Wiki 26123 with 26121? Web deepening flap (Z plasty?)

[kkidd91]

Would 26123 include all the work completed in the case below or would it be appropriate to use 26123 F2 & 26121 XS LT? Insurance is Medicare. There is no mention of Syndactyly in any of the office notes, however the case was scheduled as 26123 and 26561. My original thought is that 26123 covers the work in the palm, digit and Z plasty, however the running man flap was completed in a separate area than the digit being released, which I am thinking is considered Z plasty. I appreciate any guidance you are able to offer. Thank you.

POSTOPERATIVE DIAGNOSES:

1. Left long finger Dupuytren contracture. 2. First webspace Dupuytren contracture.

OPERATIONS PERFORMED:

Left long finger Dupuytren release with release of proximal interphalangeal joint. 2. First webspace Dupuytren Excision. 3. Web deepening flap

I placed the hand into a lead hand holder and made a curvilinear incision overlying the left long finger, starting in the mid palm and extending down the digit incorporating the original chevron[ shaped incision overlying the volar aspect of the PIP joint. After performing sharp dissection to the skin, I performed careful sharp dissection around the proximal cord extending down towards the webspace between the index and long finger.

After isolating that cord, I followed the digital nerves distally down into the finger, isolating the new cord that had formed on the digits radial aspect. I released that cord and passed it off as specimen. I sharply entered the joint releasing the accessory collateral ligaments and increasing the extension of the digit, passively after release of the volar plate and lateral collateral ligaments and medial collateral ligaments. I then turned my attention to that proximal cord, which I sharply excised under direct visualization using the tenotomy scissors to dissect beneath the cord. Once I transected it proximally, this cord was also passed off for specimen.

Once I was satisfied release of the long finger, I turned my attention to the first webspace. I made an incision between the neck of the index finger metacarpal and the neck of the thumb metacarpal, straight incision, followed by sharp dissection followed by blunt dissection to expose the cord. Once I had isolated the cord, I sharply incised it on its attachment to the thumb metacarpal head ulnarly and the index finger neck on its radial aspect. I removed the cord in its entirety. There was improvement in the thumb posture. I made another incision overlying the cord on top of the thenar eminence releasing that cord as well and excising it in a similar fashion with a longitudinal incision directly over the cord and blunt dissection around the cord to isolate it followed by excision of the cord. This was also passed off for specimen. I turned my attention back to the first webspace and created a jumping man flap. After creation of the flap using sharp dissection, I transposed the flap in the appropriate manner to deepen its webspace. I irrigated all wounds and then sutured the flap in place. After suturing of the flap, I turned my attention to the incision along the thumb thenar eminence. This was also sutured.

 

[NRaizman]

The surgeon unfortunately dug him or herself into a bit of a corner.

The best way to code this would be 26123, 26125, but would have the surgeon give you an addendum that clarifies that the first webspace contracture release and deepening was to excise the dupuytren's contracture from the thumb and release the contracted MP joint of the thumb and that dissection was carried into the thumb. This is consistent with an additional digit release.

The appropriate code for a simple webspace deepening with a jumping man flap without an underlying diagnosis of Dupuytren's is 14040, which will get kicked out for any CMS patient because of NCCI and would require a -59 modifier in a private payor - that -is- an option here, but 26125 is the better code. There was no syndactyly diagnosis and a syndactyly release code is therefore no appropriate here.

The first webspace cord is basically a spiral cord equivalent for the thumb, and it is just important for the surgeon to note that dissection is carried into the thumb and not just the palm to avoid confusion and resist audits by non-hand-surgeons who are not as attuned to the subtleties here.

 

[kkidd91]

The surgeon unfortunately dug him or herself into a bit of a corner.

The best way to code this would be 26123, 26125, but would have the surgeon give you an addendum that clarifies that the first webspace contracture release and deepening was to excise the dupuytren's contracture from the thumb and release the contracted MP joint of the thumb and that dissection was carried into the thumb. This is consistent with an additional digit release.

The appropriate code for a simple webspace deepening with a jumping man flap without an underlying diagnosis of Dupuytren's is 14040, which will get kicked out for any CMS patient because of NCCI and would require a -59 modifier in a private payor - that -is- an option here, but 26125 is the better code. There was no syndactyly diagnosis and a syndactyly release code is therefore no appropriate here.

The first webspace cord is basically a spiral cord equivalent for the thumb, and it is just important for the surgeon to note that dissection is carried into the thumb and not just the palm to avoid confusion and resist audits by non-hand-surgeons who are not as attuned to the subtleties here.

Thank you for your prompt and detailed response. Your response has also sparked my curiosity as to how billing of add-on codes is handled on the professional side as I have only billed outpatient facility claims and we don't include add on codes. I truly appreciate all the knowledge I am gaining from your guidance.

 

[NRaizman]

Add-ons get billed by the provider without a modifier and do not trigger a multiple procedure reduction.
They should always be billed.
They don't really help your facility bottom line but are very important to your providers.
N.