Orthopedic Coding Alert

Question: In a patient who complained of pain in the hand and inability to move the thumb, our surgeon confirmed a fusiform swelling in the thumb and extreme pain on passive thumb extension. Further he established the diagnosis of an infected thenar bursa. The operative note for this procedure reads as follows:

“The patient was placed supine on the table and the left arm was supported in an arm board. Under general anesthesia, the surgical preparation was done. Distally, a small longitudinal incision was made on the lateral side of the proximal phalanx of the thumb just dorsal to the interphalangeal crease. Protecting the branches of the median nerves to the thenar eminence, another incision was made on the medial aspect of the thenar eminence and was carried over to the end of the thenar bursa proximally. The fibrous sheath covering the flexor pollicis longus was identified and was incised longitudinally just proximal to the tendon’s insertion in the distal phalanx. The synovium within the sheath was incised to drain the pus. A probe was passed proximally along the flexor sheath and the end of the probe was felt in the flexor retinaculum in the volar aspect of the wrist. A catheter was left in the distal end of the sheath for drainage.”

How do we report this condition?

New Jersey Subscriber

Answer: In this situation, you confirm the drainage of only the thenar bursa and report code 26025 (Drainage of palmar bursa; single, bursa).