jvanek82
True Blue
Hi! My provider did the following surgery and there is a disagreement on what CPT code to bill. The diagnosis he listed is for a trigger finger, but he says he wants to bill 26145 for the tenosynovectomy. When it is suggested that the correct code would be 26055, he states "I would continue to use the 26145 as additional time and effort was spent in performing excisional tenosynovectomy. This is beyond the scope of a simple trigger finger release with release of the A1 pulley." Can someone review this OP note and advise if the use of 26145 would be supported?
* Trigger finger, unspecified middle finger [M65.339].
Procedure Details: Patient was identified the preoperative holding area the operative site was marked. Risks and benefits of surgery again were discussed. Risks included but not limited to bleeding, infection, damage to adjacent structures, stiffness, pain, loss of function, persistence of symptoms and need for additional surgery. Patient verbalized understanding and wished to proceed. Time-out occurred in the preoperative holding area identifying the correct patient, site, laterality and planned procedure. 10 cc of local anesthetic with epinephrine was injected about the right middle finger.
Patient was taken back to the OR. The RIGHT upper extremity was prepped and draped in the usual sterile fashion. Time-out occurred immediately prior to procedure identifying the correct patient, site, laterality, planned procedure, preoperative antibiotic and availability of equipment. Fifteen blade was used incise the skin in line with the right middle finger A1 pulley. Subcutaneous dissection was performed with tenotomies. Any points of cutaneous bleeding were addressed with bipolar cautery. Dissection was carried down to the level of the A1 pulley. Two retractors were placed. With the A1 pulley fully visualized, 15 blade was used to sharply incise the flexor retinaculum. Further release was performed proximally and distally with tenotomies. Flexor retinaculum release was carried to the proximal edge of the A2 pulley and the distal margin of the A0 pulley. Patient was then asked to flex extend the finger. There was no further crepitus or locking. Retractors were repositioned and the FDS and FDP tendons were brought through the incision. Findings of tenosynovitis more proximally between the FDS and FDP tendons. Additional findings of tenosynovitis along the undersurface of the FDS tendon. Excisional tenosynovectomy was performed with tenotomies. There was more generalized swelling about the FDP tendon. The incision was then copiously irrigated. The incision was approximated with 4-0 nylon. A sterile dressing consisting of Xeroform, 4x4s, Webril and Coban was applied.
Thank you for any help and if possible supporting documentation for the correct code.
* Trigger finger, unspecified middle finger [M65.339].
Procedure Details: Patient was identified the preoperative holding area the operative site was marked. Risks and benefits of surgery again were discussed. Risks included but not limited to bleeding, infection, damage to adjacent structures, stiffness, pain, loss of function, persistence of symptoms and need for additional surgery. Patient verbalized understanding and wished to proceed. Time-out occurred in the preoperative holding area identifying the correct patient, site, laterality and planned procedure. 10 cc of local anesthetic with epinephrine was injected about the right middle finger.
Patient was taken back to the OR. The RIGHT upper extremity was prepped and draped in the usual sterile fashion. Time-out occurred immediately prior to procedure identifying the correct patient, site, laterality, planned procedure, preoperative antibiotic and availability of equipment. Fifteen blade was used incise the skin in line with the right middle finger A1 pulley. Subcutaneous dissection was performed with tenotomies. Any points of cutaneous bleeding were addressed with bipolar cautery. Dissection was carried down to the level of the A1 pulley. Two retractors were placed. With the A1 pulley fully visualized, 15 blade was used to sharply incise the flexor retinaculum. Further release was performed proximally and distally with tenotomies. Flexor retinaculum release was carried to the proximal edge of the A2 pulley and the distal margin of the A0 pulley. Patient was then asked to flex extend the finger. There was no further crepitus or locking. Retractors were repositioned and the FDS and FDP tendons were brought through the incision. Findings of tenosynovitis more proximally between the FDS and FDP tendons. Additional findings of tenosynovitis along the undersurface of the FDS tendon. Excisional tenosynovectomy was performed with tenotomies. There was more generalized swelling about the FDP tendon. The incision was then copiously irrigated. The incision was approximated with 4-0 nylon. A sterile dressing consisting of Xeroform, 4x4s, Webril and Coban was applied.
Thank you for any help and if possible supporting documentation for the correct code.