Wiki Repair extensor pollicis longus left hand


Rothbury, MI
Best answers
I was just wondering if I can only code the repair 26418 or if I can also code the exploration.

Extensor pollicis laceration left hand

Surgical exploration of the wound, repair of the extensor pollicis longus left hand

Patient suffered a laceration to the dorsum of the hand with a cut off we'll he is unable to extend his thumb. Diagnosis of a extensor pollicis longus laceration is made surgical exploration and repair is warranted


The patient is brought into the operating room under a regional block. He is supine on the operating room table. His arm is on an arm board. The patient is now prepped and draped in sterile fashion. Preoperative markings are visible. Preoperative timeout is carried out. The arm is exsanguinated using an Esmarch bandage and the tourniquet inflated to 250 mmHg.

An ellipse of skin is taken around the wound. 2 mm on each side of the lacerated skin is resected as this area was significantly irritated and erythematous following the relatively blunt injury. Having resected the skin we identify small superficial nerve that is divided. The nerve is mobilized and placed deep in the dorsal webspace musculature.

The tensor pollicis longus stump is identified at the level of the extensor hood. The end of the tendon is cleaned and a 3-0 Supramid suture is laced onto the tendon.

The proximal tendon is identified at the level of the end of the third compartment. And it is brought out through the wound. The end of the tendon is resected so that we have cleaned tendon. The tendon is secured with a 3-0 Supramid. The tendon will reach with the thumb And some degree of abduction. An 8 strand tendon repair is carried out we have good coaptation of the tendon with no gapping. We placed the thumb through range of motion we find that we can flex the metacarpophalangeal joint to 30° before the tendon starts to come under tension.

The wound is now thoroughly irrigated and closed in layers. A sterile dressing is applied. A custom splint is placed. The patient leaves the operating room in stable condition will follow up in clinic tomorrow morning for therapy
Three things: Examination of the operative area is always included with every procedure. Look at your arthroscopic repairs. Before any repair is done the surgeon will always examine the entire joint first. That routine exam is always included with the procedure.

I think you are referring to 20103 which is the examination of a penetrating wound. If this was not a penetrating wound, then 20103 could not be reported. It does not seem to be a penetrating wound. Additionally 20103 is also listed as a "Separate Procedure" meaning that it cannot be reported with other procedures performed in the same anatomical location.

I know the surgeon indicated in the procedure section that an exploration was performed, however this is not documented in the body of the op note either.
Thank you so much. I was referring to the exploration but I did not think there was enough documentation in the body to support billing the CPT, and I also wasn't sure if it would be included in the repair.