Orthopedic Coding Alert

Initial surgery or redo?  Confirm status before you submit your claim

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 most seasoned orthopedic coding specialist. But as long as you understand what you should include in the main surgical procedure and what you should report separately, you should be able to bill hand procedures like a pro.

If you look at the following op report example, you-ll see why you have to use all of your resources before you code a hand surgery. A combination of the AAOS- Complete Global Service Data for Orthopaedic Surgery (GSD) guide, the National Correct Coding Initiative (NCCI) edits, your CPT and ICD-9 books, insurers- guidelines, and other resources should help you determine which services are billable.

Preoperative diagnosis: Complete disruption of the triangular fibrocartilage complex left wrist; left distal radioulnar joint instability; disruption of the extensor carpi ulnaris (ECU) tendon sheath; and dislocation of the extensor carpi ulnaris tendon.

Procedure overview: Secondary repair of the triangular fibrocartilage complex of the left wrist, extensor carpi ulnaris tenodesis, and reconstruction of the extensor carpi ulnaris tendon sheath.

Op Note: Trace the Hand Surgeon's Work

The pertinent details of the op report: I made a 4-cm incision over the dorsal ulnar aspect of the left wrist. I incised the retinaculum at the interval between the fifth and sixth compartments and immediately encountered hemorrhagic tissue, which I sharply excised.
 
I found that the triangular fibrocartilage proper had ruptured from the fovea at the base of the ulnar styloid and had retracted into the ulnocarpal joint. I incised the capsular tissues of the lunocarpal joints and performed a synovectomy.

I advanced the triangular fibrocartilage to the fovea and placed multiple drill holes at the site with a 0.035 Kirschner wire. I passed three Vicryl mattress sutures through the drill holes into the ligament for its reat-tachment. Before knotting the sutures, I inspected the extensor carpi ulnaris tendon sheath and found that it had ruptured, allowing subluxation or dislocation of the extensor carpi ulnaris tendon. I performed an extensor carpi ulnaris tenodesis by dividing the ulnar half of the ECU tendon proximally and left it intact distally.

I procured a 7-cm strip of the ulnar half of the tendon and withdrew it distally and passed it just beneath the distal ulnar to the level of the ulnar neck proximal to the sigmoid notch. With a power bur, I created a channel in a dorsal-to-volar direction through the ulnar neck and passed the tenodesis tendon slip in a volar-to-dorsal direction through the channel and back over the distal radio-ulnar joint.

I then reduced the distal radioulnar joint and knotted the previously placed sutures in the triangular fibrocartilage. I used multiple 4-0 Vicryl sutures to secure the triangular fibrocartilage to the distal radioulnar joint capsular ligaments. I repaired the remnants of the extensor carpi ulnaris sub sheath over the relocated extensor carpi ulnar tendon, and augmented this sub sheath by first securing the tenodesis to the periosteum over the ulnar and then to the dorsal radioulnar joint. I constructed a substantive sub sheath and reinforced the chronically disrupted triangular fibrocartilage by using the extensor carpi ulnaris tenodesis tendon strip.

Step 1: Select the Correct CPT Code

Your first step in coding this note is to check with the surgeon to confirm whether the procedure was a -redo- reconstruction. He refers to a -secondary- repair in his procedure overview, and he describes a chronic peripheral disruption in the op note. In some cases, the surgeon may tell you that he did additional work to perform a redo surgery because of the extra work involved repairing the previous injury and in navigating the scarred area.

If the surgeon states that this was the patient's first reconstruction, you should report 25337 (Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft-tissue stabilization [e.g., tendon transfer, tendon graft or weave, or tenodesis] with or without open reduction of distal radioulnar joint).

If the physician tells you that the procedure is a repeat of a previous reconstruction, ask him whether he felt that the surgery went over and above the work involved in a normal wrist reconstruction. If he believes he spent more time and resources on the procedure because of the secondary nature, you should either append modifier 22 (Unusual procedural services) or report 25999 (Unlisted procedure, forearm or wrist).

Step 2: Alter Fee if Necessary

If you report 25999 or append modifier 22, ask the surgeon to write a letter describing how much additional work went into the procedure. Compare the procedure to 25337 as a starting point, but increase your fee for the extra work involved (assuming that the surgeon documents the extra work). For instance, if the surgeon believes the procedure was 25 percent more involved, raise your fee by 25 percent.

Remember: If you append modifier 22 or report the unlisted-procedure code, the op report should ideally contain all the information necessary to substantiate the extra work or expertise that the procedure required, and the documentation in the op note should state that this was surgery through -an altered surgical field,- a key catch phrase insurance companies look for.

Writing a letter may work, too, but the op note is the first piece of information the insurance company will use as documentation of what the surgeon did during surgery. Therefore, even if your surgeon writes a compelling letter to support use of modifier 22 or the unlisted-procedure code, the insurer will only agree to increase your fee if the op note reflects what's in the letter.

Op note tip: A good rule of thumb is for the physician to state exactly what made this surgery different from a routine surgery, describe the altered surgical field, and mention how long the surgery usually takes the first time around, especially if the re-do took much longer or something happened that caused more work to be involved than anticipated.

For coding purposes, it's very helpful for the physician to mention a little bit of the history involved with the condition, whether it's a current problem or a chronic one, or if any additional surgery was performed in the area previously.

If the op note doesn't reflect this additional information, it will be harder to justify the use of modifier 22 or an unlisted-procedure code in your first billing attempt, and the information will definitely be needed if an appeal is needed later.

Step 3: Check for Additional Services

After you select the main code, ensure that you aren't missing any other procedures from the op report. Although the surgeon refers to tenodesis and joint reduction in his note, you shouldn't bill separately for these procedures.

Rationale: According to CPT, 25337 includes the tenodesis and the reduction, as well as the joint reconstruction, tendon transfer or tendon graft. In addition, the GSD states that synovectomy, tenosynovectomy, and treatment of distal radioulnar dislocation are included in reimbursement for 25337. Therefore, 25337 includes all of the surgeon's work.

Step 4: Select Your ICD-9 Codes

You should link your CPT code with diagnosis codes 718.83 (Other joint derangement, not elsewhere classified, forearm), 718.03 (Articular cartilage disorder; forearm) and 726.4 (Enthesopathy of wrist and carpus).

Denise Paige, CPC, is the coding and billing manager at Beach Orthopedic Associates in Long Beach, Calif., and the secretary of the AAPC's Long Beach Chapter.