Orthopedic Coding Alert

From the finger to the wrist, these microsurgeries can be troubling to bill.

You might consider yourself an orthopedic coding expert, but when that occasional hand surgery report comes across your desk, things might not be so simple. Check out the following five hand surgery coding questions and read on for expert advice.

Check on Specialty Differentiation

Question 1: Suppose an orthopedic surgeon in your practice performs a meniscectomy, and then 30 days later your hand surgeon performs an extensor tendon repair 26418 (Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon). Because CMS recognizes hand surgery with its own physician specialty code, your carrier will automatically separate the hand surgery from the knee surgery, right?

Answer 1: Not necessarily. Although some payers will reimburse you for both services based on the different subspecialties, it’s not automatic. 

You should ask your carrier whether it recognizes your subspecialty as a “different” specialty for coding and billing purposes. If not, the carrier will probably include the subspecialist’s services in the global surgical package, which means you’d have to append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to separate the two services from one another on the hand surgeon’s claim.

Keep the Finger Modifiers Nearby

Question 2: Many code descriptors for finger surgeries include the word “each” (e.g., 26535, Arthroplasty interphalangeal joint; each joint), indicating that the code is intended for surgery on one digit or joint only. Some code descriptors specify the number of digits per surgery (e.g. 26517, Capsulodesis metacarpophalangeal joint; two digits). Other code descriptors are not as specific (e.g. 26568, Osteoplasty lengthening metacarpal or phalanx). In which situations should you use finger modifiers and when are they not necessary?

Answer 2: Since most surgical procedures do not designate which digit is being repaired identifying the digit in question is essential, and that often means using the Level II modifiers. The 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 refer to digits on the right hand. 

These modifiers signal to the carrier that multiple entries of the same code are not a duplication but rather that the same procedure was performed on different digits. For single or multiple procedures of the fingers the appropriate modifier is chosen to indicate which finger the surgeon addressed.

You’ll use these modifiers on codes that refer to “each digit” or that don’t signify how many fingers are represented by the code. If, however, the descriptor already refers to a set number of fingers, none of the HCPCS Level II modifiers (FA through-F9) need to be appended. In the case of 26517, you don’t need the “F” modifiers because reimbursement for this procedure is already based on multiple fingers. The operative report, however, should indicate which fingers were repaired.

Illuminate Operating Scope Issues

Question 3: When are you allowed to bill for the operating microscope with your hand surgeries, and how much does it pay?

Answer 3: Before you assign 69990 every time the orthopedic surgeon uses the operating microscope, you must determine whether your payer follows CPT® guidelines or CMS guidelines. Medicare pays about $233.00 for this code.

For non-Medicare payers that don’t follow National Correct Coding Initiative guidelines, you can find instructions for when to report +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) in a note preceding the code descriptor in the CPT® manual. Before you report 69990 separately, ensue that the surgeon documents using the operating microscope for microdissection during the procedure. Keep in mind that the use of magnifying surgical loupes does not qualify for the use of 69990.

Medicare payers, or any payer that follows NCCI guidelines, allow you to report 69990 in far fewer circumstances than payers that follow CPT® guidelines. You can only report the operating microscope with “procedures described by CPT® codes 61304-61546, 61550-61711, 62010-62100, 63081-63308, 63704-63710, 64831, 64834-64836, 64840-64858, 64861-64870, 64885-64891 and 64905-64907,” CMS says in Chapter 8 of the 2015 National Correct Coding Initiative Policy Manual for Medicare Services. “CPT® code 69990 should not be reported with other procedures even if an operating microscope is utilized,” the manual states.

If your orthopedic surgeon documents in the operative note that he used the operating microscope for microsurgery, cross-check the payer’s guidelines to see whether it allows you to report the service with 69990. Some payers can provide you with a list of which codes they’ll allow with 69990.

Release This Trigger Finger Code

Question 4: Your physician performed a trigger finger release and the documentation refers to a tendon sheath procedure on the finger, so you report 26145 but it comes back denied. What happened?

Answer 4: You’ve made a common hand surgery coding error in reporting 26145 (Synovectomy, tendon sheath, radical [tenosynovectomy], flexor tendon, palm and/or finger, each tendon) for the trigger finger release. The reality is that you should actually be reporting 26055 (Tendon sheath incision [e.g., for trigger finger]) for this procedure. 

If you can’t determine which code is appropriate, the patient’s diagnosis may give you a hint. Surgeons usually perform the trigger finger release described by 26055 for patients with trigger finger. But in patients with rheumatoid arthritis, the surgeon may opt instead to perform a tenosynovectomy to help prevent ulnar drift. Therefore, if you see documentation of tenosynovitis due to rheumatoid arthritis (714.0 and 727.01), there’s a chance that 26145 is the right code, but the majority of your trigger finger releases should be billed with 26055.

Don’t Go Crazy With Hardware Removal Units

Question 5: When you remove two k-wires from a patient’s wrist, can you charge for each piece you remove or do you just charge code 20670 one time?

Answer 5: As is often the case in coding, there is more than one right answer depending upon the specific circumstances involved. The narrative for 20670 states “removal of implant; superficial, (e.g., buried wire, pin or rod) (separate procedure).” This terminology has led many coders to the conclusion that this code can be reported for each implant that is removed, but this is not always the case. 

In the example above of the surgeon removing two k-wires from a patient’s wrist, you should report 20670 only once because both implants are in the same anatomic site. 

If, however, your surgeon is removing a pin from the left index and ring fingers, it is appropriate to report 20670 twice because the implants are in two different anatomic sites. You will need to append a modifier such as 59 (Distinct procedural service) to the second code. If you do not append a modifier to the second CPT® code, you most likely will see it denied by the carrier as a duplicate.