Orthopedic Coding Alert

In the multifaceted arena of hand surgery, the range of available codes and the number of small bones in the hand and fingers add up to coding challenges for even the seasoned orthopedic coding specialist. Understanding the definitions and procedures of common hand surgeries is the first step to accurate coding and optimum reimbursement.

Definitions of Common Hand Surgeries

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., identifies some of the most common hand surgeries where bone is repaired or otherwise affected.

Open treatment of fractures: An incision is made to set or repair a broken (fractured) bone in the hand. In hand surgery, an open treatment is most likely to occur when the nature of the fracture prevents a closed setting. Common open procedures for the hand include 26615 (open treatment of metacarpal fracture, single, with or without internal or external fixation, each bone), 26665 (open treatment of carpometacarpal fracture dislocation, thumb [Bennett fracture], with or without internal or external fixation), 26735 (open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with or without internal or external fixation, each), 26746 (open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, with or without internal or external fixation, each) and 26765 (open treatment of distal phalangeal fracture, finger or thumb, with or without internal or external fixation, each).

Arthroplasty: This is the creation of an artificial joint, or an operation to restore as far as possible the integrity and functional power of a joint.

In hand surgery, arthroplasty most commonly is used to repair or correct cartilage damage and joint dislocations caused by various forms of arthritis, or to correct ankylosis. Common arthroplasties of the hand include 26530-26531 (arthroplasty, metacarpophalangeal joint) and 26535-26536 (arthroplasty, interphalangeal joint).

Capsulodesis: This is the correction of joint instability or dislocation of joints caused by injury or disease.

The physician cuts into the capsule of the joint, and then attaches the capsule with sutures to either the proximal or distal ends of the bones to provide stability. Common capsulodesis procedures include 26516-26518 (capsulodesis, metacarpophalangeal joint).

Editors note: Choose only one code from this series to indicate the total number of digits treated.

Capsulectomy or Capsulotomy: These terms indicate the creation of an opening through a capsule or through scar tissue that has formed around a joint or bone.

In hand surgery, this procedure is used to correct contracture of the joint. Common procedures for the hand include 26520 (capsulectomy or capsulotomy; metacarpophalangeal joint, each joint) and 26525 (capsulectomy or capsulotomy; interphalangeal joint, each joint).

Arthrotomy: This is the cutting into a joint for exploratory purposes or to remove a loose foreign body.

In hand surgery, arthrotomy can be either a soft-tissue or a bone surgery, depending on the nature of the problem. Common hand arthrotomies with exploration, drainage and removal of loose foreign body include codes 26070-26080. Codes 26100-26110 are arthrotomies that include biopsies of the excised tissue.

Osteotomy: Cutting a bone, usually by means of a saw or chisel. In hand surgery, an osteotomy commonly is used to correct a deformity of the bone and includes 26565-26568 (osteotomy).

Codes for other common surgeries of bones of the hand include 26546 (repair non-union, metacarpal or phalanx, [includes obtaining bone graft with or without external or internal fixation]) and 26548 (repair and reconstruction, finger, volar plate, interphalangeal joint).

Using Modifiers

When operating on multiple bones of the hand at the same time or at the same site of incision, code each bone repair separately. Correct coding of the subsequent procedures can be done in one of several ways, and carrier preference should be determined in advance whenever possible. The options are:

Appending modifier -51 (multiple procedures) to all subsequent procedures (i.e., 26615, 26615-51);

Indicating the number of units performed
(if the same procedure is performed on each bone)
in the appropriate field on the HCFA 1500 form
(i.e., 26615 x 2); or

Using HCPCS digit modifiers (F1-F9) when
the procedures are performed on different digits
(i.e., 26615-F1-F2).

Experts agree that combining modifiers (i.e., 26615-F1, 26615-51-F2) is redundant and in the worst-case scenario may result in claims being further reduced by commercial carriers (see the reader question Modifier
-51 With Wrist and Finger Fractures on page 31 of the April 1999 Orthopedic Coding Alert). Check with your carrier before submitting billing. Regardless of the modifier used, insurers probably still will reduce the fees on subsequent procedures. The rationale behind the reduced fees is that during an open procedure, for example, the preoperative and postoperative care is done only once, regardless of the number of procedures performed on the hand. Reductions usually are approximately 50 percent for the second and subsequent procedures.

Applying the Rules to a Real-life Scenario

Donna Bal, CPC, CPC-H, coding specialist at Midwest Orthopaedic Surgery Inc., a seven-physician practice with three offices in western Missouri and eastern Kansas, shares some operating notes on a recent hand surgery performed by one of her physicians:

Pre- and Postoperative Diagnosis: Degenerative arthritic changes at base of carpal metacarpal joint with dislocation.

Name of Operation: Resection arthroplasty with
removal of trapezium and placement of slip from
abductor pollicis longus through the carpi radialis tendon and back onto the abductor pollicis longus
tendon along with pin fixation of the shaft of the first
metacarpal into the scaphoid.

