Wiki Local Infiltration performed followed by redution

[LLRodgers]

Hello,

If anyone can direct me on this one, it would be very much appreciated.

Patient has right middle trigger finger, she came into the office the doctor did a local infiltration followed by a reduction then the flexor tendon was injected.

Do I just code the injection/medication or do I need to code for the local and reduction? If I do need to code the local/reduction what code would I use for this, I could not find a code that I felt was correct.

Thank you,
LLR

 

[MI_CODER]

Can you please post the op note?

 

[AlanPechacek]

If I get this right, the patient came to the office with a "locked" Trigger Finger, which usually is painful. In order to treat the patient, your physician did a Manipulation (not really a "Reduction") of the Locked PIP Joint under (local) anesthesia. The code for this is 26340. He then proceeded to do a "Tendon Sheath Injection" for Trigger Finger, 20550, with a steroid medication in hopes of "treating" the Trigger Finger to resolve swelling, inflammation, and future locking. I would probably code an office E&M with Modifier 57 (decision for procedure, which I assume he discussed with the patient and the patient consented), then the Manipulation procedure, 26340, as a primary "procedure," then the Tendon Sheath Injection, 20550, with Modifier 51 for "Multiple Procedures."

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com