A helping hand for coding
Wrist, hand, finger codes don’t have to be confusing
By M. Bradford Henley, MD; William R. Beach, MD; Gary K. Frykman, MD; Melvin M. Friedman, MD, and Margie Scalley Vaught, CPC, Cpc-H, CCS-P, ASC-OR
If the questions we’ve received about applying and using common procedure terminology (CPT) codes for wrist/hand/finger procedures are any indication, many orthopaedic surgeons and coders feel “all thumbs” in this area. Therefore, this column covers documentation and coding pertaining to wrist/hand/finger surgery.
At times, a redo or revision carpal tunnel release (CTR) can require more work than the initial surgery. In some cases, fascial grafting or hypothenar fat grafts must be fashioned to help prevent further recurrence. The AAOS Global Service Data Book (GSD) includes the following procedures in a CTR: division of transverse carpal ligament with or without Z-plasty or other local tissue rearrangement; tenosynovectomy/tenolysis of flexor tendon(s); excision of lipoma of carpal canal; exploration/incidental release of ulnar nerve; release of distal forearm fascia; and use of scope equipment.
Excluded from a CTR are: internal neurolysis of the median nerve with decompression of pathology requiring internal neurolysis with use of an operating scope; neuroplasty of ulnar nerve for documented ulnar neuropathy; and wrist arthrotomy/synovectomy.
The current coding options for a repair/revision CTR are 64721-22 (if there is supporting documentation of more extensive work) or unlisted 64999. The AAOS Coding, Coverage and Reimbursement Committee is evaluating the possibilities for CTR revisions to determine whether additional reporting for the grafting (20926) can be allowed rather than developing a new revision code. The goal is to expand the use of existing resource value unit (RVU)-rated codes instead of adding new codes that could reduce the RVU for existing codes.
Another concern when doing CTR is the ability to report release of the ulnar nerve. To report both median and ulnar nerve release, the supporting documentation must indicate that the patient has ulnar neuropathy. This requires both a separate preoperative diagnosis (establishing medical necessity) and operative notes. Otherwise, the ulnar exploration/release could be considered inherent and thus not separately reportable.
Excision interosseous nerve
Anatomy: The interosseous nerve is divided into anterior and posterior sections. The anterior interosseous nerve is essentially a motor branch of the median nerve. It arises 5 cm-8 cm below the medial epicondyle, under the arch of the flexor digitorum superficialis, after passing between the two heads of the pronator teres. Its branches supply the flexor pollicis longus, the flexor digitorum profundus indicis and, about half the time, the flexor digitorum profundus majus. It then accompanies the anterior interosseous artery as they pass through and below the flexor pollicis longus and the flexor digitorum profundus to reach the pronator quadratus. Finally, it passes deep to the pronator quadratus and ends by sending articular branches to the wrist joint. None of its branches are cutaneous.
The posterior interosseous nerve travels along the posterior aspect of the forearm between the ulna and the radius. The posterior interosseous has its roots in the cervical spine (C6, C7, C8) and arises as a branch from the radial nerve.
Coding: CPT has several codes (64732-64772) relating to the excision or transection of the nerves. The origin of the nerve root must be known to reference the proper CPT code. You must also check to see whether the excision/transection is being performed for postoperative pain control. The Centers for Medicare and Medicaid Services has stated that the global surgical package includes postoperative pain management by the surgeon (see 100-04 Claims Processing Section 40). The documentation must clearly show why the nerve is being excised/transected. The recommended code for these excisions is 64772.
Basal joint arthroplasty
Anatomy: The basal joint of the thumb is also known as the carpometacarpal (CMC) joint. Located at the base of the thumb, the basal joint usually moves quite freely to help position the thumb.
Coding: Arthritis of the basal joint is often treated with an arthroplasty. Years ago, the anchovy procedure, as it was called, was represented by 25447 (Arthroplasty, interposition, intercarpal or carpometacarpal joints), and this code is still used for the treatment of basal joint arthritis. If the tendon graft is harvested from a separate incision, 20924 (tendon graft, from a distance [eg, palmaris, toe extensor, plantaris]) can also be reported. The GSD includes the following procedures under code 25447: arthrotomy/synovectomy of wrist or intercarpal joints; excision of osteophytes, bone fragments and joint debridement; partial or total excision of trapezium or trapezoid; capsular release, repair and/or reconstruction; and internal fixation of implant. The harvesting of tendon graft through separate skin or fascial incision is excluded from code 25447.
A variation of this procedure adds a sling or suspension aspect. The first metacarpal is suspended to the second metacarpal to inhibit the proximal migration of the first metacarpal that often occurs after the excisional arthroplasty of the first CMC joint. Typically, one half (or all) of the flexor carpi radialis (FCR) is used to create the new intercarpal ligament between the first and second metacarpals.
The transfer of the FCR to the base of the first metacarpal is not a part of the basic CMC arthroplasty and must be coded separately. Use either 26480 (transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon) or 25310 (tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon, as appropriate). Modifier 51 would be appended to the secondary procedure in either the 25447 + 26480 or 25310 code pairs, according to the January 2005 CPT Assistant.
Now let’s look at some recent questions about coding hand, wrist and finger procedures.
What is the difference between 20680 and 26320?
Although 20680 covers the removal of a deep implant (buried wire, pin, screw, metal band, nail, rod or plate), the AAOS Coding, Coverage and Reimbursement Committee says that code 26320 (removal of implant from finger or hand) should be used for removal of a carpal prosthesis, carpal screws, or other material inside the wrist capsule/joint. This procedure would require capsular or retinacular closure plus skin closure.
IM rodding of metacarpal bones
What CPT code would be used to report intramedullary (IM) rodding of the metacarpal bones?
If the fracture is opened, then the AAOS Coding, Coverage and Reimbusement Committee recommends using 22615, the code for open treatment with internal fixation. Technically, the IM rod is considered as internal fixation in the revised CPT guidelines (at the beginning of the musculoskeletal section). If, however, the technique is performed percutaneously and the fracture site is not opened, then codes such as 26607 or 26727 may be more appropriate.
How should the manipulation of joint codes be applied?
According to the National Correct Coding Initiative (chapter 1) as well as the AAOS GSD, manipulation of a joint is normally performed during the course of another (major) procedure and requires no additional reporting because it is considered inherent. Problems occur, however, when manipulation is performed as the only procedure, such as outlined in the CPT code 26340 (manipulation, finger joint, under anesthesia, each joint). This and other codes were added in 2002. The January 1999 CPT Assistant noted that the phrase ‘with or under anesthesia’ in a code description meant under general anesthesia. But by 2002, this information was outdated and the terms ‘under anesthesia’ or ‘with anesthesia’ are now understood to reflect the appropriate anesthesia for a given patient and/or given situation.
M. Bradford Henley, MD, is professor of orthopaedic surgery at the University of Washington and chairman of the AAOS Coding, Coverage and Reimbursement Committee. He can be reached at firstname.lastname@example.org. William R. Beach, MD; Gary K. Frykman, MD; and Melvin M. Friedman, MD, are also members of the committee.
Margie Scalley Vaught, CPC, CCS-P, CPC-H, ACS-OR, is an independent coding specialist in Ellensburg, Wash. A BONES member, she has served on the National Advisory Board for the American Academy of Professional Coders. She can be reached at email@example.com