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Please help with cpts - Need other coder's

  1. #1
    Default Please help with cpts - Need other coder's
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    Need other coder's opinions on CPT. Looking at 26010 for I&D of index finger but unsure about I&D over second dorsal web space.

    op note: Small incision was fashioned over the central pointing area over the proximal phalanx centrally of the index finger. There was a small cental core area of necrotic skin of a few millimeters. The patient hade some purulent material that drained and this was sent for culture both aerobic and anaerobic cultures. The patient also had a small area of skin blistering over the second dorsal web space and the area over the long distal long metacarpal. That was incised and that too was noted to have a small amount of purulent material. That was also sent for culture. The skin and subcutaneous tissues were gently elevated and there were easily connected between the index finger wound and the second doral web space wound. The area of the extent of the infection cellulitis extended over the radial aspect of the index metacarpal head and extended over the ulnar aspect fo the long metacarpal head. Please note that the infection was dorsal only and not over the volar aspect of the hand. The index finger skin infection also extended over the ulnar aspect of the proximal phalanx of the index finger. There was minimal necrotic tissue noted along the central portion of the wound. Extensor tendons were noted to be intact. The wound was thoroughly irrigated with antibiotic solution. The wounds were then packed over with quarter inch lodoform. Dry sterile dressing was applied. The patient was placed in a volar splint.

    Any help is appreciated.

  2. #2
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    In my opinion only one service of 26010 should be billed for both procedures.

  3. #3
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    Would this apply since two incisions were made? Just trying to understand this.

    thanks.

  4. Default 26011 Deep SubQ + left open to drain
    Quote Originally Posted by rhblevins61@yahoo.com View Post
    Need other coder's opinions on CPT. Looking at 26010 for I&D of index finger but unsure about I&D over second dorsal web space.

    op note: Small incision was fashioned over the central pointing area over the proximal phalanx centrally of the index finger. There was a small cental core area of necrotic skin of a few millimeters. The patient hade some purulent material that drained and this was sent for culture both aerobic and anaerobic cultures. The patient also had a small area of skin blistering over the second dorsal web space and the area over the long distal long metacarpal. That was incised and that too was noted to have a small amount of purulent material. That was also sent for culture. The skin and subcutaneous tissues were gently "elevated" and there were easily connected between the index finger wound and the second doral web space wound. The area of the extent of the infection cellulitis extended over the radial aspect of the index metacarpal head and extended over the ulnar aspect fo the long metacarpal head. Please note that the infection was dorsal only and not over the volar aspect of the hand. The index finger skin infection also extended over the ulnar aspect of the proximal phalanx of the index finger. There was minimal necrotic tissue noted along the central portion of the wound. Extensor tendons were noted to be intact. The wound was "thoroughly" irrigated with antibiotic solution. The wounds were then packed over with quarter inch lodoform. Dry sterile dressing was applied. The patient was placed in a volar splint.
    Quote Originally Posted by rhblevins61@yahoo.com View Post

    Any help is appreciated.

    Please find my highlighted text in the query post.
    Per physician's (highlighted) documentation, it is clear that abscess is deep sub Q + thoroughly irrigated + packed, I'll assign 26011.

    In 26011, the abscess just reaches deep subcutaneous tissue and requires extended irrigation. The wound may be left open to drain.

    PS:If splint application performed by MD, need to assign added CPT

    RT/LT not mentioned of index finger; Query Physician, need to assign an anatomical modifier.
    Last edited by msrd_081002; 03-02-2011 at 07:25 PM.
    Thanks

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