# Unbundling - Trigger and Manipulation



## fish4codes (Mar 9, 2017)

Patient has F7 trigger and PIP joint contracture of same finger.  Surgeon did an A-1 pulley release (incision in the palm) of the F7 for trigger finger, during same procedure he documents manipulation of the PIP of same finger.   These codes have a CCI conflict, but allow for a modifier.  I question does the fact that the incision was in the palm and manipulation was up in the finger allow for unbundling? Any help and documented reference is appreciated!!


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## Orthocoderpgu (Mar 10, 2017)

When I have an NCCI conflict I ask myself "Is there significant separation" between the procedures. The trigger finger will cause the contracture of the joint. Since the joint contracture and the trigger finger are on the same digit, and because trigger finger can cause the contracture, I see this as bundled. Even if they really are considered separate issues, being that they are on the same finger I doubt you would get it paid just as a practical matter.


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## AlanPechacek (Mar 10, 2017)

This patient has two identifiable and separate diagnoses:  Trigger Finger and PIP Joint Contracture.  In order to treat both of these, your physician did two procedures: 
Primary: Open trigger finger release (through the standard palmer incision), and Secondary: Closed manipulation of the PIP joint.  Therefore, I would not consider coding each to be "unbundling."  Each should be CPT coded and submitted with a Modifier to the Secondary procedure.  The issue then is which one to use.  Modifier 51 is for Multiple Procedures, which I think would be the best.  Also there is Modifier 59:  Distinct Procedural Service, which is now a complicated Modifier to use, and probably not as good as 51 for this situation.

I hope this helps.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


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## fish4codes (Mar 11, 2017)

Thank you for your time and help!


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## fish4codes (Mar 11, 2017)

I ran across this thread from 2008...I don't have my 2017 Global Service Data yet...would appreciate any verification if this is still current....many thanks 

"According to the AAOS Global Data, the answer would be no. I have copied and pasted what is global and what is not.

12.	incision of tendon sheath (eg, 26020)
13.	tenolysis and/or tenosynovectomy of flexor tendon(s) (eg, 26145, 26440,
26442)
14.	joint manipulation (eg, 26340)
15.	release of palmar fascia (eg, 26040, 26045, 26121-26125)
16.	first annular pulley release
17.	excision of lesion of tendon sheath (eg, 26160)

Intraoperative services not included in the global service package, when indicated:

1.	supplies and medication (eg, codes 99070, HCPCS Level II codes)
2.	complicated wound closure (eg, application of wound vacuum device to open wound) or closure requiring local or distant flap coverage and/or skin graft, when appropriate (eg, 13160, 14000-14350, 15000-15400, 15570-15776)
3.	insertion, removal, or exchange of nonbiodegradable drug delivery implants (eg, 11981-11983)

I hope this helps "


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## Orthocoderpgu (Mar 13, 2017)

I'm grateful that Dr. Pechaecek gave an answer to this question. That really helps coders with pathophysiology knowledge that we don't have. If we are just looking at pathophysiology, he is correct. And that should end the debate as far as I am concerned. However, we have to look at this through the prism of different coding guidelines. Looking only at the "Guidelines" I would say that it is bundled for the reasons I have previously, there is not enough separation anatomically to report both. At least I doubt very much that any insurance company would see enough separation to allow both, but according to Dr. Pechaecek, they should. As a coder if you feel that there is enough separation to bill both, do it, and reference Dr. Pechaecek in your appeal if you need to. I recently had a physician perform a SLAP repair and then a Bankart through separate approaches. The insurance did not follow NCCI strickly, so I billed both 29806 & 29807. It was denied initially, but paid on appeal.


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## AlanPechacek (Mar 13, 2017)

Thanks for the responses and support for my reply to this question.  I would like to add that my approach to this was based on "rational logic" of the patient in question having two different identifiable problems/conditions to be treated, and which may not be related.  By this I mean that in doing Trigger Finger Releases over 40 years, I do not ever recall having a fixed PIP Joint Flexion Contracture in the same finger as the Trigger Finger that required manipulation.  Although I have seen "locked" Trigger Fingers that could not be passively corrected without anesthesia, and maybe a few that couldn't be corrected even with anesthesia, usually the flexion deformity at the PIP Joint would resolve/correct once the tendon sheath release was performed.  The patient in question that inspired this query and discussion would have to have had that Trigger Finger for a long time (years?) in order to develop a fixed flexion contracture of the joint requiring manipulation.  The other question to be posed as above is whether the flexion contracture was the result of some other disease process not related to the Trigger Finger.

I don't even know why 26340: Manipulation, finger joint, under anesthesia, each joint, is included in the "Global" for the tendon sheath release (26055) since the two so rarely occur simultaneously.  Unfortunately, I am not in a position to argue the matter with the AAOS, AMA, and CMS.

However, base on my rationale it would still be worth a try to submit both procedures with the Modifier.  If the insurance company denies it, then try appealing it.

Good luck and best wishes on this one.

Alan Pechacek, M.D.


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## fish4codes (Mar 13, 2017)

Thank you so much for your very thorough explanation Dr. Pechachek - I appreciate your time. I wish there were not so many gray areas in coding - I, too, felt these were two separate issues and I queried the surgeon to verify.


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## Orthocoderpgu (Mar 13, 2017)

Double thanks Dr. Pechacek for your additional response to this patient. This Is exactly the information that coders need. Based on the medical information that you gave, I would bill this out as non-bundled now. 

I don't have much faith in insurance companies though to really understand these situations. I'm not sure that the medical information that they receive, if any, comes from a good source.

Recently one of our physicians was performing arthroscopic knee surgery. There was a loose body that could not be reached. So the physician had to take it out through an incision. This was in a different compartment than the other procedure, and the only procedure performed through the incision. I thought that there would be no way the insurance could deny the loose body removal in this situation, but they did even after I appealed it with the medical records. Due to this, I don't have faith that insurance companies will give physicians the credit and RVU's that they really deserve.


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