Orthopedic Coding Alert

Tip: Don’t get tied up counting sutures.

Capturing all your deserved pay for hand and foot nerve repair claims can depend on such factors as whether the surgeon used an operating microscope, whether the nerves treated were motor or sensory, and whether the surgeon provided conduit repair. Follow these tips for flawless reporting of nerve repairs.

Report Nerve Repair with Tendon Repair

When reporting nerve repair, take care to not ignore any tendon repair services.  The good news is you can report these together without having to battle a bundle. You report code 64831 (Suture of digital nerve, hand or foot; 1 nerve) for repair of a single digital nerve in the hand or the foot.

Example: You may read that your surgeon repaired the ulnar digital nerve and the flexor pollicus longus tendon in the same thumb. In this case, you report code 64831 for the ulnar nerve repair.

Depending upon the location of the repair, you report 26356 (Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath [e.g., no–man’s land]; primary, without free graft, each tendon) or 26350 (Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath [e.g., no man’s land]; primary or secondary without free graft, each tendon) for the repair of the tendon that your surgeon does. There is no bundle for these codes and you can report these together.

Don’t forget to check for your surgeon’s microscope use for this repair. If this is in the documentation, you also report +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]).

“Report code 69990 only when the documentation specifies that the operating microscope was used,” confirms Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. “When the surgeon performs microscopic repair using surgical loupes, it would be inappropriate to report code 69990.  If the operative report is vague regarding which type of magnification was used (microscope vs loupes), you will need to educate the surgeon on the need for greater specificity.”

Check Numbers of Nerves Repaired

When your surgeon repairs more than one digital nerve in the hand or foot, you report code +64832 (Suture of digital nerve, hand or foot; each additional digital nerve [List separately in addition to code for primary procedure]).

Example: You may read that in a patient who reported after hand trauma, your surgeon did a micro repair of right middle finger ulnar digital nerve and right ring finger ulnar digital nerve. In this case, you report 64831 and +64832 to earn for the two digital nerves repaired by your surgeon.

Confirm Motor vs Sensory

For repair of nerves in the hand, you also need to confirm if the nerve repaired was a sensory nerve or a motor nerve. The sensory nerves in the hand include the radial, median, and ulnar nerves. The motor nerve supply is from the ulnar and median nerves.

When reporting the motor nerve repair in the hand, check for the specific nerve your surgeon repaired. For the repair of median motor nerve, you report 64835 (Suture of 1 nerve; median motor thenar) and for the repair of the ulnar motor nerve, you report code 64836 (Suture of 1 nerve; ulnar motor). 

Example: You may read that your surgeon did repair of the right median nerve, right ulnar nerve and the right ulnar artery. For the repair of the median nerve, you report code 64835 and for the repair of the right ulnar nerve, you report 64836. You report arterial repair with 35207 (Repair blood vessel, direct; hand, finger) for arterial repair.

When your surgeon repairs a sensory nerve in the hand or the foot, you report code 64834 (Suture of 1 nerve; hand or foot, common sensory nerve).

For every additional nerve that your surgeon repairs in the hand, you report code +64837 (Suture of each additional nerve, hand or foot [List separately in addition to code for primary procedure]).

The code +64837 is an add-on code that you report in conjunction with 64834-64836.

No Need to Tally Sutures

When reporting nerve repairs, you won’t need to labor over the number of sutures your surgeon may place. For a digital nerve, a single suture may suffice. For larger nerve, 3-4 sutures may be needed. This is the case when your surgeon does the repair without the aid of magnification.

When your surgeon uses magnification, the sutures may be smaller in size (8-0 or 9-0). In this case, you may read that your surgeon used 2-4 simple sutures to bring the ends closer together. For larger nerves, multiple such small sutures may be required to ensure a smooth repair such that the nerve fibers do not protrude from the epineurium.

You report the use of operating microscope with code 69990 along with the nerve repair code in such a case. “If your surgeon’s note says that he used anything smaller than 6-0 suture (such as 8-0, 9-0, or 10-0), it is almost certain that an operating microscope was used,” says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C. “The larger numbers indicate smaller suture diameters.”

Code for Conduit Repairs in Digital Nerves

You may commonly encounter conduit repairs. When your surgeon repairs the nerve using a synthetic conduit or nerve tube, you report 64910 (Nerve repair; with synthetic conduit or vein allograft [e.g., nerve tube], each nerve).

Example: Your surgeon may do a digital nerve repair in a patient with partial laceration of radial digital nerve middle finger and a complete laceration of ulnar digital nerve to both middle and ring fingers. You may read that your surgeon did a repair for the partial laceration of the middle finger radial digital nerve and covered it with Neuroflex tube and also did a micro repair of right middle finger ulnar digital nerve and right ring finger ulnar digital nerve.

In this case, you report 64910 for the partial laceration repair of middle finger radial digital nerve. For repair of right middle finger and right ring finger ulnar digital nerve, your report codes 64831 and +64832.

When your surgeon uses a venous autograft for the nerve repair, you report code 64911 (Nerve repair; with autogenous vein graft [includes harvest of vein graft], each nerve). Note that this code is inclusive of the vein graft harvesting.