Editor’s note: This article is part one in a two-part series on updated Current Procedural Terminology ^® (CPT ^®) codes addressing drug-delivery devices. Part two was published in the August issue of AAOS Now.

Prior to 2020, the only CPT codes to describe the insertion (11981), removal (11982), and removal with reinsertion (11983) of nonbiodegradable drug-delivery devices were in the integumentary section, which described the procedures in generic terms. The amount and intensity of work associated with these codes were significantly different across different medical specialties.

Because infection is one of the most common complications of musculoskeletal procedures, including total joint arthroplasty, orthopaedic surgeons and physicians in related specialties were the principal reporters of these integumentary device codes. Therefore, new codes, +20700 to +20705, were created for the 2020 CPT code set to report the manual preparation and insertion or removal of musculoskeletal drug-delivery devices. The manual preparation of biodegradable drug-delivery devices is required to report these codes.

This article provides an overview of general reporting scenarios for the new codes. Part two of this series will feature an in-depth discussion on the use of these codes in infected total joint arthroplasties, when using articulating spacers, and in other clinical scenarios.

The six new CPT codes, which were added to the Introduction or Removal subsection of the Musculoskeletal System section, more accurately describe drug-delivery device use with treatment of actual or potential soft-tissue, bone, or joint-related infections. All six codes are “add-on codes,” which describe additional intraservice work associated with the primary procedure and are designated with the + symbol. Add-on codes are reported in addition to the base code for the procedure.

Table 1 lists the six add-on codes, their descriptors, and exclusionary guidelines. Please reference the CPT code book for the parenthetical guidelines on primary procedures that may be reported in conjunction with these codes. The drug-delivery device codes may be used with any “open” procedure code, unless the base code includes insertion or removal of an antibiotic spacer. For more precise examples, please see the current CPT code book or AAOS Code-X software.

To report the drug-delivery device implantation codes, a surgeon must manually prepare the drug-delivery device, such as antibiotic beads, in the OR during the procedure. Use and insertion of commercially available premade beads would not qualify with these codes, as physician work is limited when using manufacturer-prepared beads. Therefore, insertion of commercially available premade implants and devices (e.g., prefabricated beads and articulating implants) or use of antibiotic-impregnated cement (whether commercially laden or added by the surgeon) for implant fixation is not separately reportable.

Reporting scenariosfor insertion codes
+20700
Reported: This code is reported for the manual preparation of a drug-delivery device that is implanted in a deep space (e.g., subfascial).
Example: After removal of infected tissue and associated hardware from a previous musculoskeletal repair (which is separately reported), an antibiotic drug-delivery device (code +20700) is manually prepared and implanted into the resulting defect.

+20702
Reported: This code is reported for the insertion of a manually prepared drug-delivery device into the shaft of a long bone.
Example: After treatment of an intramedullary infection of a long bone (e.g., femur), the infected intramedullary nail would be removed (code 20680, Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]). Then, the bone would be debrided (e.g., reamed and irrigated with a distal venting hole), and an intramedullary antibiotic drug-delivery device would be inserted (code +20702; e.g., antibiotic-impregnated polymethyl methacrylate intramedullary nail).

A manually prepared drug-delivery device could be placed into the bone after partial excision for infection using the following codes:

• 27071, Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur (craterization, saucerization) (e.g., osteomyelitis or bone abscess); deep (subfascial or intramuscular)
• 27360, Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia, and/or fibula (e.g., osteomyelitis or bone abscess)

+20704
Reported: This code is reported for the insertion of an intra-articular drug-delivery device and may be reported for a native joint infection, as well as an infected total joint arthroplasty with component retention.
Example: A patient has an infected pilon fracture and is indicated for ORIF (open reduction–internal fixation) of the distal tibia. Implants (code 20680) and infected bone (code 27640) are removed, and a manually prepared antibiotic spacer (code +20704) is inserted and an external fixator is applied (code 20690 if uniplanar).

The new add-on codes for the removal of implants need to be reported in conjunction with the applicable base code. If there is no base code performed and only the antibiotic spacer is being removed, report code 20680, Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod, or plate).

Reporting scenarios for removal codes
+20701
Reported: This code is reported for the removal of a nonbiodegradable drug-delivery device that was previously implanted in a deep (e.g., subfascial) space.
Example: After resolution of the deep infection, the wound is opened and explored and the drug-delivery device is removed (code +20701) prior to a separately reportable repair of the defect and/or closure (if medically necessary).

+20703
Reported: This code is reported for the removal of an intramedullary drug-delivery device that is nonbiodegradable. If no further reconstruction is required at the time of surgery and the removal of the device is the only procedure performed, report code 20680.
Example: A patient had an infected femur fracture with an intramedullary implant that had an intramedullary antibiotic spacer inserted. The infection resolved, but the patient developed a nonunion. The patient returned to the OR for removal of the intramedullary antibiotic spacer (code +20703) and insertion of a larger reamed intramedullary nail with autogenous grafting (code 27472, Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft [includes obtaining graft]).

+20705
Reported: This code is reported for the removal of an intra-articular drug-delivery device that is nonbiodegradable.
Example: A patient with the previous insertion of an antibiotic spacer and application of an external fixator for an infected pilon fracture returns to the OR for removal of the antibiotic spacer (code +20705) and external fixator (code 20694 because it is under general anesthesia). The patient then has an ankle fusion (code 27870).

In conclusion, understanding the appropriate usage, guidelines, and reporting of these drug-delivery device codes is important for accurate reporting of services rendered. For specific clinical scenarios and examples of infected total joint arthroplasties, please see the second part of this series, which will be published in the August issue of AAOS Now.

Brad Henley, MD, MBA, is the former chair of the AAOS Coding, Coverage, and Reimbursement Committee.

Adam Sassoon, MD, MS, is the former American Association of Hip and Knee Surgeons representative to the Relative Value System Update Committee and is an associate professor and director of the Adult Reconstruction Fellowship in the Department of Orthopaedic Surgery at UCLA.

Frank Voss, MD, FAAOS, is a member of the AAOS Coding, Coverage, and Reimbursement Committee, as well as a CPT advisor.

Louis Stryker, MD, FAAOS, is a former member of the AAOS Coding, Coverage, and Reimbursement Committee, as well as a representative of the American Association of Hip and Knee Surgeons.

John Heiner, MD, FAAOS, is the vice chair of the AAOS Coding, Coverage, and Reimbursement Committee, as well as an advisor to the Relative Value System Update Committee.

Coding tips

• Code +20704 is not intended to be reported with codes that include placement of a nonarticulating spacer, such as:
  • 27091, Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer
  • 27488, Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee
• Codes +20700 to +20705 do not specify whether the device is nonbiodegradable and therefore are reported for both biodegradable and nonbiodegradable devices. Note that biodegradable insertion devices may not need to be removed.

AAOS wants to hear from you

The Coding, Coverage, and Reimbursement Committee is solicitating information from AAOS members regarding coding issues they are experiencing with the new and revised 2021 Evaluation and Management (E/M) guidelines. Issues such as:

• difficulty selecting the appropriate level of E/M service
• uncertainty with interpreting the Table of Risk
• trouble determining when tests ordered are considered a credit for Medical Decision Making

Information received may be used in an upcoming AAOS webinar. Please email correspondence to coding@aaos.org by Sept. 21.