jdibble
True Blue
Good afternoon All!
I was hoping to get some help and opinions on the surgery below. My provider wants to bill 13160, 26350 x 4, 64834, 64702, 37618. 64702 does hit an NCCI edit so I know that can't be billed. I am not sure if 26350 would be correct as the surgery was done in the wrist (This part always confuses me with hand surgeries). I also don't agree with 13160 (although it does not hit an NCCI edit) however my surgeon wants to bill that on all of his surgeries where the laceration was "loosely approximated" by another surgeon. I am having trouble trying to explain to him what the code 13160 is intended for, and he has now started to say part of the wound was dehisced in order to use this code. (I just find it hard to believe that every wound that was loosely approximated now has dehisced!) So, any help on when 13160 would be appropriate to use during a surgery would be helpful too as I need to go back to him and explain this so that he would understand. Thank you for all of the guidance I can get on this!
Diagnosis
Procedures
Panel 1 Procedures: RIGHT WRIST IRRIGATION AND DEBRIDEMENT WITH ULNAR ARTERY LIGATION, MEDIAN NERVE REPAIR, TENDON REPAIR (R)
Indications: procedure for
* Wrist laceration, right, initial encounter [S61.511A]
* Ulnar artery injury, right, initial encounter [S55.001A].
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, damage to nerve and tendons, pain, loss of function, need for additional surgery. Patient understands and wishes to proceed.
The patient was taken back to the OR and underwent anesthesia without complication. The upper extremity was draped and prepped in the usual sterile fashion. A time-out occurred immediately prior to procedure identified the correct patient, site, laterality, planned procedure, preoperative antibiotics, availability of equipment and availability of imaging. The arm was exsanguinated and the tourniquet was insufflated to 250 mmHg.
There was an extensive laceration along the proximal aspect of the wrist with a length of 10-12 cm which was previously loosely approximated. The sutures were removed using a 15 blade for further secondary wound closure. A 15 blade was used to extend the laceration proximally and distally by making a cut along the center of the distal forearm proximally and along the thenar crease distally. The skin flaps were raised while dissecting down using tenotomies and a 15 blade. Distally, the flexor retinaculum was exposed and the flexor retinaculum was completely cut to released the carpal tunnel to allow mobilization of the median nerve. Proximally and also the skin flaps were released to expose the flexor tendons.
The findings of traumatic wound exploration was as follows: Partially cut of the FCR tendon about 50-60%, partial cut of the FDS-3 and partially cut out FDS-4 about 40%, complete cut of the FCU tendon, complete cut of the median nerve, complete cut of the ulnar artery. The ulnar nerve was explored and was intact, FDP tendons, FPL were explored and were intact. Also the FDS tendon to the index and small finger were intact.
Following exploration, the ulnar artery was separated and since the perfusion to the fingers was in an acceptable range, we decided to ligate the ulnar artery using a number 2-0 silk. Both proximal and distal ends of the artery were explored and ligated.
The ulnar nerve was explored and released throughout its course and the Guyon's canal was also released to remove any compression over the ulnar nerve were any kinking point.
Next we proceeded with repair of the FCU tendon using 3-0 Supramid suture with M Tang technique.
Next the FCR tendon was repaired using 3-0 Supramid suture by modified Kessler taking.
Next the FDS tendon to the middle finger was repaired using 3-0 Vicryl in a running fashion to repair the epitendinous and reinforce the cut section.
Next the FDS tendon to the middle finger was repaired using 3-0 Vicryl in a running fashion to repair the epitendinous and reinforce the cut section.
Next we proceeded with repair of the median nerve. There was no retraction of the nerve due to the maintain attachment of the epineurium on the radial side. Neurolysis of the median nerve was performed proximally and distally and the hematoma was removed. A nerve tape was used to place the nerve over the nerve tape and maintain the alignment and approximate the nerve ends using the Nerve Tape. Following repair, the nerve was stable with no tension. Range of motion of the wrist was done which showed stable repair of all tendons during range of motion of the fingers and the wrist. Copious irrigation was done with saline.
The laceration and the incisions were repaired by mobilizing the flaps with secondary wound closure and 3-0 nylon was used in a horizontal mattress fashion to repair the incisions and the laceration.
A dressing was applied using Xeroform followed by 4 x 4 and Webril. A dorsal wrist and hand splint was applied and fixed with Ace bandage.
Findings: Partial cut of the FCR, FDS to the middle, FDS to the ring, complete cut of the FCU tendon, complete cut of the ulnar artery, complete cut of the median nerve.
Complications: None; patient tolerated the procedure well.
