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need help with dx on this hand sx please

  1. #1
    Location
    Pensacola , Florida
    Posts
    122
    Default need help with dx on this hand sx please
    Medical Coding Books
    doc did : Open biopsy and dissection around the dorsal hood right long finger ...

    A curvilinear incision opened I was able to get the granular gray appearing mass in total and sent to pathology. Very careful dissection was accomplished because of the dorsal hood of the PIPJ .

    His dx is this : Suspected rheumatoid nodule over the PIPJ , right long finger

    This is how I have coded the procedure : 26116 F1

    I know I cannot code the dx as suspected rheumatoid ...but how do I code the NODULE itself

    Please help if you can ...also am I correct with the 26116 ?

    Thanks !

  2. Default
    Is this all the info that you have? It sounds to me as if he is doing a biopsy although I am not clear if it is of bone or a mass on the bone.
    Also, just on a side note, I did notice you mentioned modifier F1. That would not be accurate for the long finger of the RIGHT hand. F1 would be the second digit on the left hand.
    Are you able to provide more info than listed above?
    Thanks
    Heidi

  3. #3
    Location
    Pensacola , Florida
    Posts
    122
    Default
    Heidi ...thanks ! on the modifier ..oops ..yep, i knew that

    here is the op if you can take a look at it and tell me what you think
    Thanks!!

    PREOPERATIVE DIAGNOSIS: Suspected rheumatoid nodule over the PIPJ, right long finger.

    POSTOPERATIVE DIAGNOSIS: Suspected rheumatoid nodule over the PIPJ, right long finger.

    PROCEDURE PERFORMED: Open biopsy and careful dissection around the dorsal hood right long finger.


    DESCRIPTION OF CASE: The patient was given a brief outpatient local anesthesia for her right long finger with a digital block in the webspace, starting out with Xylocaine 1% without, followed that by dose of Marcaine 0.5% without at the end of the procedure. A curvilinear incision was planned over the area once the anesthesia had taken.

    The patient had a finger tourniquet applied. The total tourniquet time of the finger tourniquet was 8 minutes.

    A curvilinear incision having been opened, I was able to get the granular gray-appearing mass essentially in total and sent off to pathology.

    Very careful dissection was of course accomplished because of the dorsal hood of the PIPJ.

    The patient then had thorough irrigation and closure with 3-0 horizontal mattress sutures of Prolene.

    A bulky dressing was applied. Re-infiltration of the area with 0.5% Marcaine without epinephrine was accomplished, and a bulky dressing applied with Triple Antibiotic ointment and Adaptic.

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