Orthopedic Coding Alert

Question: Our surgeon did a planned release of an A-1 pulley with excision mass over DIP joint, and ended up releasing both A-1 and A-2 pulleys.  The mass over the DIP joint was followed from the subcutaneous tissue down to the joint level. It extended through the joint, causing erosion at the dorso radial aspect of the middle phalanx. The bone surface with the erosion was debrided releasing A-1 pulley.

Can we report code 26055 (Tendon sheath incision [e.g., for trigger finger])? Can we report 26116 (Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial [e.g., intramuscular]; less than 1.5 cm) for the mass excision? The surgeon did not purposely open the joint to remove the mass, but after removing it, he saw the mass (turned out to be rheumatoid nodule) had eroded the joint. How do we report this?

New York Subscriber

Answer: Since the mass has gone into the joint and the mass eroded the joint, this would be more than excision of a soft tissue mass. You should be looking at 26160 (Excision of lesion of tendon sheath or joint capsule [e.g., cyst, mucous cyst, or ganglion], hand or finger) since that is excision of lesion in joint capsule. The A1 pulley is nowhere near the DIP, so you will report both the mass excision and the trigger finger release. You should append modifier 59 (Distinct procedural service) to indicate that the procedures were done at different locations via separate incisions.

For the diagnosis of the nodule, if the surgeon knew that the mass was a rheumatoid nodule at the time of surgery, report code M06.34- (Rheumatoid nodule, hand…). If he did not know that the mass was a rheumatoid nodule, report code R22.3- (Localized swelling, mass and lump, upper limb…).