jdibble
True Blue
Can I get some opinions on this surgery? The doctor wants to bill 20103 and 26418. I have discussed with him that 20103 is a separate procedure but he still wants to bill this code. Would this code be included in the tendon repair? Also, would documentation support billing the closure separately?
Right-hand-dominant female sustained a right thumb laceration. She had been treated at an outside hospital. There have been concerns of glass within the wound bed. Exam findings consistent with the EPL tendon disruption. We reviewed the risks and benefits of operative versus non operative treatment options. She presents today for right thumb extensor tendon repair.
Procedure Details: Patient was identified in the preoperative holding area and the operative site was marked. Risks and benefits of the surgery again were discussed. Risks included but not limited to bleeding, infection, damage to adjacent structures, stiffness, pain, loss of function, incomplete recovery, tendon rerupture and need for additional surgery. Patient verbalized understanding and wishes to proceed.
The patient was taken back to the OR and underwent anesthesia without complication. The right upper extremity was prepped and draped in the usual sterile fashion. A time-out occurred immediately prior to procedure identifying the correct patient, site, laterality, planned procedure, preoperative antibiotics, availability of equipment and availability of imaging. 10 cc of local anesthetic was injected about the right thumb for digital nerve block. The arm was exsanguinated the tourniquet was insufflated to 250 mmHg. Prior sutures were removed. There is incomplete healing about the wound bed. Dissection carried through the area of incomplete healing. Fifteen blade further used to extend the prior laceration. Areas of incomplete wound healing underwent sharp resection with a 15 blade. Dissection carried down to the level of the extensor tendon. Tenotomies were next used to develop full-thickness skin flaps radially, ulnarly, proximally and distally. Along the dorsal aspect of the IP joint, extensor remained in continuity. More proximally, able to appreciate area of tendon deficiency with a pseudo tendon formation. Fifteen blade was used to extend the prior laceration proximally. Subcutaneous dissection performed with tenotomies. Retracted portion of the EPL tendon was identified at the level of the MCP joint. Pseudo tendon was excised. Wound was then copiously irrigated. Additional wound inspection was performed given the concern of residual pieces of glass. No retained foreign bodies encountered. EPL tendon was primarily repaired with 4-0 nylon in a modified Kessler configuration, 2 core strands. This was further reinforced with a figure-of-eight suture total 4 core strands. Thumb was brought into maximum flexion and opposition. No diastasis at the repair site. Wound was again irrigated. Tourniquet was let down. Any points of cutaneous bleeding were addressed with bipolar cautery. Incision and prior wound was approximated with 4-0 nylon. Sterile dressing consisting of Xeroform, 4x4s and Webril was applied. Patient was placed in a thumb spica plaster splint maintaining the wrist and thumb and extension.
Thank you for all help as I am trying to understand why he wants to bill 20103 for every surgery comparable to this surgery and am at a loss as to how to respond to him anymore!
Jodi
Right-hand-dominant female sustained a right thumb laceration. She had been treated at an outside hospital. There have been concerns of glass within the wound bed. Exam findings consistent with the EPL tendon disruption. We reviewed the risks and benefits of operative versus non operative treatment options. She presents today for right thumb extensor tendon repair.
Procedure Details: Patient was identified in the preoperative holding area and the operative site was marked. Risks and benefits of the surgery again were discussed. Risks included but not limited to bleeding, infection, damage to adjacent structures, stiffness, pain, loss of function, incomplete recovery, tendon rerupture and need for additional surgery. Patient verbalized understanding and wishes to proceed.
The patient was taken back to the OR and underwent anesthesia without complication. The right upper extremity was prepped and draped in the usual sterile fashion. A time-out occurred immediately prior to procedure identifying the correct patient, site, laterality, planned procedure, preoperative antibiotics, availability of equipment and availability of imaging. 10 cc of local anesthetic was injected about the right thumb for digital nerve block. The arm was exsanguinated the tourniquet was insufflated to 250 mmHg. Prior sutures were removed. There is incomplete healing about the wound bed. Dissection carried through the area of incomplete healing. Fifteen blade further used to extend the prior laceration. Areas of incomplete wound healing underwent sharp resection with a 15 blade. Dissection carried down to the level of the extensor tendon. Tenotomies were next used to develop full-thickness skin flaps radially, ulnarly, proximally and distally. Along the dorsal aspect of the IP joint, extensor remained in continuity. More proximally, able to appreciate area of tendon deficiency with a pseudo tendon formation. Fifteen blade was used to extend the prior laceration proximally. Subcutaneous dissection performed with tenotomies. Retracted portion of the EPL tendon was identified at the level of the MCP joint. Pseudo tendon was excised. Wound was then copiously irrigated. Additional wound inspection was performed given the concern of residual pieces of glass. No retained foreign bodies encountered. EPL tendon was primarily repaired with 4-0 nylon in a modified Kessler configuration, 2 core strands. This was further reinforced with a figure-of-eight suture total 4 core strands. Thumb was brought into maximum flexion and opposition. No diastasis at the repair site. Wound was again irrigated. Tourniquet was let down. Any points of cutaneous bleeding were addressed with bipolar cautery. Incision and prior wound was approximated with 4-0 nylon. Sterile dressing consisting of Xeroform, 4x4s and Webril was applied. Patient was placed in a thumb spica plaster splint maintaining the wrist and thumb and extension.
Thank you for all help as I am trying to understand why he wants to bill 20103 for every surgery comparable to this surgery and am at a loss as to how to respond to him anymore!
Jodi