In need of help with coding this complex finger/hand case. Can anyone please advise on codes?
I am thinking unlisted code 26989 with 76 modifier for each of the 3 fingers involved however, I am being told you should not report an unlisted code multiple times and that there should be more precise codes used for this. Any help would be greatly appreciated.
Postoperative Diagnosis:
1. Right index finger swan neck deformity.
2. Right middle finger swan neck deformity.
3. Right ring finger swan neck deformity.
Procedure Performed:
1. Right index finger capsulodesis, flexor digitorum superficialis sublimis sling of PIP joint, PIP joint pinning.
2. Right middle finger capsulodesis, flexor digitorum superficialis sublimis sling of PIP joint, PIP joint pinning.
3. Right ring finger capsulodesis, flexor digitorum superficialis sublimis sling of PIP joint, PIP joint pinning
Description of Procedure: The patient was then taken to the operative theater and placed supine on a well-padded OR table. SCD boots were placed, a seatbelt was placed, and the anesthesiologist induced anesthesia. Antibiotics were given. A total of 2 g of Ancef was administered via the patient's IV. The limb was prepped using chlorhexidine and draped sterilely. We performed a time-out, verified the correct patient, extremity, and treatment plan. Implants were present.
I drew out a volar zigzag incision leading into the palm on the index, middle, and ring fingers. I then provided 1 mL injection of Marcaine with epinephrine over the distal, middle, and proximal phalanges and the MCPJ heads. Once that was accomplished, we exsanguinated the arm with an Esmarch bandage and raised the tourniquet to 250 mmHg. The total tourniquet time was 170 minutes, followed by a 25-minute pause and another 17 minutes.
I used a #15 blade to make my incision on the index finger. We dissected down with a pair of scissors and we opened up the flaps of skin, and I tied some of these down to the middle finger and used clamps to hold the sutures to open up the radial flaps. We identified the neurovascular bundles and they were protected. Once that was accomplished, I used a Beaver blade to incise the A3 pulley along with the cruciates. I made a radial-based flap. Once we were able to pull that down, I used a clamp to shuttle vessel loops under the FDP and FDS tendons and retracted them out of the way to expose the patient's PIP joint. I then ellipsed out an approximate 3-mm section of the joint and I sent this for pathology. The joint itself was fine, but the capsule was inflamed. I then repaired this using a 3-0 Monocryl in a figure-eight fashion. I did this twice. Once that was accomplished, we then dissected proximally and between the A1 and A2 pulleys, we were able to identify a slit and I opened this with a pair of scissors, and then I was able to put the clamp around the ulnar slip of the sublimis and then shuttled a vessel loop. We then moved more proximal just proximal to the A1 pulley. I was then able to separate the sublimis from the profundus using a clamp and shuttling vessel loops. Once we were confident we had the sublimis and not the profundus, I then cut the ulnar side and we were able to pull out an ulnar slip through the window we made between the A2 and the A1 pulleys. I was then able to suture this proximal free end on the sublimis near its insertion. Doing this allowed the finger to rest at approximate 20 degrees of flexion. I used a total of four 3-0 FiberWire sutures. We then tried to place the suture anchor between the A1 and A2 pulleys. However, upon advancing the anchor, the anchor fractured; the bone did not. I did not think we had sufficient room to place another one; therefore, I did not. I then advanced a K-wire retrograde through the head of the proximal phalanx to prevent hyperextension. We then bent and cut the K-wire and then focused our attention to the middle finger. The middle finger was approached in the same fashion with a #15 blade to make the incision, dissection and separation of the tendons with vessel loops to expose the capsule. I ellipsed out another 3-mm portion of the capsule. The joint surface and the capsule both looked the same. It was repaired with Monocryl. We then dissected proximally and released the ulnar slip of the sublimis in a similar fashion, and we brought this out between the A2 and A1 pulleys and was able to tie that down onto itself near the insertion. I then deployed another Nano suture anchor. However, upon repairing the sublimis at the location where it was wrapped around the proximal A2 pulley, when I went to tie it, it pulled out. The anchor remained intact. It was slightly proud; therefore, I used a bur and I burred some of it down as I could not advance it further into the bone. This appeared to be flush with the bone and would not disturb the remaining tendons. I copiously irrigated this out. We then advanced a K-wire retrograde in similar fashion and then we bent and cut the K-wire and this helped prevent hyperextension. We then let the tourniquet down. We cauterized a few small bleeders and we closed these wounds using nylons for the corner sutures and 3-0 chromic for the remaining simples.
We then made the incision on the ring finger in a similar fashion. After 25 minutes, we put the tourniquet back up. I then exposed the PIP joint, ellipsed out a portion of the capsule, and sutured this down. We shuttled the sublimis slip in a similar fashion after sectioning it proximal to the A1 pulley and then wrapping it at the proximal aspect of the A2 pulley, and I tied this in a similar fashion using four 3-0 FiberWire sutures. We then advanced the K-wire. In all 3 fingers, I was able to passively flex the patient down to meet her palm; therefore, I did not feel the need to make a dorsal incision. After suturing the volar capsule, all the fingers had approximate 20-degree flexion contracture; however, that was increased with the advancement of the K-wire, which was done to prevent hyperextension and to allow the soft tissues to heal. I then provided more anesthetic local.
