jhaleycoder
Networker
HI--
I billed the following codes 20680, 25295, 26445. The insurance will only pay for the hardware removal and bundling the other procedures as per the NCCI Chapter 1 ", “A provider/supplier shall not unbundle services that are integral to a more comprehensive procedure". Does this mean I should of only billed the removal of hardware?
Below is the operative report for more detail. If anyone had any further insight it would be greatly appreciated.
Operation
1. Removal of right wrist volar plate (deep hardware)
2. Removal of right wrist dorsal spanning plate (deep hardware)
3. Tenolysis of right hand extensor tendons (EDC to index finger and EIP tendons)
4. Tenolysis of right wrist flexor tendons (FCR and FPL tendon)
5. Right index finger MCP joint manipulation under anesthesia
6. Right wrist manipulation under anesthesia
7. Excision of right dorsal hand subcutaneous scar
8. Conservative management for subtle persistent distal radial fracture instability
Findings
All hardware removed uneventfully. Moderate adhesions to the right hand extensor tendons (EDC to index finger and EIP). Moderate adhesions to the right wrist flexor tendons (FCR and FPL). Full range of motion obtained following right index finger MCP joint manipulation under anesthesia. Right wrist manipulation under anesthesia achieved 50 degrees of wrist extension and 30 degrees of wrist flexion. With terminal motion of the wrist there was noted to be subtle instability across the transverse distal radial fracture line. Right dorsal hand nodules with the appearance of postoperative scar.
Technique
The patient identification, operative sites, and operative procedures were verified with the patient preoperatively in the holding area and again at the safety pause in the operating room. The anesthesia team administered a regional block to the right upper extremity in the preoperative holding area. The patient was transferred to the operating room in a supine position on a stretcher. She was then transferred to the operating table and a belt was placed. All bony prominences were padded. The anesthesia team administered general anesthesia. The right upper extremity was extended onto an arm table and a well-padded upper arm tourniquet was placed. The right upper extremity was then prepped and draped using the standard sterile technique with Betadine. A timeout was performed and all were in agreement. The right upper extremity was exsanguinated with an Esmarch and the tourniquet was inflated. A 5 cm longitudinal incision was marked over the existing scar over the volar aspect of the wrist along the course of the FCR tendon. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. Full-thickness skin flaps were elevated and great care was taken to protect the median nerve and the radial artery. Significant scar and tendon adhesions were noted surrounding the FCR tendon and the FCR tendon sheath. The scar and the tendon adhesions were carefully excised using forceps and scissors. The FCR tendon was subsequently noted to be gliding smoothly within the sheath. The exposure progressed to the level of the FPL tendon and the pronator quadratus. The FPL tendon was also noted to be surrounded with moderate scar and mild tendon adhesions. The scar and the tendon adhesions were carefully excised using forceps and scissors until the FPL tendon was completely free. The pronator quadratus was divided along the radial margin and elevated off of the volar plate. The screws were removed sequentially in the standard fashion and the volar plate was delivered from the wound. A rongeur was used to remove the soft tissue ingrowth into the recesses of the plate to create a smooth bone surface. The wound was copiously irrigated. We then turned our attention to the dorsal side. Two 3 cm longitudinal incisions were marked over the existing scars over the dorsal forearm and dorsal index metacarpal. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. Superficial neurovascular structures were protected. Full-thickness skin flaps were elevated. Distally over the dorsal index metacarpal, two separate subcutaneous nodules were identified and excised using forceps and scissors. These nodules had the appearance of postoperative scar. Significant scar and tendon adhesions were noted to be surrounding the extensor tendons to the index finger (the EDC to the index finger and the EIP tendons). A careful tenolysis was performed to free up these tendons until they were appropriately mobilized and gliding freely. The scar was then elevated off of the distal portion of the spanning plate and the screws were removed sequentially in the standard fashion. Proximally over the dorsal forearm, a window was created between the dorsal forearm musculature to gain access to the proximal portion of the spanning plate. The scar was elevated off the plate and the screws were removed sequentially in the standard fashion. A Freer elevator was placed underneath the plate to loosen it, and the plate was delivered out of the distal wound. A rongeur was used to remove the soft tissue ingrowth into the recesses of the plate to create a smooth bone surface proximally and distally. Both wounds were copiously irrigated. We then turned to the index finger MCP joint manipulation under anesthesia. Several cycles of gentle firm pressure were provided across the index finger MCP joint in flexion and extension until full range of motion was obtained. The remaining joints in the fingers were tested and noted to have full range of motion as well. We then turned our attention to the wrist manipulation under anesthesia. Several cycles of gentle firm pressure were provided across the wrist in flexion and extension. Final range of motion achieved 50 degrees of extension and 30 degrees of flexion. With terminal motion of the wrist there was noted to be subtle instability across the transverse distal radial fracture line. Since the displacement under pressure was minimal, we made the decision to manage this subtle persistent instability conservatively. All wounds were then copiously irrigated and the tourniquet was released after a total of 49 minutes with immediate return of blood flow to the hand. A bipolar was used to maintain hemostasis. The subcutaneous skin layers were closed with 4-0 Vicryl sutures and the skin was closed with running 4-0 Stratafix sutures. Over the volar incision, several 4-0 nylon sutures were used to reinforce the closure. A dry sterile bulky nonadherent dressing was placed over all incisions and overwrapped with Webril. A volar wrist splint was fashioned to protect the operative sites. The procedures were uncomplicated. The counts were correct. The patient tolerated the procedures well and was transferred to the PACU in stable condition.