I was hoping to get some help and opinions on the surgery below. My provider wants to bill 13160, 26350 x 4, 64834, 64702, 37618. 64702 does hit an NCCI edit so I know that can't be billed. I am not sure if 26350 would be correct as the surgery was done in the wrist (This part always confuses me with hand surgeries). I also don't agree with 13160 (although it does not hit an NCCI edit) however my surgeon wants to bill that on all of his surgeries where the laceration was "loosely approximated" by another surgeon. I am having trouble trying to explain to him what the code 13160 is intended for, and he has now started to say part of the wound was dehisced in order to use this code. (I just find it hard to believe that every wound that was loosely approximated now has dehisced!) So, any help on when 13160 would be appropriate to use during a surgery would be helpful too as I need to go back to him and explain this so that he would understand. Thank you for all of the guidance I can get on this!
Diagnosis
| Pre-op Diagnosis * Wrist laceration, right, initial encounter [S61.511A] * Ulnar artery injury, right, initial encounter [S55.001A] | Post-op Diagnosis * Wrist laceration, right, initial encounter [S61.511A] * Ulnar artery injury, right, initial encounter [S55.001A] |
Procedures
Panel 1 Procedures: RIGHT WRIST IRRIGATION AND DEBRIDEMENT WITH ULNAR ARTERY LIGATION, MEDIAN NERVE REPAIR, TENDON REPAIR (R)
Indications: procedure for
* Wrist laceration, right, initial encounter [S61.511A]
* Ulnar artery injury, right, initial encounter [S55.001A].
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, damage to nerve and tendons, pain, loss of function, need for additional surgery. Patient understands and wishes to proceed.
The patient was taken back to the OR and underwent anesthesia without complication. The upper extremity was draped and prepped in the usual sterile fashion. A time-out occurred immediately prior to procedure identified the correct patient, site, laterality, planned procedure, preoperative antibiotics, availability of equipment and availability of imaging. The arm was exsanguinated and the tourniquet was insufflated to 250 mmHg.
There was an extensive laceration along the proximal aspect of the wrist with a length of 10-12 cm which was previously loosely approximated. The sutures were removed using a 15 blade for further secondary wound closure. A 15 blade was used to extend the laceration proximally and distally by making a cut along the center of the distal forearm proximally and along the thenar crease distally. The skin flaps were raised while dissecting down using tenotomies and a 15 blade. Distally, the flexor retinaculum was exposed and the flexor retinaculum was completely cut to released the carpal tunnel to allow mobilization of the median nerve. Proximally and also the skin flaps were released to expose the flexor tendons.
The findings of traumatic wound exploration was as follows: Partially cut of the FCR tendon about 50-60%, partial cut of the FDS-3 and partially cut out FDS-4 about 40%, complete cut of the FCU tendon, complete cut of the median nerve, complete cut of the ulnar artery. The ulnar nerve was explored and was intact, FDP tendons, FPL were explored and were intact. Also the FDS tendon to the index and small finger were intact.
Following exploration, the ulnar artery was separated and since the perfusion to the fingers was in an acceptable range, we decided to ligate the ulnar artery using a number 2-0 silk. Both proximal and distal ends of the artery were explored and ligated.
The ulnar nerve was explored and released throughout its course and the Guyon's canal was also released to remove any compression over the ulnar nerve were any kinking point.
Next we proceeded with repair of the FCU tendon using 3-0 Supramid suture with M Tang technique.
Next the FCR tendon was repaired using 3-0 Supramid suture by modified Kessler taking.
Next the FDS tendon to the middle finger was repaired using 3-0 Vicryl in a running fashion to repair the epitendinous and reinforce the cut section.
Next the FDS tendon to the middle finger was repaired using 3-0 Vicryl in a running fashion to repair the epitendinous and reinforce the cut section.
Next we proceeded with repair of the median nerve. There was no retraction of the nerve due to the maintain attachment of the epineurium on the radial side. Neurolysis of the median nerve was performed proximally and distally and the hematoma was removed. A nerve tape was used to place the nerve over the nerve tape and maintain the alignment and approximate the nerve ends using the Nerve Tape. Following repair, the nerve was stable with no tension. Range of motion of the wrist was done which showed stable repair of all tendons during range of motion of the fingers and the wrist. Copious irrigation was done with saline.
The laceration and the incisions were repaired by mobilizing the flaps with secondary wound closure and 3-0 nylon was used in a horizontal mattress fashion to repair the incisions and the laceration.
A dressing was applied using Xeroform followed by 4 x 4 and Webril. A dorsal wrist and hand splint was applied and fixed with Ace bandage.
Findings: Partial cut of the FCR, FDS to the middle, FDS to the ring, complete cut of the FCU tendon, complete cut of the ulnar artery, complete cut of the median nerve.
Complications: None; patient tolerated the procedure well.