Wiki Billing 26442 vs 26055?

[smfrickl]

My fellow coders and I are struggling to understand when it would be medically necessary to bill a tenolsyis (26442) for a trigger finger repair instead of 26055. We have a hand practice where all surgeons ONLY bill 26442 for every trigger finger case. They never want to bill 26055. Can anyone provide any information on when they should choose 26442 over 26055 and what should we be looking for in the documentation? Here is an example of a case where a surgeon billed 26442. Does this documentation support it? Thank you.

Pre-operative Diagnosis: Left ring finger trigger

Post-operative Diagnosis: same as preop diagnosis
Description of procedure:
Left ring finger
Surgical timeout site verification was performed. The extremity was prepped and draped. The limb was exsanguinated total tourniquet time was 10 minutes at 250 mmHg.
The finger was given a metacarpal block. 1% lidocaine without epinephrine 5 cc 0.5% Marcaine without epinephrine 5 cc.
The left ring finger was examined. There was catching and locking consistent with triggering. An oblique incision was made over the A1 pulley. Radial and ulnar digital bundles were identified and protected the entire the case. The A1 pulley was identified and released and's entirety. Inspection of the FDS and FDP showed no significant pathology. A complete tenolysis was performed using sharp dissection from palm into the finger. The finger was taken through range of motion. There is no longer catching or locking. The ulnar and radial digital bundles were inspected and were intact. The wound was then irrigated. Skin was closed using 4-0 nylon in a horizontal mattress. Sterile dressing was applied tourniquet was deflated finger pinked up nicely. Patient was taken to the PACU in stable condition. Patient will give instruction on wound care follow-up and pain management.

 

[NRaizman]

That is -always- 26055.

The tenosynovectomy, what they're suggesting is a tenolysis, is inherent to the trigger release.
Tenolysis is a far more extensive procedure, valued by CMS/RUC with an average intraoperative time of 90 minutes, and would only be appropriate if there were documented adhesions, with a separate diagnosis, in which case, the pulley release would be incidental to the tenolysis.

What they are doing is entirely inappropriate, and I would challenge, or actually dare, those surgeons to submit their operative reports for coding guidance to the ASSH Coding Committee, the AAOS Coding Committee/Code-X or to KZA, just for confirmation.

 

[amyjph]

I agree with Dr. Raizman.
Have you talked with each of the providers about it? Or, are you just going by a template or codes that are "auto" populated? Are they manually choosing this code? Is a coder correcting this before it goes out?

In addition, if you read 26442, it states palm AND finger. (even if the code was correct, which it is not for what you describe)

If they are actually doing this purposefully, they are doing it because 26055 has 3.11 work RVUs and 26442 has 9.75.
NOT good. How many are there? This is a pretty common hand/wrist case, you'd have to correct and fix every one. Not to mention if these are being inappropriately billed/paid to CMS...

 

[smfrickl]

That is -always- 26055.

The tenosynovectomy, what they're suggesting is a tenolysis, is inherent to the trigger release.
Tenolysis is a far more extensive procedure, valued by CMS/RUC with an average intraoperative time of 90 minutes, and would only be appropriate if there were documented adhesions, with a separate diagnosis, in which case, the pulley release would be incidental to the tenolysis.

What they are doing is entirely inappropriate, and I would challenge, or actually dare, those surgeons to submit their operative reports for coding guidance to the ASSH Coding Committee, the AAOS Coding Committee/Code-X or to KZA, just for confirmation.

Dr. Raizman, Thank you for taking the time to review and respond. We really needed to hear this from another provider. We have been going back to these providers, 4 in total who all code this way but document differently. We tell them that what they are performing would be coded as 26055 and they push back on us every time. We have sent the documentation to our QM/Compliance department, and they agreed with the providers because they say it is documented that they performed 26442. These providers never bill 26055 for any trigger finger releases which I find hard to believe. We have used KZA in the past for ortho coding seminars but I am curious about having the AAOS or ASSH coding committee taking a look. Maybe that will get someone's attention and hear us for a change. How can I get in touch with those coding committees?

 

[smfrickl]

I agree with Dr. Raizman.
Have you talked with each of the providers about it? Or, are you just going by a template or codes that are "auto" populated? Are they manually choosing this code? Is a coder correcting this before it goes out?

In addition, if you read 26442, it states palm AND finger. (even if the code was correct, which it is not for what you describe)

If they are actually doing this purposefully, they are doing it because 26055 has 3.11 work RVUs and 26442 has 9.75.
NOT good. How many are there? This is a pretty common hand/wrist case, you'd have to correct and fix every one. Not to mention if these are being inappropriately billed/paid to CMS...

These providers choose their own codes and the coders will review them if they hit some kind of edit and that is when we discover the issue. Our protocol is to go back to the providers to discuss why we need to change the codes they choose and that is when they push back and tell us we are incorrect and that they are doing more than 26055. I have been telling our leaders that I suspect this is RVU driven but I get pushed back on that as well for "assuming". It's obvious that is what's driving this because we have seen this in other coding instances with them. We had an issue where they were billing fasciotomies with every single carpal tunnel release. We kept speaking up until someone finally heard us and got the attention of the head of the ortho dept. He finally stepped in and agreed with us, told them to stop billing the fasciotomy and then they started finding other codes to add in. I can only assume, to increase the RVUs that they were no longer getting from fasciotomy. I agree with you, this procedure so common and the fact that they NEVER bill or want to just bill 26055 blows my mind. We have other hand providers in different practices who do not code this way. It's just the 4 at this one location. We've been dealing this similar coding issues with this practice for years and kept requesting an internal audit. We just learned that RAC audits were done, and they told them these were supposed to be billed as 26055.

 

[NRaizman]

Shannon - if they (or anyone) are an AAOS Code-X subscriber, they can submit questions for review through Code-X.
To query the AAOS CCRC, you could email Joanne Willer (last name at aaos dot org)
To query the ASSH PRCC, you could email the request to Pamm Schroeder (first initial last name at assh dot org)
If you want to get really deep into it, you can query the AMA CPT Assistant (cptassistant@ama-assn.org). Then the question will get farmed out to us at AAOS, but the response may get written up in CPT-A. This is likely overkill, and I would recommend the routes mentioned above.

 

[smfrickl]

Shannon - if they (or anyone) are an AAOS Code-X subscriber, they can submit questions for review through Code-X.
To query the AAOS CCRC, you could email Joanne Willer (last name at aaos dot org)
To query the ASSH PRCC, you could email the request to Pamm Schroeder (first initial last name at assh dot org)
If you want to get really deep into it, you can query the AMA CPT Assistant (cptassistant@ama-assn.org). Then the question will get farmed out to us at AAOS, but the response may get written up in CPT-A. This is likely overkill, and I would recommend the routes mentioned above.

Thank you so much. I appreciate your help.