Clinical Documentation: Connecting the Dots | Join Webinar & Earn 1 AAPC® CEURegister Now >>

Orthopedic Coding Alert

Reader Questions:

Consider What Surgeon Excised to Choose Code

Question: Our surgeon performed a cyst excision to the distal interphalangeal (DIP) joint on the ring finger. The operative report indicates that the cyst was deep down into the DIP joint. Which code should I report?

Kansas Subscriber
Answer: If the orthopedic surgeon excised a lesion, you should report 26160 (Excision of lesion of tendon sheath or joint capsule [e.g., cyst, mucous cyst, or ganglion], hand or finger).

If he excised a bone cyst, you should instead report 26210 (Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger).

If the orthopedic surgeon's notes didn't indicate the type of cyst that he excised, you should show him both codes and ask him which code best applies to the patient's situation. You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J.

Other Articles in this issue of

Orthopedic Coding Alert

View All