Properly Coordinate Your Wrist Coding
Grasping the anatomy of so many tiny, complex parts will aid in coding of wrist diseases and injuries.
The wrist is classified as an “intermediate” joint, but consists of many intricate structures and bones. Accurate coding of wrist diagnoses, services, and procedures requires a solid working knowledge of wrist, hand, and distal forearm anatomy.
Match Wrist Parts to Diagnosis Codes
The wrist, or carpus, contains eight carpal bones. There are three bones in the proximal row (scaphoid, lunate, and triquetrum) and five bones in the distal row (trapezium, trapezoid, capitate, hamate, and pisiform). The trapezium is also known as the greater multangular, the trapezoid as the lesser multangular, and the scaphoid as the navicular bone.
In ICD-10-CM, most wrist conditions coded from chapter 13 (M codes) have a “3” in the fifth position of the code such as M19.031 Primary osteoarthritis, right wrist. Common conditions of the wrist and distal radius from chapters 13 and 19 (M and S codes) are:
- Wrist drop (M21.33-)
- Contracture of wrist (M24.53-)
- Flail joint of wrist (M25.23-)
- Infective tenosynovitis of wrist (M65.13-)
- DeQuervain’s disease (radial styloid tenosynovitis) (M65.4)
- Ganglion cyst of wrist (M67.43-)
- Crepitant synovitis of wrist (M70.03-)
- Abscess of wrist bursa (M71.03-)
- Carpal idiopathic aseptic necrosis (M87.037, M87.038)
- Fracture of lower (distal) end of radius (S52.5-)
- Physeal (Salter-Harris) fracture of lower end of radius (S59.2-)
- Fracture of ulnar styloid process (S52.61-)
- Fracture of navicular (scaphoid) bone (S62.0-)
- Fracture of (other) carpal bone (S62.1-)
- Subluxation and dislocation of wrist (S63.0-)
- Wrist sprain (S63.5-)
Recognize Triangular Fibrocartilage Complex
The triangular fibrocartilage complex (TFCC) is a band of cartilage that cushions the area in the wrist where the ulna, lunate, and triquetrum intersect. The TFCC suspends the distal radius and ulnocarpal joints from the distal ulna. A primary function of the TFCC is to facilitate forearm rotation with a flexible connection between the distal radius and ulna, stabilizing the distal radioulnar joint (DRUJ) and supporting the ulnocarpal structures. The TFCC provides a continuous gliding surface across the distal radius/ulna for flexion, extension, supination, pronation, and radial/ulnar deviation. Damage to the TFCC is often caused by:
- A fall on an outstretched hand;
- A drill-bit injury where the wrist rotates rather than the bit;
- A distraction force onto the volar forearm or wrist; or
- A sequela of a distal radius fracture.
Excessive load on the ulnocarpal joint can cause a TFCC tear. Synovitis of the wrist is often a byproduct of a TFCC disease or injury, and is treated during the same operative session as a TFCC repair. Signs and symptoms of a TFCC injury are ulnar-sided pain near the ulnar styloid, swelling, instability, and greatly reduced grip strength. A repair of the TFCC usually is performed arthroscopically, as reported with 29846 Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement.
For more severe TFCC-related cases, such as complex injuries or profound degeneration causing wrist instability, an open procedure may be necessary, such as a ligamentous reconstruction (25337 Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint). Alternatively, a shortening of the ulnar bone (25390 Osteoplasty, radius OR ulna; shortening) may be performed to relieve pressure on the TFCC and prevent further degeneration. A shortening of the joint capsule or extensor retinaculum may improve DRUJ stability in less severe cases.
Pinpoint SLAC and SNAC
A wrist defect often requiring surgical intervention is scapholunate advanced collapse (SLAC.) SLAC is a condition of progressive instability that causes advanced radiocarpal and midcarpal osteoarthritis. SLAC describes a specific pattern of progressive subluxation with loss of articulation between the scaphoid and lunate bones. SLAC usually results from trauma to the wrist, but may be caused by a degenerative process such as calcinosis or as a sequela of a prior injury. SLAC is estimated to account for more than half of all non-traumatic wrist osteoarthritis cases.
Signs and symptoms of SLAC include:
- Difficulty bearing weight across the wrist;
- Decreased wrist range of motion;
- Dorsal swelling or tenderness directly over the scapholunate ligament;
- A focal point of pain in the scapholunate region; and
- Hand weakness or stiffness, especially with regard to grip strength.
A popular test to detect SLAC is the Watson scaphoid shift test, which evaluates four progressive stages of carpal arthritis.
A “sister” disease to SLAC is a scaphoid non-union advanced collapse (SNAC), which is a classification of post-traumatic wrist arthritis. This condition is a sequela of a scaphoid fracture, and characterized as chronic non-union. SNAC manifests as sharp pain and profound weakness in the wrist, with restricted range of motion. SNAC of the left wrist caused by a displaced fracture of the distal pole of the scaphoid is reported with ICD-10-CM code S62.012K Displaced fracture of distal pole of navicular (scaphoid) bone of left wrist, subsequent encounter for fracture with nonunion.