I billed the following codes 20680, 25295, 26445. The insurance will only pay for the hardware removal and bundling the other procedures as per the NCCI Chapter 1 ", “A provider/supplier shall not unbundle services that are integral to a more comprehensive procedure". Does this mean I should of only billed the removal of hardware?
Below is the operative report for more detail. If anyone had any further insight it would be greatly appreciated.
Operation
1. Removal of right wrist volar plate (deep hardware)
2. Removal of right wrist dorsal spanning plate (deep hardware)
3. Tenolysis of right hand extensor tendons (EDC to index finger and EIP tendons)
4. Tenolysis of right wrist flexor tendons (FCR and FPL tendon)
5. Right index finger MCP joint manipulation under anesthesia
6. Right wrist manipulation under anesthesia
7. Excision of right dorsal hand subcutaneous scar
8. Conservative management for subtle persistent distal radial fracture instability
Findings
All hardware removed uneventfully. Moderate adhesions to the right hand extensor tendons (EDC to index finger and EIP). Moderate adhesions to the right wrist flexor tendons (FCR and FPL). Full range of motion obtained following right index finger MCP joint manipulation under anesthesia. Right wrist manipulation under anesthesia achieved 50 degrees of wrist extension and 30 degrees of wrist flexion. With terminal motion of the wrist there was noted to be subtle instability across the transverse distal radial fracture line. Right dorsal hand nodules with the appearance of postoperative scar.
Technique
The patient identification, operative sites, and operative procedures were verified with the patient preoperatively in the holding area and again at the safety pause in the operating room. The anesthesia team administered a regional block to the right upper extremity in the preoperative holding area. The patient was transferred to the operating room in a supine position on a stretcher. She was then transferred to the operating table and a belt was placed. All bony prominences were padded. The anesthesia team administered general anesthesia. The right upper extremity was extended onto an arm table and a well-padded upper arm tourniquet was placed. The right upper extremity was then prepped and draped using the standard sterile technique with Betadine. A timeout was performed and all were in agreement. The right upper extremity was exsanguinated with an Esmarch and the tourniquet was inflated. A 5 cm longitudinal incision was marked over the existing scar over the volar aspect of the wrist along the course of the FCR tendon. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. Full-thickness skin flaps were elevated and great care was taken to protect the median nerve and the radial artery. Significant scar and tendon adhesions were noted surrounding the FCR tendon and the FCR tendon sheath. The scar and the tendon adhesions were carefully excised using forceps and scissors. The FCR tendon was subsequently noted to be gliding smoothly within the sheath. The exposure progressed to the level of the FPL tendon and the pronator quadratus. The FPL tendon was also noted to be surrounded with moderate scar and mild tendon adhesions. The scar and the tendon adhesions were carefully excised using forceps and scissors until the FPL tendon was completely free. The pronator quadratus was divided along the radial margin and elevated off of the volar plate. The screws were removed sequentially in the standard fashion and the volar plate was delivered from the wound. A rongeur was used to remove the soft tissue ingrowth into the recesses of the plate to create a smooth bone surface. The wound was copiously irrigated. We then turned our attention to the dorsal side. Two 3 cm longitudinal incisions were marked over the existing scars over the dorsal forearm and dorsal index metacarpal. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. Superficial neurovascular structures were protected. Full-thickness skin flaps were elevated. Distally over the dorsal index metacarpal, two separate subcutaneous nodules were identified and excised using forceps and scissors. These nodules had the appearance of postoperative scar. Significant scar and tendon adhesions were noted to be surrounding the extensor tendons to the index finger (the EDC to the index finger and the EIP tendons). A careful tenolysis was performed to free up these tendons until they were appropriately mobilized and gliding freely. The scar was then elevated off of the distal portion of the spanning plate and the screws were removed sequentially in the standard fashion. Proximally over the dorsal forearm, a window was created between the dorsal forearm musculature to gain access to the proximal portion of the spanning plate. The scar was elevated off the plate and the screws were removed sequentially in the standard fashion. A Freer elevator was placed underneath the plate to loosen it, and the plate was delivered out of the distal wound. A rongeur was used to remove the soft tissue ingrowth into the recesses of the plate to create a smooth bone surface proximally and distally. Both wounds were copiously irrigated. We then turned to the index finger MCP joint manipulation under anesthesia. Several cycles of gentle firm pressure were provided across the index finger MCP joint in flexion and extension until full range of motion was obtained. The remaining joints in the fingers were tested and noted to have full range of motion as well. We then turned our attention to the wrist manipulation under anesthesia. Several cycles of gentle firm pressure were provided across the wrist in flexion and extension. Final range of motion achieved 50 degrees of extension and 30 degrees of flexion. With terminal motion of the wrist there was noted to be subtle instability across the transverse distal radial fracture line. Since the displacement under pressure was minimal, we made the decision to manage this subtle persistent instability conservatively. All wounds were then copiously irrigated and the tourniquet was released after a total of 49 minutes with immediate return of blood flow to the hand. A bipolar was used to maintain hemostasis. The subcutaneous skin layers were closed with 4-0 Vicryl sutures and the skin was closed with running 4-0 Stratafix sutures. Over the volar incision, several 4-0 nylon sutures were used to reinforce the closure. A dry sterile bulky nonadherent dressing was placed over all incisions and overwrapped with Webril. A volar wrist splint was fashioned to protect the operative sites. The procedures were uncomplicated. The counts were correct. The patient tolerated the procedures well and was transferred to the PACU in stable condition.