Orthopedic Coding Alert

You must determine where the surgeon got the tendon
 
You can avoid problems coding for tendon transfers that your surgeon performs with carpometacarpal interposition arthroplasties if you ask yourself two simple questions.

Orthopedic surgeons often treat patients with arthritis using interposition arthroplasty of the carpometacarpal (CMC) joint at the base of the thumb using a transferred tendon.

When your surgeon performs a CMC interposition arthroplasty, your first step should be to determine whether she harvested the tendon or not. If so, find out where she obtained the transferred tendon, and that will help you select the appropriate code.

Don't Forget Tendon Transplant Codes

Check out the following operative note scenario: Patient Jones has severe arthritis of the CMC joint. Dr. Smith excises the trapezium, then performs a tenotomy and tenolysis on the flexor carpi radialis.

She draws the detached part of the tendon out through the wrist wound, loops it through a drill hole in the base of the first metacarpal and wraps it around to stabilize the joint. She then rolls the end of the tendon into an anchovy and interposes it in the gap left by the removal of the trapezium.

Wrong way: You might be tempted to code the procedure with 25447 (Arthroplasty, interposition, intercarpal or carpometacarpal joints), and leave it at that. But don't stop there, unless you want to miss out on more than $800 in reimbursement.

Right way: You should report 25447 and 25310 (Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon) for the patient in our example.

That's because the physician detaches one end of the FCR and cuts it, then uses the cut end to repair the CMC joint. The other end, however, still remains in its original place.

Tip: Some orthopedic surgeons may refer to the 25310/25447 combination procedure as the Burton LRTI procedure in their op notes.

"The 'LRTI' refers to ligament reconstruction, tendon interposition," says Orvis Chitwood III, MD, a hand surgeon at Southern Bone & Joint Specialists in Dothan, Ala.

Confirm the Harvest Site

Suppose the surgeon in our example above harvests the tendon from the back of the hand instead of the wrist. In that case, you should report 25447 with 26480 (Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon). You would not report 25310 in this situation.

Trap: Some coders report 26480 for every transfer because the surgeon always transfers the tendon to the carpometacarpal area. But the correct code choice depends on where the surgeon gets the tendon, not where it's going.

Modifier alert: According to the January 2005 CPT Assistant , you should append modifier 51 (Multiple procedures) to either 26480 or 25310 when you bill those codes with 25447.

Tendon Graft? Don't Automatically Report 20924

Alternative Op Report: Dr. Adams excises the  trapezium and harvests the abductor pollicis longus tendon, which he balls and inserts where the trapezium was. Surgeons often refer to this practice as the  anchovy procedure.
This is a traditional harvesting situation, in which the transplanted tendon is completely removed from the origin site. The work involved in such a tendon graft is included in 25447, according to the American Society of Surgery for the Hand's (ASSH) Global Service Guide for Hand Surgery.

Beware of NCCI Bundling Issues

In addition, the National Correct Coding Initiative (NCCI) bundles 20924 (Tendon graft, from a distance [e.g., palmaris, toe extensor, plantaris]) with 25447, says Annette Grady, CPC, CPC-H, healthcare adviser with Eide Bailly LLP, and AAPC officer for the National Advisory Board.

Private-Payer Alert

Some coders report that their private insurers do not follow NCCI or ASSH guidelines, and therefore allow practices to report both 20924 and 25447 if the surgeon harvests the tendon from a separate incision.

The January 2005 CPT Assistant states, "If the tendon is harvested at a different site through a separate incision(s), the harvesting of the tendon graft should be coded separately with 20924."