Coding the Surgery

When you are coding surgery from an operative report it is advisable to start by identifying the procedure(s) performed as indicated by the surgeon under the heading Name of Operation, says Heidi Stout, CPC, CCS-P, coding and reimbursement specialist at University Orthopaedic Associates in New Brunswick, N.J, who works with 11 physicians at three locations, specializing in various orthopedic specialties. In this case we have the following information:

1. Resection arthroplasty (Although it is not
specifically stated, it is safe to conclude that the arthroplasty is of the carpometacarpal joint, as the patients diagnosis is degenerative arthritis of the carpometacarpal joint, says Stout);

2. Removal of trapezium;

3. Placement of abductor pollicis longus slip through the flexor carpi radialis; and

4. Pin fixation of the first metacarpal to the scaphoid.

Lets start with the resection arthroplasty, says Stout. If you start your search in the CPT index under the main term arthroplasty, you will immediately get confused, because the carpometacarpal joint is not mentioned. However, we know were dealing with the wrist, and there are 11 different code options offered for wrist arthroplasties in the code range 25441-25447. Upon reviewing the narratives for these codes, you will quickly determine that only 25447 (arthroplasty, interposition, intercarpal or carpometacarpal joints) mentions the carpometacarpal joint. Stout then refers to Global Service Data for Orthopaedic Surgery (available from the American Academy of Orthopaedic Surgeons at www.aaos.org.) and sees that the following intraoperative services are included in the global service package for 25447:

1. Arthrotomy/synovectomy of wrist of intercarpal joints;

2. Excision of osteophytes, bone fragments and joint debridement;

3. Partial or total excision of trapezium or trapezoid;

4. Capsular release, repair and/or reconstruction;

5. Harvesting and insertion of tendon or fascial graft; and

6. Internal fixation of implant.

After reviewing this information, says Stout, it is obvious that 25447 will be the only code you report for this surgical procedure, as it includes all of the components listed by the operating surgeon. After settling on a code, Stout says to review the text of the operative report to make sure the documentation supports that code. In this case, all of the components listed by the surgeon under Name of Operation are addressed in the body of the operative report.

Blair Filler, MD, FACS, director of medical education at Los Angeles Orthopedic Hospital in California, agrees with Stouts assessment of the surgery. Because the usual ICD-9 code will be 715.xx (osteoarthritis [with fourth and fifth digits to indicate severity and location]) for degenerative arthritis, the procedure code should relate to treatment of the metacarpal trapezial joint and not to a carpal excision code. Therefore, Filler explains, the carpectomy code 25210 (carpectomy; one bone) is not a good choice. He agrees that the most appropriate code is 25447 because some other tissue or substance is inserted between the metacarpal and scaphoid bones. Even though the tendon strip is used mainly to stabilize the remaining joint, this procedure is an arthroplasty, Filler explains.

Filler adds that unless the tendon graft is obtained from a separate incision, no tendon graft code should be used. If the graft is obtained through a separate incision, use 20924 (tendon graft, from a distance [e.g., palmaris, toe extensor, plantaris]) and not tendon transplant codes. Tendon transplant codes are used when active tendon function is required, not passive stabilization.

Another Example

Another operative report describes a surgical procedure performed on a female patient with multiple deformities of the hand secondary to rheumatoid arthritis, including ulnar deviation of the hand and subluxation of all metacarpophalangeal joints of the fingers. According to Stout, a well-structure operative report will include a concise statement at the top of the form listing the preoperative diagnosis, postoperative diagnosis and procedure(s) performed. This report lists silastic arthroplasties of the left index, middle, ring and little finger metacarpophalangeal joints, fusion of the thumb metacarpophalangeal joint and open reduction and internal fixation of the interphalangeal joint of the left hand.

When dealing with a complex surgical case such as this, the best place to start is by finding the codes that describe each component of the procedure. After you have completed this step, you can determine which codes can be reported together and which should be bundled into other codes, says Stout. The following codes could be considered for the described procedures:

1. Silastic arthroplasty of the metacarpophalangeal joint. Codes 26530-26536 describe arthroplasties of the finger joints, with and without implants. Careful review of each code, says Stout, shows that the correct choice is 26531 (arthroplasty, metacarpophalangeal joint; with prosthetic implant; each joint). Because the narrative for this code specifies each joint, the code is reported four times, as the procedure was performed on the index, middle, ring and little fingers.

2. Arthrodesis of the thumb metacarpophalangeal joint. Codes 26850 and 26852 describe an arthrodesis of the thumb metacarpophalangeal joint with internal fixation or with autograft. In this case, you will need to read the body of the operative report to determine which code to report, Stout explains. The report says that a K-wire was used to fuse the joint and there is no mention of a bone graft. Therefore, you will report 26850 (arthrodesis, metacarpophalangeal joint, with or without internal fixation).

3. Open reduction and internal fixation of the interphalangeal joint of the left hand. Unfortunately, the surgeon neglected to mention in the op report which finger is involved, says Stout. However, upon reading the text of the operative report, one finds that it is the interphalangeal joint of the thumb that has been reduced and fixed using a K-wire. For this procedure, report 26785 (open treatment of interphalangeal joint dislocation, with or without internal or external fixation, single).

At this point, check your unbundling guide, either The American Academy of Orthopaedic Surgeons Complete Global Service Data for Orthopaedic Surgery or Medicares Correct Coding Initiative, to see if any of these codes could be considered an integral part or a component of another code, Stout says. She explains that it is appropriate to report all of the aforementioned codes: 26531, 26531-51, 26531-51, 26531-51, 26850-59 and 26785-59. I chose modifier -59 (distinct procedural service) for 26850 and 26785 as these could potentially be rebundled by the carrier. Modifier -59 will identify these procedures as being performed at different sites than 26531.

Note: See A Procedural Coding Primer: Increase Pay Up for Soft Tissue Surgery of the Hand on page 44 of the June 2000 Orthopedic Coding Alert for part one of this two-part story on hand surgery.