“Four-corner fusion” may be used to correct SLAC, SNAC, and other forms of wrist osteoarthritis. This method removes the scaphoid, followed by internal fixation of the other seven carpal bones. The main advantage, versus conventional total wrist arthrodesis, is that some intercarpal and radiocarpal function is preserved. Four-corner fusion is reported with 25820 Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) or 25825 Arthrodesis, wrist; with autograft (includes obtaining graft).
Identify De Quervain’s Disease
De Quervain’s disease (radial styloid tenosynovitis) is an inflammation of the first dorsal extensor compartment; this is entrapment tendinitis causing tendon thickening, which leads to restricted motion and a grinding sensation with tendon movement (crepitus). De Quervain’s is diagnosed by means of a Finkelstein’s Test, in which the patient makes a fist and the provider pulls the wrist away from the thumb. Pain is a typical indicator of De Quervain’s.
Preliminary or stop-gap treatment may include fitting to a short-arm splint or cast. For more severe cases, the practitioner may resort to a tendon release by an incision into the extensor tendon sheath (25000 Incision, extensor tendon sheath, wrist (eg, de Quervains disease)).
Pay Attention to Payer Guidelines and NCCI Edits
It’s important to understand payer guidelines and National Correct Coding Initiative (NCCI) bundling rules. Common examples of unbundling and miscoding errors include:
- Reporting a ganglion cyst excision (25111 Excision of ganglion, wrist (dorsal or volar); primary) in addition to a synovectomy of the wrist (25118 Synovectomy, extensor tendon sheath, wrist, single compartment): 25111 is bundled into the 25118.
- Reporting a partial synovectomy (29844 Arthroscopy, wrist, surgical; synovectomy, partial) in addition to an arthroscopic TFCC repair (29846 Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement) when the synovectomy is included in the repair.
- Reporting 25215 Carpectomy; all bones of proximal row for a carpectomy of all proximal row bones when not all three bones (scaphoid, lunate, and triquetrum) are excised.
- Reporting a trapezium excision (25210 Carpectomy; 1 bone) in addition to a carpometacarpal joint arthroplasty (25447 Arthroplasty, interposition, intercarpal or carpometacarpal joints).
- Separately reporting bone grafts (20900 Bone graft, any donor area; minor or small (eg, dowel or button) or 20902 Bone graft, any donor area; major or large) with procedures that include these grafts.
- Billing for initial application of a short-arm cast (29075 Application, cast; elbow to finger (short arm)) or short-arm splint (29125 Application of short arm splint (forearm to hand); static) with a surgical procedure on the wrist.
- Coding fracture of carpal bone (S62.1- Fracture of other and unspecified carpal bone(s)) when the diagnosis is a distal radius fracture (S52.5- Fracture of lower end of radius).
Learn By Example
Case 1: The patient is a 49-year-old woman who presents to the ER with an acute onset of pain in her right wrist after she was chased by a dog and fell onto an outstretched hand while running for her front door. X-rays of her right hand and wrist confirmed she had sustained a Colles’ distal radius fracture. The orthopedist on call performed a closed reduction of the fracture. She was told to follow up in two to three weeks, or if the pain exacerbates.
25605-RT 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 – Right Side
99283-57 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity – Decision for surgery
S52.531A Colles’ fracture of right radius, initial encounter for closed fracture
W01.198A Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter
Y92.017 Garden or yard in single-family (private) house as the place of occurrence of the external cause
Three weeks later, there is no improvement in her pain. A percutaneous skeletal fixative reduction is done for better stabilization of the fracture.
Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation – Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period
S52.532A Colles’ fracture of left radius, initial encounter for closed fracture
Case 2: The patient is a 42-year-old man with the diagnosis of scapholunate advanced collapse on his right wrist, with synovitis. An orthopedic surgeon performs an arthroscopic excision, TFCC repair, debridement, and partial synovectomy (percutaneous endoscopic).
29846-RT Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement
M65.831 Other synovitis and tenosynovitis, right forearm
Case 3: The patient is a 68-year-old gentleman who was woodworking in the basement workshop in his single-family home. He lost his grip on a powered sander while refinishing a table and suffered a crushing injury into the capitate and hamate of his right wrist. He underwent a flexor tendon decompression fasciotomy including extensive debridement of muscle and nerve tissue, as well as a two-bone carpectomy.
25023-RT Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve
25210-RT x 2
S67.31XA Crushing injury of right wrist, initial encounter
W31.2XXA Contact with powered woodworking and forming machines, initial encounter
Y92.018 Other place in single-family (private) house as the place of occurrence of the external cause
Y93.D3 Activity, furniture building and finishing