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tendon exploration

  1. #1
    Boone, NC
    Default tendon exploration
    Medical Coding Books
    Patient's finger was hit by soccer ball. Exam/symptoms indicated possible avulsion tendon injury. Patient was taken to OR for tendon repair (flexor profundus, finger). Any ideas what can be coded? Unlisted procedure?

    Thanks for your help!

    OPERATIVE PROCEDURE: Patient was taken to the operating room and
    placed supine on the operating room table. After satisfactory general
    anesthesia had been obtained, the left hand and arm was prepped and
    draped in the usual sterile fashion. The hand and arm were
    exsanguinated with an Esmarch bandage and the tourniquet on the
    forearm inflated to 250 mmHg pressure. The volar aspect of the middle
    digit was addressed. A Brunner incision was made from the PIP flexion
    crease to the pulp of the middle finger. Incision was carried down
    through subcutaneous tissue. The tissue was elevated off the
    underlying flexor tendon sheath. Exploration revealed that the flexor
    profundus insertion on the distal phalanx volar surface was intact and
    there was no significant edema, bruising, ecchymosis, etc. in that
    area. The A4 pulley was intact and the flexor sublimis and profundus
    tendon were present proximal to the A4 pulley. Traction on the
    profundus tendon easily flexed the DIP joint. I placed traction on
    the tendon and was able to feel the tendon unit pull in the palm and
    pull in the volar forearm indicating muscle tendon attachment was
    still intact as well. Again traction on the tendon flexed the digit.
    With her under anesthesia a tenodesis effect was intact where if I hyperextended the wrist, the PIP joint and DIP joint would flex.
    There did not appear to be a disruption of the flexor profundus or
    sublimis tendons. The wounds were irrigated, the skin closed with 5-0
    nylon. Vaseline gauze and a bulky dressing was applied. The patient
    tolerated the procedure well and taken to recovery in stable

  2. #2
    so no tendon was repaired? look at 26080 for the exporation

  3. #3
    Boone, NC
    Thanks for your response! I ended up choosing 26020 + 52 mod (since there was no tendon drainage). Didn't feel comfortable w/ 26080 since it didn't appear that joint was incised.

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