Orthopedic Coding Alert

Coding key: Identify which structures are being drained.

When your surgeon performs a drainage procedure on patient's hand, he may target different structures, as there are several points of collection of pus. You may need to report procedures like drainage of a finger abscess, tendon sheath, or palmar bursa. Read on for tips on identifying where in the hand your surgeon did the drainage and how you report it.

Look For Diagnosis of Swollen Finger Tip

Your surgeon may drain a swollen and painful fingertip. This may be a felon, an abscess that forms along the volar surface in the finger tip. "A felon is a very serious infection of the volar surface of the distal finger tip and its associated soft tissues. An enclosed pocket of pus or infection develops and causes severe pain as it expands. Felons are usually caused by the bacterium Staphylococcus aureus," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. "Treatment should be sought rapidly as the swelling can compress blood vessels in the finger and cut off circulation. The decreased blood supply due to the swelling can make it difficult for the body to fight the infection. A felon almost always needs to be opened and drained by a doctor to allow the healing process to begin."

What to look for: If you read that your surgeon 'anesthetized the finger by using lidocaine for a digital block and then cleaned the area to ensure aseptic precautions,' you confirm preparation for an incision and drainage. You may further read that your surgeon 'identified the point of maximum tenderness and made a longitudinal incision on this point on the volar surface keeping the incision distal to the distal interphalangeal crease.' You confirm that this was a felon that was drained and report code 26011 (Drainage of finger abscess; complicated [eg, felon]). Your surgeon may further open the incision to allow drainage and send a culture to the laboratory for analysis.

"The most appropriate CPT® code for a felon infection drainage procedure is 26011," advises Stumpf. "It is less likely that more superficial incision and drainage procedures, such as 10060 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) and 10061 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple) would describe dissection for treatment of a felon."

Confirm if Mass is Tendon Sheath

A mass in the hand could be a swollen or infected tendon sheath. This also may need an incision and drainage. Make sure your surgeon documents what structure is incised and if any drainage was done.

Example: Your surgeon may diagnose a mass on the volar aspect of the proximal phalanx of the right ring finger and perform an exploration of the ring finger. You may read in the operative note that the surgeon made 'an incision at the volar aspect of the proximal phalanx of the right ring finger.' You may further read, 'No frank abnormality was noted except for a prominent profundus sublimis tendon that appeared not to have any turning, locking or other abnormalities. No biopsy was taken. The tourniquet was released. The bleeding points were carefully cauterized; the skin approximated with 4-0 nylon material, and a bulky dressing was applied. The patient tolerated this procedure and left the operating room in satisfactory condition.'

What to code: For this procedure, you report 26020 (Drainage of tendon sheath, digit and/or palm, each). Additionally, you may append modifier 52 (Reduced services) as your surgeon did not do a drainage. Code 26020 implies that there is a drainage process involved, and your surgeon actually did not do drainage and neither did he do a biopsy.

Here's another example. Your operative note may indicate that the patient complained of inability to flex the right index finger, following which he was hospitalized for an emergency irrigation and drainage of the necrosed flexor tendon sheath. Your surgeon may do a 'surgical release of the flexor tenosynovitis' using a 'two-incision technique with a closed-irrigation method'. You may further read that a #8 French catheter was inserted through the flexor tendon sheath proximally for about 2 cm.'

Here again, the incision of the tendon sheath is evident. You report 26020. Remember that the catheter insertion is integral to the procedure and you do not report it separately.

Keep Count of Palmar Bursae

When your surgeon drains the palmar bursae, you should count how many bursae he actually drained. When your surgeon drains a single palmar bursa, you report 26025 (Drainage of palmar bursa; single, bursa) and when your surgeon drains more than one bursa, you report 26030 (Drainage of palmar bursa; multiple bursa).

"There are two main bursae in the palmar region of the hand: the hypothenar bursa that covers the tendons of the index, middle and ring fingers and extends to the wrist; and the thenar bursa that covers the tendon of the thumb and extends to the wrist crease. CPT® code 26025 would include release of one bursae, radial or ulnar. Documentation would need to support release of both bursae for support of 26030," says Stumpf.

Caution: Do not count the number of incisions your surgeon made for the drainage. "The number of incisions may not reflect the number of bursae incised due to the intimate nature of the bursae as they approach the wrist joint. Multiple incisions may imply only one bursa, due to the extension of the bursa across the palmar area," says Stumpf.

Also remember that infection from one bursa can spread to another as the two lie close together. "It is relatively common, due to the proximity of the structures, that infectious processes will affect both bursae. In a fairly large percentage of cases a normal communication exists or is created by the infectious process between the two bursae. Infection of one bursa would in this situation likely affect the adjacent bursa," says Stumpf. So, you exercise caution in reporting the number of bursae drained to earn your deserved payment.

Anatomy note: Infections in the hand spread fast as the structures lies close together. "The thenar space lies between the two bursae, infections of the hypothenar or thenar bursa can often spread transversely to the thenar space and can affect the tendons, lumbricals, digital vessels and nerves that are included in this region," says Stumpf. The infection may spread up the sheaths of the fingers. "The hypothenar bursa infection can be a serious infection as it contains the finger flexors and can involve the finger tendons," she adds.