Orthopedic Coding Alert

Consider the closure method to choose the correct amputation code

If your orthopedic surgeon performs finger amputations in the OR, you-re all too familiar with the 26910-26952 series. But what happens when a patient amputates part of his finger before he arrives at the hospital? We-ll show you how to select the accurate code depending on the surgeon's documentation and the nuances between the amputation codes.

Read the following operative note that one of our subscribers submitted and review our experts- coding recommendations.

Scrutinize the Op Report

The basics: A 37-year-old male patient accidentally injured the fourth and fifth fingers of his left hand in a chain-and-sprocket configuration. The machine amputated the tip of the patient's fifth finger at the mid-nail level  and left an additional four centimeters of mangled finger and bone below the amputation. The patient also had minor lacerations over the dip joint volarly at the fourth finger.
 
Procedure: The surgeon administered a Marcaine block and sterilely prepped the fourth and fifth fingers. Using a Penrose drain for a tourniquet about the base of the finger, the surgeon amputated the mangled portion of the finger and sharply debrided the injury at the amputation site, including the bone, with a rongeur.

The surgeon carried out sterile betadine and saline irrigation, then created a V-Y flap to cover the remainder of the finger and sutured it with 5-0 nylon. The surgeon then cleansed the fourth finger with saline and betadine and used single 5-0 nylon to repair the less-than-half-centimeter laceration.

Problem: -Our surgeon wants to bill 14040 and 26765 for this, but another physician in our practice disagrees,- the coder tells Orthopedic Coding Alert.

Step 1. Report Amputation, Wound Care

We shared the subscriber's operative note with our coding experts: Thomas W. Wolff, MD; Barbara Spaulding, CPC; Tamra L. Avis, CPC; Donna Clemmons; and Kari Wood of Kleinert, Kutz and Associates Hand Care Center in Louisville, Ky. The Kleinert, Kutz team offers the following advice for coding the operative note:

The practice should report 26952-F4 (Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps [V-Y, hood]; Left hand, fifth digit) to represent the surgeon's work amputating the mangled finger, incising the overlying skin and dissecting the tissues to the bone.

She removed the bone with the rongeur and closed the injury with a V-Y flap closure, which warrants 26952. Link the procedure to the ICD-9 code 886.0 (Traumatic amputation of other finger[s] [complete] [partial]; without mention of complication).

Note: If the surgeon had not created the V-Y flap but had instead used direct closure, you would have reported 26951 (... with direct closure) instead.

To represent the surgeon's simple wound repair to the fourth finger, the practice should bill 12001-59-F3 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less; Distinct procedural service; Left hand, fourth digit). Pair this CPT code with 883.0 (Open wound of finger[s]; without mention of complication).
 
Step 2. Finger Modifiers May Not Override NCCI

Tip: Although the National Correct Coding Initiative (NCCI) bundles 12001 into 26952, the different finger modifiers and modifier 59 (Distinct procedural service) show the insurer that the surgeon addressed two separate fingers.
 
Some individual carriers don't accept the finger modifiers such as F4, Spaulding and Avis say. In fact, they say, their Medicaid carrier processes claims for finger modifiers, but their Medicare payer will not.

Therefore, the addition of modifier 59 should help you clinch payment.

Step 3. Overlook Fracture Care Codes
 
Because the orthopedic surgeon did not document a fracture, the practice should not report 26765 (Open treatment of distal phalangeal fracture, finger or thumb, with or without internal or external fixation, each).

Remember: The surgeon may have recommended 26765 because she recalls performing open fracture treatment, but without appropriate documentation, the coder would have no way of knowing whether the surgeon treated a fracture.

-The medical coders are not in the OR with the surgeons, so the coders rely heavily on the surgeons to dictate at the highest level of specificity on every procedure (such as length of laceration, level of debridement, site of injury, etc.),- Spaulding and Avis say. -As we were taught by our instructors, -If it is not in the operative note, the procedure was never done.- -