Orthopedic Coding Alert

Question: There’s a conflict between the professional and technical coding for this procedure. The provider performed a left-hand Dupuytren’s excision where the A1 pulleys of both the small finger (SF) and ring finger (RF) were released but only the SF proximal interphalangeal (PIP) joint was released.

Here is a sample of the operative note:

Palmar incision was mapped out along the prominent palmar cord extending to the SF P2. Soft tissue dissection was performed to separate the diseased palmar fascia from the surround tissues. Partial palmar fasciectomy of the fascia to the small finger was removed and sent to pathology. A1 pulleys of both SF and RF were released. Digital nerves both radial and ulnar to the small and ring finger were found and protected. The SF PIP joint was released to allow for full correction after Manipulation of the PIP joint under anesthesia (MUA). The wounds were irrigated, the tourniquet released and after 8 min to allow localized clotting, the wound was explored and small vessels were cauterized with bipolar. Z plasty performed at the SF MCP joint flexion crease. The wound was closed with 5-0 Prolene and a compressive dressing was applied. The capillary refill to all 5 digits was less than 2 sec and the skin flaps were well vascularized. The patient emerged from anesthesia without complications and taken to PACU in stable condition.

What procedure codes should I assign?

New Hampshire Subscriber

Answer: You’ll assign 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)) as the information is presented in the op note.

An A1 pulley release is a surgical procedure used to treat trigger finger, but it is not part of a typical Dupuytren’s surgery and would generally be bundled in. If the physician didn’t make an additional diagnosis of trigger finger, there is no justification for 26055 (Tendon sheath incision (eg, for trigger finger)) appended with modifier 59 (Distinct procedural service). According to the National Correct Coding Initiative (NCCI) edit pairs, 26055 is a column 2 code of 26123, which means the trigger finger release is bundled into the fasciectomy. The additional dissection in the palm also gets bundled in.

Additionally, it is incorrect to use +26125 (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); each additional digit (List separately in addition to code for primary procedure)) along with 26123 if the surgeon doesn’t specify that the release or fasciectomy extended into the finger.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC