time frame between primary and secondary treatment

cep1106

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I have a physician that is billing 26373 and is getting denied by the insurance company who is recommending 26370. The repair of the FDP tendon with phalanx fracture. The procedure was not performed for 12 days after the injury. The physician feels this should be a secondary repair because it wasn’t performed immediately after the injury as stated in the procedure description.

26373- Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon.


Orthonet is a company that Tufts uses for claim review. They are suggesting we change the code to 26370


26370-Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon primary repair.

The injury occurred on 9/2, the patient was seen in the Emergency room on 9/3 and then by the hand specialist on 9/11 with surgery taking place on 9/14. When reading the description of the surgeries in encoder pro it states

Primary repair is done immediately after injury.
Secondary repair is done sometime after the incident of injury or following a previous surgical repair

Is there a time frame that constitutes primary vs secondary repair.

Thanks for the help!!
cprovost
 
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