Orthopedic Coding Alert

Most orthopedic surgery coders are familiar with the 26XXX series of CPT Codes for hand surgery. But unlike many surgery chapters for other specialties, there is an intimidating abundance of hand surgery codes. Questions frequently arise as to the slight but important distinctions between the different types of hand surgery procedures and the accompanying codes. Our coding primer examines some of the complexities of hand surgery coding. Because of the breadth of the subject, this primer will be presented in a two-part series, the first dealing with soft tissue surgeries of the hand. The second part of the series, involving surgery of the bones of the hand, will appear in the July 2000 issue of Orthopedic Coding Alert.

Definitions of Common Hand Surgeries

Dr. James Guerra, MD, VACS, of Collier Sports Medicine and Orthopedic Center in Naples, Fla., identifies the most common orthopedic surgeries of the hand.

Incision Surgeries

Fasciotomy: Incision through a fascia; used in the treatment of certain vascular disorders and injuries when marked swelling is anticipated that could compromise blood flow; may be combined with embolectomy in the treatment of acute arterial embolism. In hand surgery, says Guerra, fasciotomy is often used to treat a compartment syndrome of the hand, which may occur due to a crush injury.

Decompressive fasciotomy (hand): The removal of swelling or pressure in the hand through the use of an incision in the fascia of the hand.
Codes
26037 (decompression fasciotomy, hand)
26040 (fasciotomy, palmar [e.g., Dupuytrens contracture]; percutaneous)
(Often used for the treatment of Dupuytrens contracture; a disease of the palmar fascia resulting in thickening and shortening of fibrous bands on the palmar surface of the hands and fingers.)
26045 (fasciotomy, palmar; open, partial)

Tenotomy: The surgical division of a tendon for the relief of a deformity caused by congenital or acquired shortening of the muscle. Guerra explains that in hand surgery, tenotomy is commonly used to treat spastic hand disorders in which a tendon contracture occurs.
Code
26060 (tenotomy, percutaneous, single, each digit)
For multiple digits during the same surgery, repeat the code using a -59 modifier for distinct procedural service.

Arthrotomy: The cutting into a joint. For hand surgery, arthrotomy is used to explore a joint for a foreign body or debride a joint for an infection.
Codes
26070 (arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint)
26075 (arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each)
26080 (arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each)

For codes 26075 and 26080, when operating on multiple joints at the same time and at the same site of incision, code each joint separately and use modifier -51 for multiple procedures on the subsequent joints.

Guerra pointed out that the most commonly performed incision surgery to the hand is 26055 (tendon sheath incision), most often used for the relief of trigger finger, an affection in which the movement of the finger is arrested for a moment in flexion and then continues with a jerk.

Excision Surgeries

Arthrotomy: An excisional arthrotomy includes a biopsy of the excised tissue.
Codes
26100 (arthrotomy with biopsy; carpometacarpal joint, each)
26105 (arthrotomy with biopsy; metacarpophalangeal joint, each)
26110 (arthrotomy with biopsy; interphalangeal joint, each)

For codes 26100-26110, when operating on multiple joints at the same time and at the same site of incision, code each joint separately and use modifier -51 for multiple procedures on the subsequent joints. Some carriers will allow you to use the Level II (HCPCA/National) modifiers to indicate units or digits (e.g., -F2 = left hand, third digit, -F8 = right hand, fourth digit, etc.) rather than the -51 modifier. Check with your carrier before submitting billing, but bear in mind that regardless of the modifier used, insurers will probably reduce the fees on subsequent joints.

Fasciectomy: The excision of strips of the fascia, often used for Dupuytrens contractures of the hand.
Codes
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 the primary procedure]) (note that this is an add-on, not a stand-alone code).

Synovectomy: The excision of a portion or all of the synovial membrane of a joint. Removing all or part of the synovial lining is typically performed for rheumatoid synovitis in the hand.
Codes
26130 (synovectomy, carpometacarpal joint)
26135 (synovectomy, metacarpophalangeal joint including intrinsic release and exterior hood reconstruction, each digit)
26145 (synovectomy, tendon sheath, radical [tenosynovectomy], flexor tendon, palm and/or finger, each tendon)

Related Terms

Synovial membrane the connective tissue membrane that lines the cavity of the synovial joint and produces the synovial fluid; it lines all internal surfaces of the cavity except for the articulator cartilage of the bones
Palmar referring to the palm of the hand
Carpal, carpus pertaining to the wrist
Carpometacarpal joint the synovial joint(s) between the carpal and metacarpal bones
Metacarpal the five bones of the hand between the carpus (wrist) and the phalanges
Phalanges one of the long bones of the fingers
Interphalangeal pertaining to the two short bones in the fingers
Z-plasty surgery to elongate a contracted scar or to rotate tension 90 degrees, the middle line of a Z-shaped incision is made along the line of the greatest tension or contraction, and triangular flaps are raised on opposite sides of the two ends and transposed.

Applying the Rules to a Real-life Scenario

Donna Bal, CPC, CPC-H, coding specialist at Midwest Orthopaedic Surgery Inc., a seven-
physician practice with three offices in western Missouri and Eastern Kansas, shares some operating notes on a recent hand surgery performed by one of her physicians.

Pre- and Postoperative Diagnosis: Mass on the volar aspect of the proximal phalanx of the right long and ring fingers.

Name of Operation:
1. Under general anesthesia, excision of mass of the long finger, which appeared to be a giant cell tumor.
2. Exploration of the ring finger, although no frank abnormalities or mass was noted other than the prominent flexor and sublimis tendon. No biopsies were taken on the ring finger.

Description of Operation: The patient was brought to the operating room, where after general anesthesia was administered, a surgical prep of the right arm was done. A tourniquet was inflated to 250 mmHg pressure, 100 mmHg over systolic pressure. After a modified Brunner incision was made and carried down through the skin and subcutaneous tissues, a large, what appeared to be brown cell tumor from the tendon sheath of the long finger was excised. On the ring finger, an incision was made at the volar aspect of the proximal phalanx. No frank abnormality was noted except for a prominent profundus sublimis tendon that appeared not to have any turning, locking or other abnormalities. No biopsy was taken. The tourniquet was released. The bleeding points were carefully cauterized, the skin approximated with 4-0 nylon material, and a bulky dressing was applied. The patient tolerated this procedure and left the operating room in satisfactory condition.

For the first part of the surgery, says Guerra, Code 26160 (excision of a lesion of tendon sheath or capsule [e.g., cyst, mucous cyst, or ganglion], hand or finger) is used. For the procedure on the ring finger, 26020 (drainage of tendon sheath, digit and/or palm, each) applies. Since the op report states that no biopsy of the ring finger was performed, this is really the only code to apply here. I would append with a -52 modifier (reduced services), because code 26020 implies that there is a drainage process involved, and no drainage occurred. Use modifier -59 (distinct procedural service) (or the unit/digit modifiers depending on carrier) to make it clear to the insurance company that it was a different finger from the first part of the surgery and keep the codes from being bundled. Another option is to use code 26989 (unlisted procedure, hands or fingers) for the second part of the surgery, but be prepared to submit your operative report to the carrier, and price the 26989 similarly to the 26020.