Outpatient Facility Coding Alert
Distinguish Left from Right for Thumb Sprain Diagnosis
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Question: One of our physicians recently saw a patient with gamekeeper’s thumb. The operative notes indicate our physician examined the thumb and index finger, made the diagnosis, and immobilized the thumb. What codes should I report for the immobilization procedure? Can I report a separate E/M service in this scenario?
New Jersey Subscriber
Answer: The code that you will report depends on the immobilization technique the physician used. If he performed the immobilization using an ACE bandage or other strapping material, report 29280 (Strapping; hand or finger) for the service. If he applied a thumb spica cast to immobilize the injury, report 29085 (Application, cast; hand and lower forearm [gauntlet]) for the service.
No matter which CPT® code you choose, don’t forget to include the appropriate diagnosis to support your claim for the procedure. In this case, report ICD-10 code S63.641A (Sprain of metacarpophalangeal joint of right thumb, initial encounter) if the sprain is in the right thumb or S63.642A if the sprain is in the left thumb.
It is possible that you may be able to also report an E/M service in this scenario. If you do, make sure your physician’s documentation indicates and supports a separately identifiable E/M service that goes beyond what is incidental to the procedure. In the scenario you describe, it is possible the physician performed the history and physical exam elements beyond those elements associated with simply immobilizing the thumb, in which case you would be justified in reporting an E/M code that reflects the history, examination, and medical decision making documented. To further indicate the separately identifiable nature of the E/M service, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified Health care professional on the same day of the procedure or other service) to the E/M code.
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