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Hand Coding

  1. Default Hand Coding
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    One of my hand surgeons and I have a difference of coding opinion on the following OP report:

    A sterile marking pen was then utilized to mark out a curvilinear incision overlying the ulnar
    border of the thumb MCP joint. An Esmarch was utilized to exsanguinate the upper extremity
    and the tourniquet was inflated to 250 mmHg. A #15 blade was used to incise the skin.
    Meticulous hemostasis was obtained in subcutaneous plane with bipolar cautery. Several
    superficial branches of the radial sensory nerve were identified and protected throughout the
    procedure. The sagittal band was then released off of the ulnar border of the extensor pollicis
    longus leaving a 2mm cuff of the band attached to EPL for later repair. A longitudinal
    capsulotomy of the MCP joint was performed along the ulnar border of the joint line. This
    allowed for excellent exposure of the underlying ulnar collateral ligament injury and the
    proximal phalanx fracture. The patient had a complete avulsion of the ulnar collateral ligament
    off of the proximal phalanx with an associated bony avulsion fracture. The proximal phalanx
    fragment was very small and multi-fragmented. As such, the proximal phalanx fragments were
    carefully excised. The ulnar collateral ligament was then carefully unfolded and brought back
    out to length. The ulnar corner of the proximal phalanx was completely devoid of cortical bone
    at the native footprint for the collateral ligament. As such, two Keith needles were advanced
    from the ulnar corner of the proximal phalanx in an anterograde and radial direction to exit along
    the radial border of the thumb proximal phalanx.
    Two 2-0 prolene sutures were then passed through the ulnar collateral ligament in a running,
    non-locking fashion. The prolene suture tails were then passed through the Keith needles and the
    Keith needles were pulled through the proximal phalanx to shuttle the suture tails through the
    bone. The suture tails were then passed through a layer of Xeroform and gauze followed by a
    polypropylene button along the radial border of the proximal phalanx. The thumb MCP joint
    was then carefully reduced and held in a semi-flexed posture while each set of suture tails were
    sequentially tightened and tied to reduce the ulnar collateral ligament down to the proximal
    Tensioning of the repair was then checked with the MCP joint in both full extension as well as
    30 degrees of flexion. All testing demonstrated excellent restraint against apex ulnar deviation
    stress at the level of the thumb MCP joint. The repair was then further reinforced by retensioning
    the ulnar MCP joint capsule with 3-0 vicryl sutures (capsulodesis). The ulnar sagittal
    band and the adductor aponeurosis were then repaired with 3-0 vicryl sutures to re-centralize the
    EPL tendon.

    He feels that CPTs: 26540, 26437, 26235 and 26516 are all warranted..

    I believe that 26540 and 26437 are the only CPTs that should be billed.

    Just was wondering if a diferent set of eyes could help!


  2. #2
    Salt Lake North
    Default My take
    I have not had a hand surgeon for a year so I am a bit rusty, but I more or less see it your way Heather. I have had two surgeons join our practice right out of fellowship and neither one was taught anything about reporting the correct set of codes and bundling. All they seem to be taught was the CPT for the procedures, but not every procedure can be submitted. Example, you can't bill for carpal bone removal for a CMC arthroplasty since the removal of the trapezium is part of the procedure. By not knowing the diagnosis I was a bit handicapped as well. Codes 26235 & 26516 both bundle with 26437. At best and depending on the official diagnosis codes 26540 & 26437 would be the only codes reported. I would think that due to the extra work modifier -22 could be used as well.

    I hope others with more recent experience will look at this.

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