Question Dupuytren partial palmar release left small & possibly left ring

kmuth

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Here is my question I know I can code 26123-F5 but through out the op note he is also dissecting the left ring finger which he also says is involved but he did not state the left ring finger in the operation performed/ postop diagnosis. Can I bill 26123-F5 and 26125-F4 or just 26123?

PREOPERATIVE DIAGNOSIS:
Dupuytren disease with metatarsophalangeal joint and proximal interphalangeal
joint contractures, left small finger.

POSTOPERATIVE DIAGNOSIS:
Dupuytren disease with metatarsophalangeal joint and proximal interphalangeal
joint contractures, left small finger.

OPERATIONS PERFORMED:
1. Partial palmar fasciectomy, left hand.
2. Digital fasciectomy, left small finger with proximal interphalangeal and
metatarsophalangeal joint contracture releases.

ANESTHESIA:
Block with general.

INDICATION:
Patient is a 59-year-old male who presents with fixed fibrous Dupuytren disease
affecting the MP joint of his left ring and small finger as well as the PIP
joint of his left small finger. He has significant pretendinous and spiral
cords contributing to the correct contractures.

PROCEDURE IN DETAIL:
Patient was taken to the operating room on 07/30/2020 where he was given a
general block anesthetic. Next, his forearm, arm, and hand were prepped and
draped in normal sterile fashion. Next, his arm was elevated, exsanguinated
with an Esmarch bandage and tourniquet inflated to 250 mmHg. Next, incisions
were outlined extending from the mid palm just past the DIP flexion crease of
the left small finger. I then very carefully elevated skin flaps radially and
ulnarly to elevate the skin, thick enough to provide vascularity, but thin
enough to remove as much disease as possible. The skin flaps were elevated
with care and 4-0 nylon were used as retention sutures. I identified the
pretendinous cords of the ring and small fingers, which were both involved. I
dissected these free and then transected the cords at the mid palm and then
traced them from proximal to distal. I split the cord so that would be used to
dissect them. I preserved the transverse fibers of the superficial palmar
fascia to the ring finger to keep the neurovascular structures deep, but on the
small finger I did sacrifice the transverse fibers as they were intimately
associated with the longitudinal fibers. I located all nerves including the
common digital nerve to the 3rd and 4th web spaces and the proper digital
nerves to the small finger and the ulnar side of the ring finger. I then
proceeded to dissect the diseased fascia, which was very thick and fibrous
particularly just distal to the proximal digital crease of the small finger, it
was tedious. The natatory cord was also involved and this was excised. This
was causing a web space contracture between the ring and small. That was
excised along with the pretendinous cords and spiral cord. The radial digital
nerve to the small finger was intimately associated with the diseased almost
forming I could not pass through the diseased tissue making its dissection
rather difficult, but all nerves and arteries were preserved throughout the
entire operation. Once I had the cord removed, I was able to fully straighten
the MP joint and the PIP joint. I then rearranged the skin slightly with
Z-plasty to facilitate closure and try to prevent subsequent scar contracture.
I then irrigated the wound with copious amounts of saline. I irrigated the
wound with copious amounts of saline and closed the skin with running 5-0 nylon
and interrupted 5-0 nylon modified horizontal mattress sutures. I then
released the tourniquet. The patient was placed in a dressing and splint. He
tolerated the procedure well and sent to discharge area. Specimen was
Dupuytren cords. Total tourniquet time was 1 hour 16 minutes.
 

Orthocoderpgu

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I'm not sure if you are aware, but F4 and F5 are on different hands. The thumb on the right hand is F5.

I know you can bill 26121 as documented, but I am not sure about 26123. In code 26123 the flexor tendon has to be released at the PIP joint. I don't see how you do that without releasing a pulley. You may want to query your surgeon about that. I don't see any documentation that the tendon was released at the PIP, but I am not a hand surgeon either. I would also encourage you to speak to your physician about documenting time for procedures. Your surgeon encountered multiple areas that may have taken significantly more time than usual. You may want to consider 26121-22. But speak to your surgeon and see if the tendon/s were released at the PIP and if documented 26123 would be appropriate.
 
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cpc2007

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The work at the PIP is not as clear as it could be, but I could minimally support the 26123 for the left small finger. From the lay description of CPT 26123: " Use 26123 if the zigzag incision is extended over the proximal interphalangeal joint and the fascial cord in a single finger is removed along with the fascial cord in the palm. Use 26125 for each additional finger from which the fascial cord is excised." I do see the surgeon extending that zig zag incision just past the DIP flexion crease in the left small finger. After releasing the cord at the level of the palm, he then removes diseased fascial cord on the left small finger as well "just distal to the proximal digital crease." I've included a link here since I'm a visual person and it helps me to see the area being referenced. If he is distal to the proximal digital crease, he is on the finger just beyond the metacarpophalangeal joint and working out from there: http://image.slidesharecdn.com/hand...-included-not-to-post-5-728.jpg?cb=1270817528. He then continues until all diseased tissue is removed. Finally, while he started with metacarpophalangeal joint and proximal interphalangeal joint contractures, he confirms at the end of the case that he is able to fully straighten both joints. Those details would confirm for me that the tendons were released at the PIP. It could be clearer, but I would say he has enough to support the 26123 minimally for the left small finger.

I would not add the 26125 since he didn't release the PIP on the left ring finger and 26123/26125 do require that work. Agree with the previous answer as well that modifier 22 may have been considered if the effort of completing this procedure was documented more specifically in terms of extra time/percentage of difficulty. Also agree with the previous answer that the F modifiers on the left hand starting with FA for the left thumb and proceed to F4 for the left small finger. So I would code 26123.F4 only with the current documentation. I hope that helps!

Kim
www.codingmastery.com
 

kmuth

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Thank you! I see you answering questions all the time and just so you know all your help and knowledge is truly appreciated. I know the finger modifiers and just did not pay attention when posting. Do you have any recommendations on what to read or webinars that help with hand coding? This doc does not respond to queries, and if I get a response it will usually say just bill what you can, or "not improving the dictations."
 
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