Orthopedic Coding Alert

Question: Our surgeon excised mass in the finger. The procedure is as follows:

Excision of multiple soft tissues masses was done. These appeared to be benign tumors encapsulated from the right fifth finger and the dorsum of the DIP base of the distal phalanx and also extended palmar radially. These appeared to originate possibly from the radial edge of the extensor tendon insertion. The second lobule was on the ulnar side of the extensor insertion and it was hard to say if this came from underneath the extensor tendon or across the top of the original radial lobules. There was a separate palmar nodule on the radial side accessible from the mid axial incision with this being deep to the neurovascular bundle and that was resected as well.

What is the most appropriate code we can use to report this procedure?

Texas Subscriber

Answer: If all the masses excised are through different incisions, report 26160 (Excision of lesion of tendon sheath or joint capsule [e.g., cyst, mucous cyst, or ganglion], hand or finger). You report multiple units of 26160 for the number of incision with modifier 59 (Distinct procedural service....). If it is through one incision only, report 26160 once only.

However, in the most ideal case, you should review the surgical pathology report to determine the nature of the nodules. The final code selection will depend on what the nodules are and/or where these nodules originated from.