# Cpt 20650



## MI_CODER (Nov 2, 2017)

Hello,

I need another coder's opinion regarding CPT 20650. My provider wants to bill for this but I feel like the way that he is documenting it, it would be included in the main procedure. There are no CCI edits between 26541 and 20650, however, my thinking is that since CPT 20650 is a "separate procedure" we would not code for this since it was done in the same area as the reconstruction? Also, the Coder's Desk reference states that this code is used for fracture treatment. The documentation isn't for a fracture so would I not even consider this code?

Thank you in advance.

Procedure(s):
1. Ulnar collateral ligament reconstruction with palmaris longus autograft CPT 26541
2. Pinning right thumb metacarpophalangeal joint CPT 20650

Post-operative Diagnosis:  Post-Op Diagnosis Codes:
   * Rupture of ulnar collateral ligament (UCL) of thumb

We utilized a standard incision over the ulnar aspect of the mcp joint.  The radial nerve identified and taken dorsally.  Incising the capsule the collateral was disrupted centrally and of poor quality.  We proceeded with reconstruction with palmaris.  First the MP joint was pinned to provide skeletal stabilization/traction under c-arm fluoroscopy and images saved.  Addressing the mp joint two burr holes were created at the origin of the collateral and proximal.  At the phalanx holes were fashioned at the insertion of the proper and accessory collateral.  A good bony bridge was left proximal and distal.  We harvested the palmaris with two 1cm volar wrist incisions and then split the graft.  The graft was passed in a figure of 8 fashion through the drill hole construct and weaved in to itself tucking the ends in the drill holes.  Sewn with a 4-0 fiberwire we then closed the capsule and adductor fascia to supplement the repair.  Skin was closed with a 5-0 chromic.  Pin was bent and cut and a sterile dressing applied followed by a thumb splint.


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## AlanPechacek (Nov 3, 2017)

I agree with you.  The pin placed across the MP joint was for "temporary" reduction and stabilization of the MP joint at the time of the procedure, and left in place postoperatively to protect his ligament reconstruction until healing is complete.  If he "trusted" his ligament reconstruction sufficiently, he could have removed the pin after the reconstruction and used an external protective method of support such as a Thumb Spica Cast or Splints instead.  I have no argument with leaving it in place throughout the healing process as he did, but I would consider it to be an integral part of the procedure, just as a cast or splint (initial postoperative dressings) would have been had he chosen to use that instead.  I also agree with you that 20650, as per CPT is "Insertion of wire or pin with application of skeletal traction ...," does not fit his use of the pin.

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


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## MI_CODER (Nov 4, 2017)

Thank you. This helps me out a lot.


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## Orthocoderpgu (Nov 6, 2017)

*Your not alone*

I have a hand surgeon that wants to bill this all the time too. This seems to be the only code with the word "pin" in it, so it gets chosen.


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