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Hand surgery with multiple cpt's

  1. #1
    Columbus, Ohio
    Question Hand surgery with multiple cpt's
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    Good morning coders, I have a hand surgery that the surgeon coded but I don't feel the documentation supports what he wants to code and I'm not sure what procedures could be bundled. I have the op note and his codes. Am I making this harder than it should be? I need your advice. Thanks, Paula

    Left hand dog bite with deep infection.
    Left hand dog bite with deep infection with left hand penetrating wound
    of dog bite in the first and second web space with deep palmar space
    infection, with flexor tenosynovitis of the fingers and deep infection
    in the carpal tunnel in Guyon's canal.
    1. Left first and second web space exploration of separate penetrating
    wounds, left thumb, index, long, ring and small finger A1 pulley
    release, left hand deep palmar multiple bursa infections with irrigation
    and debridement.
    2. Left flexor tendon sheath of the thumb, index, long, ring and small
    finger irrigation and debridement.
    3. Left Guyon's canal and carpal tunnel release.
    4. Left tenosynovectomy of the flexor digitorum sublimis of the small,
    ring, long and index finger.
    The patient was identified in preop holding, both verbally and by her
    identification tag, transferred to the operative suite and placed on the
    operating table in supine position. Anesthesia saw the patient, gave
    her general anesthetics, secured her airway. The patient's left hand
    was all very firm and tense, swollen. Her fingers were in a flexed
    position. She, at this point, had a puncture wound which was closed
    over the dorsal first and second web space, these were incised.

    Exploration of the penetrating wounds was performed and explored. She
    had some thickened serous fluid from these. There was no abscess or
    pus. No foreign body. The patient then had a carpal tunnel incision
    made over the ulnar border of the carpal tunnel. Dissection was carried
    down and Guyon's canal was identified and released. She had thickened
    serous fluid in Guyon's canal. Ulnar neurovascular bundle was protected
    and the transverse carpal tunnel was released off the hook of the
    hamate. There was purulent pus and thickened synovial fluid in the
    carpal tunnel. The flexor tendons had thickened tenosynovium.
    Tenosynovectomy was performed. The median nerve was identified and
    protected. The patient's deep bursae were irrigated and debrided in the
    deep bursal spaces of the hand. The patient had incisions made over the
    A1 pulley of the thumb, index, long, ring and small finger and these
    fingers then had dissection carried down over the A1 pulley. The
    neurovascular structures were protected. The A1 pulley was released.
    Each of the flexor tendon sheaths had thickened purulent material with
    even some thickened pus in the long and index finger. The patient
    underwent irrigation and lavage with 1 liter of normal saline and bulb
    syringe lavage of the hand followed by 2 liters of normal saline. After
    thorough irrigation and debridement, the tissue seemed appropriate. The
    pus was gone. The tenosynovium, which was pathologic, was debrided.
    The patient's wounds were closed with 4-0 nylon suture. They were left
    loosely approximated and a Silastic drain was placed in each wound. She
    had eight Silastic drains placed. A sterile dressing was applied
    followed by a volar wrist splint. She was transferred to PACU in stable

    The surgeon coded:
    20103 x2
    26020 x5
    26145 x5

    Should the I&D of the bursae be coded with 26030?
    Is the 26020 part of 26145?
    Is the A1 pulley release billable ? and did he document how many he did?
    questions, questions, I over thinking this?

  2. #2
    Columbus, Ohio
    Hello coders, I was hoping someone could help me with this surgery, I appreciate any feedback..does anyone code hand surgeries? they are so confusing..thanks again, Paula...sorry to beg for help..

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