Orthopedic Coding Alert

Confirm location, incision, and synovectomy, if any.

Reporting nodular masses in the hand can be challenging if you’re not clear on the tumor type, location, or exactly what services the surgeon provided. Let the examples below guide your hand mass excision coding.

Determine Location of the Mass

The first step for you when reporting an excision in the hand is to determine the extent of the excision. You may turn to 26111 (Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greater) or 26116 (Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial [e.g., intramuscular]; less than 1.5 cm), depending upon the location and the size of the nodule. You’ll also need to check the op note to see if the mass eroded into any other adjoining structures. This will guide you to more coding options.

Example 1: You may read that your surgeon excised a mass over the DIP joint that extended through the joint, causing erosion at the dorso radial aspect of the middle phalanx. In this case, the mass seems to have gone into the joint and eroded the joint. This would be more than excision of a soft tissue mass. You should be looking at 26160 (Excision of lesion of tendon sheath or joint capsule [e.g., cyst, mucous cyst, or ganglion], hand or finger) and not 26116 for the mass excision as your surgeon is excising the lesion in the joint capsule. “CPT^® code 26116 would be reported for lesions not documented as attached, involved in, or arising from the capsule or tendon. Documentation would be the key to determine the correct service,” says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. 

Example 2: You may also read that your surgeon debrided the eroded bony surface and released the A-1 pulley. In this case, you may report code 26055 (Tendon sheath incision [e.g., for trigger finger]) for the trigger finger release. So, you report both the mass excision and the trigger finger release. You should append modifier 59 (Distinct procedural service…) to indicate that the procedures were done at different locations via separate incisions.

Payer alert: But don’t forget to check with your payers. “You do not report the two together for federal payers. CCI edits bundles 26055 to CPT^® code 26160.  American Academy of Orthopedic Surgeons (AAOS) Global Service Data Guide (GSDG) allows for separate reporting of CPT^® codes 26055 and 26160,” says Stumpf. “Again, the documentation must clearly support the medical necessity and pathology for both procedures for support of 59 modifier use for private payers.”

“When your surgeon excises a mucous cyst from the DIP joint and releases the A-1 pulley for a diagnosis of trigger finger, both services are reportable by virtue of their separate locations,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Report Multiple Units for Finger Nodule Excision

You can report multiple units of 26160, provided your surgeon uses separate incisions. “Documentation must clearly support the separate lesion and separate incisional approach,” says Stumpf. “The CPT^® description lists “tendon sheath or joint capsule” – this is not listed as a plural procedure.  There may be issues with some payers as there is only one joint capsule, but the separate incision and separate lesion documentation and guidelines should prevail in appeal.”

Example: You may read that your surgeon excised multiple soft nodules that originated from the extensor tendon insertion. The nodules appeared to be benign tumors encapsulated from the right fifth finger and the dorsum of the DIP base of the distal phalanx and extended radially on to the palmar surface. You may further read that your surgeon also excised another palmar nodule using a mid axial incision.

What to code: In this case, the masses excised are through different incisions. You will report this with code 26160. You report multiple units of 26160 for the number of incisions with modifier 59. If it is through one incision only, report 26160 once only. “The palmar nodule might be reported with code 26111-26116 depending on the nature of the lesion,” says Stout.

Note: Don’t forget to review the surgical pathology report to determine the nature of the nodules. The final code selection will depend on what the nodules are and/or where these nodules originated from.

Confirm If Ganglion Excision Is Inclusive Of Synovectomy

Be careful when reporting ganglion excision with a synovectomy. A common example can be a patient with a ganglion in the hand who developed tenosynovitis. “Commonly, there is minor tenosynovitis at the site of the ganglion attachment,” says Stumpf.  “If the ganglion excision is truly the target, 25111 (Excision of ganglion, wrist [dorsal or volar]; primary) is the procedure that is reported.  The tenosynovectomy would be the inclusive procedure.”

The rationale: According to the AAOS Complete GSDG, synovectomy codes, 25105 (Arthrotomy, wrist joint; with synovectomy), 25115 (Radical excision of bursa, synovia of wrist, or forearm tendon sheaths; flexor), 25116 (Radical excision of bursa, synovia of wrist, or forearm tendon sheaths; extensors) or 25118 (Synovectomy, extensor tendon sheath, wrist, single compartment), are included in the global charge for 25111.

“AAOS GSDG includes tendon mobilization, tenolysis and/or tenosynovectomy, including sheath repair in the ganglion excision code 25111,” says Stumpf. “CCI edits bundle the ganglion excision to the deeper tenosynovectomy procedures. Additionally, if an arthrotomy is performed for excision or debridement of the ganglion stalk for a joint ganglion, this would be an included service. CCI bundles the same incision synovectomy of the wrist joint (25105) into the ganglion excision service.”

Check On Modifiers

You may separately report 25105 and 25111, provided you have clear supporting documentation. “AAOS GSDG allows separate reporting for additional intra-articular surgery for private payers,” says Stumpf. “The coder needs to be aware that separate reporting of CPT^® code 25105 would require clear documentation of extensive, prolific, or pathological synovitis for medical necessity support of separate reporting CPT^® code 25105. The 59 modifier will need to be used.”

Caveat: Be aware that “59 modifier application would need to be clearly be supported by documentation and a separate ICD-9 code reflecting medical necessity, NOT merely removal of the intra-articular extension of the joint ganglion,” advises Stumpf.

“Before appending modifier 59 to override a code edit, you must discern whether or not the CPT^® criteria for the modifier have been met, specifically- 1) separate session or encounter, 2) different site, organ system, 3) separate excision/incision, 4) separate lesion, 5) treatment o separate injuries,” says Stout.

Follow These Tenosynovectomy Guidelines

When tenosynovectomy is the main service you are reporting, you need to confirm if the ganglion excision is inclusive. “As an additional scenario, for federal payers, if the patient suffers from significant, symptomatic, clearly documented tenosynovitis, the tenosynovectomy would be the main target and the reportable service,” says Stumpf. “Per CCI edits and NCCI guidelines, the excision of the ganglion would be bundled or included to the approach for the deeper procedure if via the same incision.”

AAOS does not address removal of a symptomatic ganglion along with tenosynovectomy for clearly documented pathological tenosynovitis.  You will need to confirm with your payer and append the right modifiers. “The 59 modifier would not apply if removed via the same incisional approach,” says Stumpf. “For private payers, the 51 (Multiple procedures) modifier can be used to allow the payer to apply their internal edits.  The coder needs to carefully ascertain that the medical necessity for both services exists.”

Important: Make sure the op note shows separate and distinct services. “Documentation must clearly support the separate incision, separate extremity and separate and distinct pathology,” says Stumpf. “Finally, if a separate incision is utilized for the ganglion excision and tenosynovectomy, or if the procedure was performed on the contralateral extremity, the 59 modifier would certainly be applicable.”