Orthopedic Coding Alert

If you've ever found yourself thumbing through the pages of your CPT book trying to decipher what codes to include when a hand surgery op note lands on your desk, there's hope. The task can be easier than you think, provided you follow this 3-step strategy. Your payers will hand over the ethical reimbursement your orthopedist deserves -- the first time around.

Although you may be used to coding an interposition arthroplasty with suspensionplasty,the following "unusual surgery" note lands on your desk. It says:

Diagnosis: Degenerative arthritic changes at base of carpal metacarpal joint with dislocation. (This is often called the trapezoimetalcarpel joint or even the basilar thumb joint, says Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.)

Operation: Resection arthroplasty with removal of trapezium and placement of slip from abductor pollicis longus through the carpi radialis tendon and back onto the abductor pollicis longus tendon along with pin fixation of the shaft of the first metacarpal into the scaphoid.

When you are coding surgery from an operative report, first identify the procedure(s) the surgeon performed, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver. In this case, you should work with the following information:

1. Resection arthroplasty. You may conclude that the arthroplasty is of the carpometacarpal joint even though the surgeon doesn't specifically state it. Rationale: The patient's diagnosis is degenerative arthritis of the carpometacarpal joint, Mallon says.

2. Removal of trapezium.

3. Placement of abductor pollicis longus slip through the flexor carpi radialis.

4. Pin fixation of the first metacarpal to the scaphoid.

Let's start with the resection arthroplasty.

Problem: If you start your search in the CPT index under the main term "arthroplasty," you will immediately get confused. "The index has multiple listings for arthroplasty but with anatomic locations that may not exactly match the terminology your surgeon uses, such as 'carpometacarpal joint,'" Hammer warns. You know, however, you're dealing with the wrist, and so you'll find 11 different code options offered for wrist arthroplasties in the code range 25441-25447.

Upon reviewing the narratives for these codes, you will quickly see that only 25447 (Arthroplasty, interposition, intercarpal or carpometacarpal joints) mentions the carpometacarpal joint.

Rationale: Because the usual ICD-9 code will be 715.xx (Osteoarthritis [with fourth and fifth digits to indicate severity and location]) for degenerative arthritis,the procedure code should relate to treatment of the metacarpal trapezial joint and not to a carpal excision code. Therefore, the carpectomy code 25210 (Carpectomy;one bone) is not a good choice, Mallon explains.

The most appropriate code is 25447 because some other tissue or substance is inserted between the metacarpal and scaphoid bones. Even though the tendon strip is used mainly to stabilize the remaining joint, this procedure is an arthroplasty.

When you use 25447, you should include these services:

• athrotomy/synovectomy of wrist of intercarpal joints

• partial or total excision of trapezium

• capsular release, repair, and/or reconstruction

• harvesting and insertion of tendon or fascial graft

• internal fixation of implant.

If you check the Physician Fee Schedule, you'll see this code carries a hefty 10.95 relative value units (RVUs). These RVU reflects all of the work involved.

Result: After reviewing the services this code includes, you should report only 25447, as this code includes all the components the operating surgeon lists."Not sure if this is good news though," Mallon says. "We would like to be able to report more codes."

Finally, after settling on a code, review the text of the op report to make sure the documentation supports that code. Otherwise, your claim may not stand up to an audit.