# Can you bill a 64702 separately of 26356?



## Nelson (Aug 18, 2017)

Hello,

Question has come up with several of us differing in opinions. Would like to throw this out to see what others are doing.

27-year-old patient sustained a traumatic laceration to the ulnar aspect of right hand while prepare a frozen chicken.

His traumatic laceration measured 4.5 cm and was transverse in orientation.  Hematoma was evacuated.  The wound was copiously irrigated.  I first began by identifying the ulnar neurovascular bundle.  The ulnar digital nerve was actually intact, spanning across the wound.  The ulnar digital artery had been lacerated.  Both the proximal and distal aspects were identified.  I elected not to repair this due to the fact that his finger remained perfused.  I did perform a neurolysis of the ulnar digital nerve at this time, freeing it from fascia proximally and distally so that the ulnar digital nerve was free and easily retracted from the flexor tendons.  I then visualized the radial neurovascular bundle.  A limited neurolysis was performed at this level, verifying that the nerve remained intact, as well as the artery.  At this point, I directed my attention to the flexor tendons.  There was a transverse laceration to the flexor tendon sheath between the A1 and A2 pulleys.  The pulleys were left intact, with the exception that I did release a portion of the distal aspect of the A1 pulley.  Hematoma was evacuated from within the flexor tendon sheath.  The proximal aspect of the tendons was easily retrieved using a hemostat.  3-0 Prolene suture was then placed at the distal edge of the tendons to mobilize them.  Additionally, a hypodermic needle was placed through the A1 pulley to pierce the tendons to remain them out to length.  With hyperflexion of the small finger, I was able to deliver the distal aspects of the tendon through our wound.  The FDP tendon escape from distal to the A2 pulley, though this was retrieved easily with the 3-0 Prolene suture and delivered beneath the A2 pulley.  The FDS tendon was then placed superficial to the A1 pulley to increase the space for the FDP.  I first began by repairing the radial slip of the FDS tendon.  This was repaired using 4-0 Ethibond suture in a figure-of-eight fashion.  Two separate figure-of-eight sutures were placed with an excellent repair.  I then began by repairing the FDP tendon.  I first placed a 6-0 Prolene epitendinous suture on the dorsal surface of the tendon.  A 4-strand cruciate repair was then replaced as a core stitch using 4-0 Ethibond suture.  I then completed the epitendinous repair for a complete 360-degree epitendinous repair.  It was a very neat repair site without bunching.  As it was a sharp laceration, we had excellent tendon apposition and essentially no bunching.  As the repair was performed at the proximal aspect of the A2 pulley, I elected to excise the ulnar slip of the FDS so that there was adequate space beneath the pulley for the FDP tendon to glide easily through.  The ulnar slip was then excised.  I did leave the proximal aspect of the FDS superficial to the A1 pulley, while leaving the FDP tendon deep to it.  This was also done to decrease the gliding resistance for the FDP tendon.  The wound was copiously irrigated at this point.  The finger had a normal resting cascade.  I was able to fully extend the finger without triggering or bunching of the FDP repair.  The wound was irrigated once again.  The incision was then closed with 4-0 Prolene suture.  4.5 cm of traumatic laceration were repaired, as were the surgical extensions.


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## Nelson (Aug 21, 2017)

Anyone?


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## AlanPechacek (Aug 24, 2017)

What this amounts to is an Exploration and Repair of a 4.5 cm laceration of the hand at the base of the small finger with laceration of the ulnar digital artery (both ends ligated), but without injury to the ulnar digital nerve nor the radial digital nerve &/or artery.  Because there were complete lacerations of the Flexor Digitorum Sublimis (FDS) and Flexor Digitorum Profundus (FDP) tendons requiring repair, this makes it a Complex Repair of the wound, 13132, which includes everything done except the tendon repairs.
     As for the tendon repairs, he did 26356: Primary Repair of the FDP, which he kept within the tendon sheath, in Zone 2, each tendon.  For the FDS, he did a (partial) Primary Repair in that he repaired the radial slip (only) and excised the remains of the ulnar slip(s).  The fact that he did this repair "outside" the tendon sheath has no effect on the procedure done, which is also 26356.  So he did 26356 x 2 as this code applies for each tendon.
     So the end result is 13132 and 26356 x 2. 

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


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