Orthopedic Coding Alert

You could be missing out on reimbursement if you don't thoroughly read the op note.

If coding hand surgeries involving a slew of specific terms has you scratching your head, a few minutes brushing up on your hand anatomy could be just what you need to improve your hand surgery acumen.

Here's how: Take a look at the following hand surgery and see if you-re on par with our expert provided coding recommendations.

Note: The following op note was provided by Chris Ford with the billing department of Coastal Orthopedics and Sports Medicine Group in Oceanside, Calif. Do you have a difficult case? Send your op note to the editor (suzannel@eliresearch.com) and see it discussed in future Orthopedic Coding Alert issues!

First, Read This Op Note

Pre-op dx: Right hand wound dehiscence with extensor tendon ruptures and open wound

Post-op dx: Right hand wound dehiscence with extensor tendon ruptures and open wound

Procedures:

1) Extensor tendon repair, extensor digitorum communis, right long finger

2) Extensor digitorum communis, right index finger, tendon transfer, side-to-side to extensor indicis proprius

3) Right ring finger common extensor tendon side-to-side transfer to extensor of the long finger.

4) Right small finger common extensor tendon side-to-side transfer to extensor of the long finger.

Indications: Patient had previous right hand extensor tenosynovectomy. Postoperatively, this was complicated by wound dehiscence that was closed with delayed primary closure. She then dehisced again and underwent I&D with delayed primary closure. She dehisced a second time and ruptured two extensor tendons on the dorsum of the hand. She underwent irrigation and debridement and the extensor tendon rupture was primarily repaired. She was treated with local wound care.

Findings: Ruptured extensor digitorum communis of the index finger, ring finger, and small finger. Intact extensor to the indicis proprius. Middle finger common extensor intact but necrotic. Intact extensor digiti minimi.

Op report: [anesthesia and prep -] dorsal skin flaps around the open wound that were adherent to the extensor tendons were elevated and freed - all of the extensor tendons proximally and distally into normal tissue were freed up and the ends trimmed to normal, healthy-appearing tendons. The common extensor of the long finger was noted to have a necrotic central area, which was excised. The common extensor of the long finger was then repaired with Krakow stitch of 3-0 Ethibond reinforced with a running epitendinous suture of #4-0 nylon. The common extensor to the index finger was then woven into the extensor indicis proprius tendon under appropriate tension with three weaves with a Pulvertaft technique. Each weave point was secured with an interrupted box suture of #4-0 ethibond. The ring finger and small finger extensor tendons were then repaired in a side-to-side transfer to the proximal stump of the long finger extensor tendon. These were all done with the hand in about 20 degrees of extension and this brought her MP and IP joints of the fingers up into nearly full extension. This was felt to be excellent tension on all the tendons - Patient turned over to Dr. B for the reverse radial artery forearm flap to provide good soft tissue coverage over the tendons [his dictation is separate] - [closure and dressing].

Examine Your Anatomy

When you-re dealing with hand surgery, you need to know the anatomy of the hand/wrist. "You need to know more anatomy, because you have to understand how all the tendons connect and interact," says John Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates and presenter of "Hand & Wrist Coding: Including Surgery Case Studies, Common Diagnoses, AAOS vs. CPT Codes , & More" at The Coding Institute's 2008 Multispecialty Conference in Orlando, Fla. (go to http://www.codingconferences.com to order a CD).

The tendons in this op note "are on the dorsal side of the hand," points out Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network, and executive officer on the AAPC's National Advisory Board.

Heads up: Because most surgical procedure codes do not designate which digit the physician is repairing, identifying the digit in question is essential. You should append HCPCS Level II modifiers to CPT Codes for this purpose. Modifiers FA and F5 apply to the left and right thumbs, respectively; F1, F2, F3, and F4 apply to digits on the left hand; F6, F7, F8, and F9 apply to digits on the right hand.

Benefit: These modifiers signal to the carrier that multiple entries of the same code are not a duplication but, rather, that the physician performed the same procedure on different digits.

Fig. 1 The extrinsic extensor tendons include the following: Extensor carpi radialis longus (ECRL), Extensor carpi radialis brevis (ECRB), Extensor carpi ulnaris (ECU), Extensor digitorum communis (EDC), Extensor digiti minimi (EDM), Extensor indicis proprius (EIP), Abductor polliis longus (APL), Extensor pollicis brevis (EPB), and Extensor pollicis longus (EPL).

Isolate Your CPT, ICD-9 Codes

For this procedure, you should report four CPT Codes For the four procedures.

1) The op note states, "The common extensor of the long finger was then repaired with Krakow stitch of 3-0 Ethibond reinforced with a running epitendinous suture of #4-0 nylon."

For the EDC long finger repair, you should report 26410-F7 (Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon; Right hand, third digit).

2) The op note states, "The common extensor to the index finger was then woven into the extensor indicis proprius tendon under appropriate tension with three weaves with a Pulvertaft technique." For the EDC index to EIP transfer, you should report 26480-F6 (Transfer or transplant of tendon; carpometacarpal area or dorsum of hand; without free graft, each tendon; Right hand, second digit).

3) and 4) The op note states, "The ring finger and small finger extensor tendons were then repaired in a side-to-side transfer to the proximal stump of the long finger extensor tendon." For the EDC ring to EDC long, you should report 26480-F8 (- Right hand, fourth digit). For the EDC small to EDC long, you should report 26480-F9 (- Right hand, fifth digit).

Note: Reading the op note fully matters. The physician describes the excision of the central portion of the EDC long ("The common extensor of the long finger was noted to have a necrotic central area, which was excised") but doesn't list this as a procedure. You may try to report this service as 26170 (Excision of tendon, palm, flexor or extensor, single, each tendon) with modifier 52 (Reduced services).

For your diagnosis, you should report 727.63 (Rupture of tendon, nontraumatic; extensor tendons of hand and wrist), Grady says.

Contemplate Modifiers

You might be able to apply modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) for the complication, Grady says. The op note states, "Postoperatively, this was complicated by wound dehiscence that was closed with delayed primary closure."

Action: You would apply modifier 78 onto all the codes because all of these services are related to the first procedure and required the use of the OR.