ortho coding guidance: repair extensor pollicis longus tendon and pinning IP joint


Kings Beach, CA
Best answers
Requesting coding guidance on left thumb extensor pollicis longus laceration.
CPT codes from MD include: 26418, 11043, 20650

20650 states (separate procedure) however, i am not able to find a code for the pinning (or an appropriate repair code that includes pinning)

Any suggestions or thoughts would be greatly appreciated!

1. Left thumb laceration.
2. Left thumb extensor pollicis longus laceration.

1. Irrigation and debridement of left thumb wound
2. Repair of left extensor pollicis longus tendon.
3. Pinning of left thumb IP joint.

The left thumb laceration was extended proximally and distally.
This was a transverse laceration just proximal to
the thumb IP joint. Sharp dissection through skin was followed by blunt
dissection through subcutaneous tissues. Skin edges of the laceration
were carefully debrided. No foreign material was appreciated. Nonviable
tissues were debrided including skin, subcutaneous tissue, and peritendinous
tissue. Flaps were elevated. The EPL was identified.
There was complete laceration in line with the skin laceration
with proximal retraction of the tendon. The tendon was carefully mobilized
and was still somewhat tight. Releases were performed to allow for the
tendon to approximate to its distal end; however, was necessary to keep the
thumb in relative extension and retropulsion. A 0.035 K-wire was advanced
across the thumb IP joint under multiplanar fluoroscopy to help maintain
thumb extension and to limit stress on the repair. Once this was completed,
the pin was cut and the EPL was reapproximated using FiberWire suture in a
modified Kessler fashion with additional Vicryl sutures in a figure-of-eight
fashion. Tendon ends did meet and approximated well, but were under some
tension, which was neutralized by the pinning and the thumb being held in
extension. No graft was deemed necessary at this point. Final debridement was performed.
The pin was cut and a Jurgan ball was placed.


Best answers
Whoa Nellie! Unfortunately you have wandered way off course with some of your proposed &/or considered codes. The code 26418 is correct for repair of the extensor pollicis longus tendon laceration of the thumb. But, 20650 is for the placement of a K-wire or Steinman Pin for the application of skeletal traction for fracture care, and does not apply to this situation, stabilization of the IP joint of the thumb. He did this part of the procedure to help with his tendon repair, and to take tension off of and protect his repair, as opposed to relying on an external splint postoperatively. As such, it would be an integral part of his procedure, and not a separate procedure, just as applying postoperative dressings and casts/splints are an integral part of the procedure. Your code 11043 does not really apply to this clinical situation. I refer you to the CPT section for Surgery/Integumentary System, in particular the section on Repair (Closure). Your surgeon did an Exploration, Debridement (skin and subcutaneous and tendinous tissue), then repair of the tendon and thumb laceration. In particular, under Instructions for wound repair, #4: Involvement of nerves, blood vessels, and tendons, where it says: "Report under appropriate system (Nervous, Cardiovascular, Musculoskeletal) for repair of these structures. The repair of these associated wounds is included in the primary procedure unless it qualifies as a complex repair, in which Modifier 59 applies." What this means is that unless the wound is very extensive, grossly contaminated, or required extensive tissue debridement (which it did not), the treatment of the laceration is part of the tendon repair, and couldn't be separately code and charged, even with Modifiers. For what it is worth, the only thing that can be charged for is the tendon repair, the primary procedure.

I am not intending to upset you, but help you get on the right track.

Respectfully submitted, Alan Pechacek, M.D.