I'm struggling as well, post-service auditing this case. I went back to earl 2023 in the clinicals and followed it forward. Any help would be appreciated especially if I'm missing something. Believe it or not, there's not a lot of surgical videos our there to visualize what is being done....mostly verbal lectures and diagrams.
- I'm having a time with auditing this scenario. From a documentation standpoint the patient has a longstanding condition of trigger finger which to my understanding after such a time can cause contracture and mimic Dupuytren's. Unfortunately there are no pre-/post-op photos to support where the Dupuytren's was located as it can be the thumb, ring, middle, index fingers. The documentation to me seems too general in order to bill the fasciectomy and the trigger finger releases which are bundled with the fasciectomy. According to AAOS 2022 Guidelines for Orthopedic Surgery, CPT 26121 includes "incision of tendon sheath and/or incision/excision of pulley".
- I'm leaning towards the surgeon only can claim the 26055 x4 and the 64721, because the Dupuytren's is not clearly identified documented regarding fascia tissue removal nor the anatomical area (which digit, one or all). Either way the surgeon had to make an incision to access the A1 pulley's and by their dictation an L-shaped 5cm incision was made, no grafting noted and no fascia involvement dictated.
Thoughts ?????
OPERATIVE NOTE(S)
Procedures performed:
Left hand palmar-digital fasciectomy
Let hand index finger A1 pulley release
Left hand middle finger A1 pulley release
Left hand ring finger A1 pulley release
Left hand small finger A1 pulley release
Left carpal tunnel release
Diagnosis:
Left index trigger finger - M65.322
Left middle trigger finger - M65.332
Left ring trigger finger - M65.342
Left small trigger finger - M65.352
Left hand Dupuytren's contracture - M72.0
Left carpal tunnel syndrome - G56.02
Patient complains of more triggering in the left hand with multiple fingers, contracted cords in the palm of the left hand, and numb and tingling left hand.
A sterile tourniquet was applied to the left arm, After exsanguination with an Esmarch, the tourniquet was inflated to 250 mmHG. *Then we
turned our attention for palmar-digital fasciectomy of the left hand. A
"L" shaped incision was made on the distal aspect of the palm of the left hand.
The length of the incision was about 5cm. Sharp dissection was carried through the skin and subcutaneous tissue. Neurovascular bundles on both sides were identified and protected. Then we continued with dissection from proximal to distal. The
pretendinous cord and the spiral cord were identified and resected. The palmar-digital fasciectomy of the left hand was performed successfully. Samples were sent for pathological studies.
Not part of the OP note(s) just inserted for visual of the pretendinous and spiral cord(s)
Then we turned our attention to address left finger stenosing tenosynovitis. Sharp dissection was carried through the skin and the subcutaneous tissue. Neurovascular bundles were identified. Two small retractors were applied. The A1 pulley of the
left ring finger was exposed. It was found that the A1 pulley was inflamed and thick, about 3mm in thickness. Then a sharp blade was used to
release the A1 pulley of the left finger successfully. Then a small scissors were used to extend the release proximally and distally. Great attention was paid to protect the A2 pully.
Then we turned our attention to address
left middle finger trigger digit. The middle finger
A1 pulley was exposed and released with a sharp blade. Great attention was paid to protect bilateral neurovascular structures.
Left Index finger - identical procedural dictation
Left small finger - identical procedural dictation
Then we turned our attention to carpal tunnel release. A 2.o cm longitudinal incision was made in line with the radial border the ring ginger from the intersection of the Kaplan Cardinal line proximal to the wrist flexion crease. Sharp dissection was carried through the skin and the subcutaneous tissues. The palmar aponeurosis was exposed and split with a sharp scissor and then the distal border of the transverse carpal ligamaent was exposed. A sharp scissor was used to make a small cut in the center of the transverse carpal ligament. Then the distal portion of the transverse carpal ligament was released with a sharp scissor under direct visualization with a piecemeal fashion. Then a small retractor was applied to the proximal portion of the wound. Then we turned our attention to release the proximal portion of the transverse carpal ligmaent. The proximal portion of the transverse carpal ligament was released with a sharp scissor under direct visualization. Then we extended our release to the distal antebrachial fascia. At this time the carpal tunnel was completely released. It was noted that the median nerve was flat. Compression from the transverse carpal ligament was evident. Then the wound was packed with sterile dressing.
What was coded:
26121-LT
26055-59F1
26055-59F2
26055-59F3
26055-59F4
64721-XULT