Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CPT code set, including logic and rationale related to the updates. The CPT code set for 2022 includes extensive changes to the Musculoskeletal System section, which had a large number of updates in both guidelines and definitions. The key changes to the Musculoskeletal System section which will be highlighted in this blog include revised introductory guidelines, revised fracture and dislocation treatment definitions and new guidance regarding injection of bone-substitute material for bone marrow lesions and closed treatment of nasal fractures.

Introductory Guideline Updates

The introductory guidelines in the Musculoskeletal System section have been revised and reorganized to clarify the following:

• All services in the Musculoskeletal System section include the application and removal of the first cast, splint, or traction device when performed
• A cast removal code (29700, 29705, 29710) should be reported if a cast is removed by someone other than the physician or other health care professional who applied the cast
• Subsequent replacement of cast, splint, or strapping (29000-29750) and/or traction device (eg, 20690, 20692) during or after the global period may be reported separately
• Application of casts, splints, and strappings are not considered part of preoperative care, and therefore, modifier 56, Preoperative Management Only, is not applicable
• If the person providing the initial treatment will not be providing subsequent treatment, then modifier 54, Surgical Care Only, should be appended to the treatment code
• If the fracture treatment provided is not included in the treatment definitions located in the Musculoskeletal System section introductory guidelines, then an E/M code should be reported for the treatment
• There is no coding correlation between the type of fracture/dislocation (eg, open, closed) and the type of treatment (eg, open, closed, percutaneous) provided. For example, a closed fracture may require an open reduction

Updates to Fracture/Dislocation Treatment Definitions

The following fracture/dislocation treatment definitions have also been revised to provide clarification of each treatment provided:

• Manipulation: Reduction by the application of manually applied forces or traction to achieve satisfactory alignment of the fracture or dislocation. If satisfactory alignment (reduction) is not maintained and requires subsequent re-reduction of a fracture or dislocation by the same physician or same qualified health professional, append modifier 76 to the fracture/dislocation treatment code.
• Traction: The application of a distracting or traction force to the spine or a limb. Skeletal traction includes wire, pin, screw or clamp that is attached to (penetrates) bone. Skin traction is the application of force to a limb using strapping or a device that is applied directly to the skin only.
• Closed Treatment: The treatment site is not surgically opened (ie, not exposed to the external environment nor directly visualized). Closed treatment of a fracture/dislocation may be performed without manipulation (eg, application of a cast, splint, or strapping), with manipulation, with skeletal traction, and/or with skin traction. Casting, splinting or strapping used solely to temporarily stabilize the fracture for patient comfort is not considered closed treatment.
• Percutaneous skeletal fixation: Treatment that is neither open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (eg, pins, screws) is placed across the fracture site, typically with imaging guidance.
• Open Treatment: The site is opened surgically to expose the fracture/dislocation to the external environment for treatment, or the fracture/dislocation is treated through the traumatic wound or an extension thereof or is treated with an intramedullary nail or other internal fixation device is placed through a surgical exposure that is remote from the fracture site with or without direct visualization of the fracture site.
• External Fixation: The use of pins and/or wires that penetrate the bone(s) and interconnection devices (eg, clamps, bars, rings) for fracture/dislocation treatment. External fixation may be used for temporary or long-term fracture/dislocation treatment. Uniplanar external fixation places all the pins in approximately the same plane but may also include triangular fixation across a joint. Multiplanar external fixation uses transosseous wires and threaded pins placed in several planes that are held with interconnected stabilizing and/or tensioning rings and/or half rings. External fixation may be used for all types of fracture/dislocation treatment (ie, closed, percutaneous, open). Codes for external fixation are reported separately only when external fixation is not listed in the code descriptor as inherent to the procedure.

Injection of Bone-Marrow Substitute for Bone Marrow Lesions

A new code (0707T) has been established to report injection of bone-substitute material into a subchondral bone defect, including imaging guidance and arthroscopic assistance for joint visualization. In accordance with the establishment of code 0707T, a parenthetical note has been added following code 20615 in the Musculoskeletal System section, directing coders to report code 0707T for injection of bone-substitute material for bone marrow lesions. A parenthetical note has also been added to 0707T instructing coders that code 0707T should not be reported with codes 29805, 29860, 29870 and 77002.

20615 Aspiration and injection for treatment of bone cyst

(For injection of bone-substitute material for bone marrow lesions, use 0707T)

0707T Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and arthroscopic assistance for joint visualization

(Do not report 0707T in conjunction with 29805, 29860, 29870, 77002)

New Guidance Regarding Closed Treatment of Nasal Fractures

Closed treatment of nasal bone fractures can be performed in the following ways:

• without manipulation
• with manipulation and stabilization
• with manipulation, without stabilization

Prior to 2022, codes 21310 (Closed treatment of nasal bone fracture without manipulation), 21315 (Closed treatment of nasal bone fracture; without stabilization) and 21320 (Closed treatment of nasal bone fracture; with stabilization) did not specify how to report manipulation when it is performed with closed treatment. To address this issue, code 21310, Closed treatment of nasal bone fracture without manipulation has been deleted, and codes 21315 and 21320 have been revised.

A parenthetical note has also been added following 21315 which states “For closed treatment of nasal bone fracture without manipulation or stabilization, use appropriate E/M code.”

Additional Information

Additional information regarding CPT Code Updates for FY 2022 can be found below:

• American Medical Association (AMA) CPT 2022 Professional Edition (includes rules and guidelines from the AMA’s CPT Editorial Panel)
• AHA Coding Clinic for HCPCS, First Quarter 2022 Page: 1-4 Surgery section CPT code update 2022: integumentary and musculoskeletal systems