Orthopedic Coding Alert

Hand surgeons who perform surgical procedures on multiple digits should append the finger modifiers (-FA, -F1 through -F9) to the procedure code rather than reporting multiple units, in the absence of strict carrier advice.

Most carriers do not specifically advise orthopedists on how to denote surgery on multiple fingers, tendons or bones of the hand. For instance, an orthopedist repairs extensor tendons in the second and third fingers of the left hand. The appropriate code would be 26426 (Repair of extensor tendon, central slip, secondary [e.g., boutonniere deformity]; using local tissue[s], including lateral band[s], each finger), and the following variations are common among insurers:

1. Append modifier -51 (Multiple procedures) to subsequent sites, i.e., 26426, 26426-51
2. Indicate the number of units performed, for example, 26426 x 2
3. Use the site modifiers, i.e., 26426-F1, 26426-F2.

If your carrier does not specifically dictate its coding preference, use the finger modifiers, says Linda Kellner, coder at The Hand Center, a four-surgeon practice in Houston: "We used to submit these claims with the number of units addressed, but Medicare considered the subsequent units 'repeat procedures' and denied all of them. We only got paid for one procedure, and then we would spend time appealing. Once we started using the finger modifiers, we stopped having problems."

Regardless of the modifier your practice uses for these services, insurers will probably still reduce your fees on subsequent procedures, since they argue that the preoperative and postoperative work is only done once, no matter how many fingers, tendons, etc., you address.

If the surgeon treats multiple hand tendons or bones, for instance, 26450 (Tenotomy, flexor, palm, open, each tendon), the finger modifiers may apply. In these cases, list the tendons on separate line items with modifier -51 appended to the subsequent sites, says June Orlamski, office manager at GLO Orthopaedics, a two-surgeon practice in Tampa, Fla.

"Listing them separately versus billing multiple units can help the separate tendons stand out to the insurer so they don't just ignore the multiple units," she says.

Some carriers specifically dictate that they prefer modifier -59 (Distinct procedural service) when separate sites are addressed. For instance, suppose a patient suffered a workers' compensation injury when a box fell on his hand. The orthopedist performed 26735 (Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with or without internal or external fixation, each) on the third finger and 26727 (Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each) on the fourth finger.

Although the CCI dictates that 26727 is a component of 26735, you should report both codes because the procedures are being performed on separate fingers. Append modifier -59 to 26727, and submit a copy of the operative report demonstrating that separate fingers were addressed.

Hand surgery coders sometimes assign codes to denote everything the orthopedist addresses, without first consulting the CCI or American Academy of Orthopaedic Surgeons (AAOS) guidelines to determine what procedures are included in their primary surgery. Reporting tenolysis with capsulotomy is one common mistake.

For instance, report only 26440 if you perform tenolysis of a flexor tendon in a patient's palm and capsulectomy of the interphalangeal joint. According to the April 2002 CPT Assistant, coders need not report 26525 (Capsulecto-my or capsulotomy; metacarpophalangeal joint, each joint) separately, since 26440 includes the capsulectomy.

Because the CCI can include more than 40 "component codes" within one hand surgery code, always consult the most recent version of CCI and the AAOS guidelines before billing these codes.

Next month: Specialty Spotlight will feature coding tips for spinal surgery specialists.