ED Coding and Reimbursement Alert

Question: Should I report this as a nailbed repair or use a laceration repair code?

Patient presents with an injury of 1.5cm involving the nail bed with a jagged laceration to dorsal aspect of distal phalanx of right index finger. Skin/tissue flap noted. Distal neuro/vascular/tendon intact. Anesthesia: Digital block administered with 4 mls of 1% lidocaine. Wound prep: Extensive irrigation and exploration of the wound. Moderate cleansing with Betadine, Subungal hematoma is drained. Nail avulsed fully and removed. Closed with 8 5-0 chromic and nail bed repaired, nail reattached and tacked down with 2) 5-0 vicryl sutures. Dressed with Bacitracin, tube gauze.

Alabama Subscriber

Answer: The question to answer in coding this case is determining whether it is a nail bed repair or a laceration repair and which discrete services may be reported. CPT® Assistant provides the following description of a nail bed repair as opposed to a laceration repair of the area.

“For lacerations to the nail bed, a portion or all of the nail plate is removed in order to visualize the laceration. The laceration of the nail bed is repaired meticulously with sutures. When the nail bed wound extends under the proximal nail fold, bilateral incisions may be made on either side of the proximal nail fold to access the wound. The nail fold is raised, and the nail bed wound is repaired with sutures.”

Code the scenario above as a nail repair using 11760 (Repair of nail bed).

Other codes you might have considered are typically bundled into the nail bed repair code:

• 11730 (Avulsion of nail plate, partial or complete, simple; single) has a CCI edit with 11760 and in this case can’t be reported.
• 11740 (Evacuation of subungual hematoma) also has a CCI edit in place with 11760 and can’t be separately reported

Of note, the 12000 series laceration repair codes also have CCI edits and are bundled into the nail bed repair.

The digital block 64450 (Injection, anesthetic agent; other peripheral nerve or branch) is bundled both by CCI edits for 11760 and according to the CPT surgical package instructions.

Update from the February issue You Be The Coder

The You be The Coder case from the February issue (Vol. 19, No. 2) “That Middle Finger Injury Could Be No Joking Matter” had an extra code listed in the answer. The joke ended up on us when we listed an I&D code although no such procedure was mentioned in the case. The original case was shortened for space consideration and the I&D procedure note was removed from the published version, without also removing the matching code from the answer to that case a few pages later in the issue. The original procedure note appears below, which would have justified the code assigned, 26011 (Drainage of finger abscess; complicated [e.g., felon]). We regret any confusion this may have caused.

Medical Decision Making & ED course

Has abscess to his middle third right finger he is unable to flex MCP PIP or DIP. Patient’s finger is very edematous red tender with induration there is an area of possible fluctuance possible foreign body will sent for an x-ray to rule out foreign body patient will probably need I&D due to extension and streaking of the infection he will have IV antibiotics and labs.

Consent was obtained. Time out was called and appropriate site was identified. The finger was prepped in the usual fashion.

10cc of 1:1 mixture of 1% lidocaine, 0.5% marcaine were used to perform a finger block of the R LF. A 11 blade was used to make a 1cm L-shaped incision over the fluctuant area into the subcutaneous tissue and 2cc of bloody/purulence was expressed. I was unable to collect any gross specimen in a container. A wound swab was used and sent for culture. The wound was packed with 5cm of 1/4” iodoform packing. A clean dressing was placed.

Consult with Ortho obtained.