Wiki Help me decide the correct code!!!

[dsibley67]

Can someone please help me code this? I want to code 26045, but the Z-plasty is throwing me off. I have looked at 26123 with a 22 modifier. I can't decide which one would be the most appropriate. Any help will be greatly appreciated. Thanks!

PREOPERATIVE DIAGNOSIS: Dupuytren's disease.
POSTOPERATIVE DIAGNOSIS: Dupuytren's disease.
PROCEDURES PERFORMED: Right ring finger cordotomy, right small finger cordotomy, Z-plasty
right palm.
ANESTHESIA: Local block.
ESTIMATED BLOOD LOSS: Minimal.
BRIEF H&P: He was noted to have Dupuytren's disease with a ring and small finger cord with
approximately 30 degrees contracture of the ring and small finger MP joint. We discussed with him
treatment options at length and elected to proceed with a cordotomy. Risks were explained including
stiffness, infection, neurovascular injury, recurrence or need for repeat procedure and he wished to
proceed.
DESCRIPTION OF PROCEDURE: The patient was seen preoperatively, site was marked and
verified. Local block was performed in the palm, taken back to the OR, began with a longitudinal incision
in the palm with 60-degree flaps for planned Z-plasty. We then elevated each flaps carefully. He had a
ring and small finger cord which were transected at the proximal and distal extent of the wounds. This
allowed the fingers to come out to full extension. We protected the underlying neurovascular bundle. We
then created our Z-plasty by transposing the flaps and then sutured them with 4-0 Prolene. This achieved
a nice repair with minimal tension. The wound was then dressed in sterile fashion. A bulky dressing was
applied. He tolerated the procedure well.

 

[NRaizman]

This is strictly a palmar fasciotomy and the op note does not describe any incisions carried out into the fingers nor excision of cords, thus 26123/26125/26121 would all be inappropriate

Z-plasty is included in both 26121 and 26123 in the code descriptor itself as well as the GSD, but not in 26045, so local tissue rearrangement would be codable.

There is zero justification for a 22 modifier.

If the surgeon carried these incisions into the fingers and took out any cord material documented as such, it would be 26123, 26125, which reimburses far better. But he didn't.

 

[amyjph]

Side note on Modifier 22 for learning. It can't be appended without clear documentation that there was substantial additional work and the reason is documented in the op note. Take a look at the description in Appendix A of the CPT book.

Example info: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00135206

https://www.aapc.com/blog/63312-when-to-append-modifier-22/?srsltid=AfmBOorB97_xrOP5q9o0GMYNtrF1hTJcEnTlosOdeKt3JBicm3qJ5xfZ

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf There are other areas with reference to Modifier 22 in this linnk you can search.
20.4.6 - Payment Due to Unusual Circumstances (Modifiers “-22” and “-52”)(Rev. 1, 10-01-03)B3-15028The fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. Thus, A/B MACs (B) may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation.
10. Unusual Circumstances Surgeries for which services performed are significantly greater than usually required may be billed with the “-22” modifier added to the CPT code for the procedure. Surgeries for which services performed are significantly less than usually required may be billed with the “-52” modifier. The biller must provide:• A concise statement about how the service differs from the usual; and • An operative report with the claim. Modifier “-22” should only be reported with procedure codes that have a global period of 0, 10, or 90 days. There is no such restriction on the use of modifier “-52.”