I am thinking unlisted code 26989 with 76 modifier for each of the 3 fingers involved however, I am being told you should not report an unlisted code multiple times and that there should be more precise codes used for this. Any help would be greatly appreciated.
Postoperative Diagnosis:
1. Right index finger swan neck deformity.
2. Right middle finger swan neck deformity.
3. Right ring finger swan neck deformity.
Procedure Performed:
1. Right index finger capsulodesis, flexor digitorum superficialis sublimis sling of PIP joint, PIP joint pinning.
2. Right middle finger capsulodesis, flexor digitorum superficialis sublimis sling of PIP joint, PIP joint pinning.
3. Right ring finger capsulodesis, flexor digitorum superficialis sublimis sling of PIP joint, PIP joint pinning
Description of Procedure: The patient was then taken to the operative theater and placed supine on a well-padded OR table. SCD boots were placed, a seatbelt was placed, and the anesthesiologist induced anesthesia. Antibiotics were given. A total of 2 g of Ancef was administered via the patient's IV. The limb was prepped using chlorhexidine and draped sterilely. We performed a time-out, verified the correct patient, extremity, and treatment plan. Implants were present.
I drew out a volar zigzag incision leading into the palm on the index, middle, and ring fingers. I then provided 1 mL injection of Marcaine with epinephrine over the distal, middle, and proximal phalanges and the MCPJ heads. Once that was accomplished, we exsanguinated the arm with an Esmarch bandage and raised the tourniquet to 250 mmHg. The total tourniquet time was 170 minutes, followed by a 25-minute pause and another 17 minutes.
I used a #15 blade to make my incision on the index finger. We dissected down with a pair of scissors and we opened up the flaps of skin, and I tied some of these down to the middle finger and used clamps to hold the sutures to open up the radial flaps. We identified the neurovascular bundles and they were protected. Once that was accomplished, I used a Beaver blade to incise the A3 pulley along with the cruciates. I made a radial-based flap. Once we were able to pull that down, I used a clamp to shuttle vessel loops under the FDP and FDS tendons and retracted them out of the way to expose the patient's PIP joint. I then ellipsed out an approximate 3-mm section of the joint and I sent this for pathology. The joint itself was fine, but the capsule was inflamed. I then repaired this using a 3-0 Monocryl in a figure-eight fashion. I did this twice. Once that was accomplished, we then dissected proximally and between the A1 and A2 pulleys, we were able to identify a slit and I opened this with a pair of scissors, and then I was able to put the clamp around the ulnar slip of the sublimis and then shuttled a vessel loop. We then moved more proximal just proximal to the A1 pulley. I was then able to separate the sublimis from the profundus using a clamp and shuttling vessel loops. Once we were confident we had the sublimis and not the profundus, I then cut the ulnar side and we were able to pull out an ulnar slip through the window we made between the A2 and the A1 pulleys. I was then able to suture this proximal free end on the sublimis near its insertion. Doing this allowed the finger to rest at approximate 20 degrees of flexion. I used a total of four 3-0 FiberWire sutures. We then tried to place the suture anchor between the A1 and A2 pulleys. However, upon advancing the anchor, the anchor fractured; the bone did not. I did not think we had sufficient room to place another one; therefore, I did not. I then advanced a K-wire retrograde through the head of the proximal phalanx to prevent hyperextension. We then bent and cut the K-wire and then focused our attention to the middle finger. The middle finger was approached in the same fashion with a #15 blade to make the incision, dissection and separation of the tendons with vessel loops to expose the capsule. I ellipsed out another 3-mm portion of the capsule. The joint surface and the capsule both looked the same. It was repaired with Monocryl. We then dissected proximally and released the ulnar slip of the sublimis in a similar fashion, and we brought this out between the A2 and A1 pulleys and was able to tie that down onto itself near the insertion. I then deployed another Nano suture anchor. However, upon repairing the sublimis at the location where it was wrapped around the proximal A2 pulley, when I went to tie it, it pulled out. The anchor remained intact. It was slightly proud; therefore, I used a bur and I burred some of it down as I could not advance it further into the bone. This appeared to be flush with the bone and would not disturb the remaining tendons. I copiously irrigated this out. We then advanced a K-wire retrograde in similar fashion and then we bent and cut the K-wire and this helped prevent hyperextension. We then let the tourniquet down. We cauterized a few small bleeders and we closed these wounds using nylons for the corner sutures and 3-0 chromic for the remaining simples.
We then made the incision on the ring finger in a similar fashion. After 25 minutes, we put the tourniquet back up. I then exposed the PIP joint, ellipsed out a portion of the capsule, and sutured this down. We shuttled the sublimis slip in a similar fashion after sectioning it proximal to the A1 pulley and then wrapping it at the proximal aspect of the A2 pulley, and I tied this in a similar fashion using four 3-0 FiberWire sutures. We then advanced the K-wire. In all 3 fingers, I was able to passively flex the patient down to meet her palm; therefore, I did not feel the need to make a dorsal incision. After suturing the volar capsule, all the fingers had approximate 20-degree flexion contracture; however, that was increased with the advancement of the K-wire, which was done to prevent hyperextension and to allow the soft tissues to heal. I then provided more anesthetic local.