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please advise on coding new to orthopedic and should I code the nail avulsion ?

louise Posted Thu 28th of March, 2019 15:11:25 PM
1. Irrigation and debridement of left hand.dibridemb finger 11044 2. Open reduction internal fixation left ring finger P2 with antibiotic spacer placement 26765 3.Open reduction PIP long finger fracture dislocation with internal fixation 4. Splint application. 26765 Comminuted P2 fracture of the ring finger. Comminuted articular surface at P2 proximal aspect in the middle finger. avulsed the skin overlying P2 in both the middle finger and ring finger. Aavulsion of the nail on the small finger, which was removed and the nailbed stuffed with Xeroform. We first started with the ring finger. We noted extensive comminution and bone loss at P2, but noted the distal articular portion of P2 to be well-approximated with a towel clamp in 2 large fragments. There was extensive bone loss proximally, but a small portion of the PIP joint remained. We placed 2 transverse K-wires from ulnar to medial in the distal aspect of P2 to hold our reduction. We then placed 2 wires from the tip of the distal phalanx of the middle finger, traversing the DIP joint and the PIP joint. The position of the wires was verified under fluoroscopy in both AP and lateral planes. We then removed the most distal transverse K-wire in the P2 fragment. Reduction was maintained under fluoroscopy. We then placed antibiotic cement in the void of the proximal aspect of P2 of the middle finger. avulsed completely over P2. We noted that the joint surface at the proximal phalanx was completely destroyed with no articular cartilage left. Given that the joint surface was not salvageable, we elected to pin the PIP and DIP joints. We flexed the PIP joint 40 degrees and extended the DIP joint to neutral and placed one K-wire from distal to proximal through the DIP and into the proximal portion of P3 of the middle finger. The placement of K- wire and the position of DIP and PIP were all verified under fluoroscopy in both the AP and lateral planes. We then copiously irrigated the wounds of the middle finger and repaired the extensor tendon with 4-0 Ethibond in a figure- of-eight fashion overlying the middle finger as well
SuperCoder Answered Fri 29th of March, 2019 08:09:12 AM

As per report, there are open fractures at P2 of ring and middle finger. CPT code 26765 is for the ORIF distal phalangeal fracture, finger or thumb, which is P3 of finger. Each finger is composed of proximal (P1), middle (P2), and distal (P3) phalanx, except for the thumb. In your case, it is P2 (middle phalanx), so CPT 26735 is appropriate to bill instead of 26765. In CPT 26735 (Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each), the provider makes an incision in the skin over the fractured bone (Ring and Middle Finger-P2 in your case). He then dissects down through subcutaneous tissue, protecting the nerves and vessels. He retracts the muscles to have adequate exposure of the phalanx fracture. He then adjusts the bone to reduce the fractured fragments, or to bring the dislocated bones back to their normal alignment. He may fix the fracture using implants like a plate, screws, nail, or wires. He closes the wound by suturing the skin layers together. He places the patient’s finger in a brace or splint for a period of about four weeks. Hence, splint will not be coded separately. Also, he may perform an X–ray examination of the finger or thumb bone to confirm the reduction of the fracture.

Per coding perspective, use CPT 26735 for the ORIF of left ring finger P2 with modifier F3 (Left hand, fourth digit) and again CPT 26735 for left middle finger P2 with modifier F2 (Left hand, third digit).

CPT 26418 is for middle finger extensor tendon repair. In this procedure, provider uses this procedure to treat an injury of an extensor tendon by primary or secondary repair. He dissects through subcutaneous tissue and gains adequate exposure of the extensor tendon. He then repairs the tendon to restore the lost function caused by injury of the tendon. Finally, he obtains hemostasis at the surgical site and closes the wound by suturing the soft tissue in layers. Use one unit of this code for each tendon repaired. This code does not include the use of a graft for repair. Also, append modifier F2 for left hand, third digit.

CPT 11760 can be used for the avulsion of nail repair. In CPT 11760, the physician removes the nail and repairs the nail bed. He can perform a hematoma evaluation or drain blood with absorbable sutures, which is included in this code. Check the documentation for nail repair, if anything is missing from the procedure then append the modifier 52 (Reduce Services). Also, append modifier F4 for left hand, fifth digit.

Since, your provider has performed the fluoroscopy, then use CPT 76000 for this service. According to the guidelines, code 76000 is a column 2 code for 26735, modifier 59 is allowed in order to differentiate between the services provided. Use modifier 59 with code 76000.

Hope this helps!

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