofasciectomy • CPT-4 codes 26121-26125. • 26121 - Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) • 26123 - Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); • 26125 - each additional digit (List separately in addition to code for primary procedure)

  36. Management / Interventions Dermofasciectomy

  37. Management / Interventions • Fasciotomy – Enzyme Injection • In 2009 Clostridium histolyticum collagenase injection (J0775) became a promising new nonsurgical treatment for Dupuytren’s disease. The injection of this enzyme targets excessive collagen deposition and rupturing the fibrous tissue cords that cause the contractures.

  38. Management / Interventions • Fasciotomy – Enzyme Injection: 1st Part • CPT-4 code 20527 Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture)

  39. Management / Interventions • Manipulation – 2nd Part Post Injection • 26341 Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord • In this procedure the wrist is held in flexion while gentle but firm traction is placed across the contracted finger until rupture of the fascial cord is felt and the digit fully extends. • This process can be repeated two more times at 10-minute intervals if full extension is not initially achieved. Once the digit is fully extended, the tendon function is evaluated.

  40. Management / Interventions • Manipulation – 2nd Part Post Injection • Clinical Example • A 60-year old male with Dupuytren’s contracture who underwent enzyme injection into a palmar cord the previous day presents for manipulation of the contracted finger. Post procedure the patient’s hand was placed in a molded brace for continued post procedure resolution.

  41. Management / Interventions

  42. Head, Neck & Spine

  43. CPT codes 21010-21499 are for procedures performed on the head. Procedures cover a variety of items: Tumor removal Osteotomy, ostectomy, contouring, and Bone grafts and reconstructive surgeries NOTE: Many procedure performed on the cervical, thoracic, and lumbar spine are performed in an inpatient setting. Head, Neck & Spine

  44. CPT codes 21501-21899 involve soft tissues of the neck and thorax The list is short but sufficient with description of tumor removals, excision of rib(s), sternum, various open and closed procedures, some of which are performed in an inpatient setting Note: Spinal procedures are under a separate subheading Spine (vertebral column) in codes 22010-22899 Head, Neck & Spine

  45. CPT codes 21920-21936 are for the back and flank These procedures are only for soft tissue tumor resection and removal Head, Neck & Spine

  46. CPT codes 22010-22899 involve the spine or vertebral column The spine is broadly arranged into several regions: Head, Neck & Spine

  47. The majority of procedure codes for spine surgery are designated by the approach used to perform the procedure. The two most common approaches are: Anterior Posterior Whatever approach is used should be well documented in the operative note. Head, Neck & Spine

  48. There is an important difference to take note of between vertebra/vertebrae and the vertebral interspace. CPT defines the vertebral interspace as: “The non-bony compartment between two adjacent vertebral bodies, which contains the intervertebral disk, and includes the nucleus pulpous, annulus fibrosus, and two cartilaginous endplates.” The vertebra or vertebral segment is the bone itself. Head, Neck & Spine

  49. For example: “L1” is a vertebra, whereas L1-L2 describes an interspace. The span from L1 to L5 includes five vertebrae and four interspaces. NOTE: Decompression of the spinal cord is described with codes from the nervous system (60000 series) portion of CPT. For removal of a disc without decompression; utilize codes from the 22000 CPT series. Head, Neck & Spine

  50. The most frequently reported spinal procedures for orthopaedics include: Decrompression/Laminectomy/Laminotomy/Hemi-laminectomy: CPT codes 63001-63103 Laminotomy and laminectomy are spinal decompression surgeries performed on the lamina. Laminotomy is the partial removal of the lamina. Laminectomy is the complete removal of the lamina. It is important to know that the terms are often used interchangeably. Common Spine Surgeries

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