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Tag Archives: Hand

Help with hand surgery please

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DIAGNOSIS: Open complex dislocation to the left fourth digit involving volar plate collateral ligaments with near total avulsion of the fingertips with involvement of the digital nerves.

OPERATION PERFORMED
1.Open irrigation and debridement including removal of foreign material, devitalized soft tissue extending down to tendinous structures involving open complex dislocation.
2.Repair of ulnar collateral ligament.
3.Repair of radial collateral ligament.
4.Repair of radial digital nerve.
5.Repair of ulnar digital nerve.
6.Repair of volar plate of interphalangeal joint.

INDICATIONS FOR OPERATION: This patient is status post a very complex dislocation in which he nearly totally avulsed his finger and due to extensive ligament tendon injuries he was sent for a specialist consultation. This was much more complex than a normal tendon or ligament repair, which is often done by emergency room physicians. The patient was referred by ____[CLINIC].

This patient’s occupation is construction, and on this date, he did have a very large piece of concrete fall on him, severing and causing a near avulsion, open dislocation, of which his finger bent over backwards completely with the bone protruding and only connected by some soft tissue, nearly completely ripping all the ligamentous structures of the interphalangeal joint.

OPERATION IN DETAIL: After sterile preparation and draping in the normal fashion, and a regional digital block anesthesia, tourniquet exsanguination of the fingers, the digit was approached. The collateral ligaments were repaired using 4-0 PDS suture. The wound was also cleansed and irrigated copiously using antibiotic saline solution. Removal of foreign body, devitalized, crushed soft tissue was done for the open complex dislocation. The patient also had near complete amputation. There were 2 significant sized digital nerve branches, which were repaired under magnification using an epineural repair using micro technique and micro instruments and they were my own microinstruments.

However, prior to this, the patient also had disruptions of the volar plate. This is thought to be one of the main causes of the patient having no flexion of the digit and minimal movement.

The volar plate was repaired after using PDS suture. The profundus tendon was examined and found to be intact. It required no repair other than the surrounding structures around it. The patient did regain some movement after this; however, did not have forward flexion. He did have function of his extensor tendon and it was thought that part of the flexor belly was in spasm; however, the proximal and distal portions of the flexor tendon were intact upon extensive traction of the area prior to the repair of the previous mentioned structures.

Detailed instructions and appropriate dressings were used for the patient with followup discussed with the patient. He was also under the instruction that he should be very careful, keep his finger splinted at all times, and we will start him on a hand rehabilitation regimen, which will take months before he is able to have fairly normal function of the digit and it will not be back near its normal strength for 4 to 6 months.

Medical Billing and Coding Forum

Hand infection debridement

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Does anyone know what the appropriate CPT code would be for an irrigation and debridement of deep palmar infection of the hand?

OP report says: "First, I slowly cleaned the hand of chronic purulence that was stuck into the palm. Despite a preoperative scrub and sterilization, there was still caked on dead skin that took quite a bit of time to slowly clean her hand down to the level of the normal tissue. Once we got to that point, it was clear that there was infection deep in the palm at the level just distal to the carpal tunnel. There was a fair amount of purulence that was debrided at the level of the flexor tendon sheath and bursa throughout the palm. I copiously irrigated and debrided and eventually closed the wound with interrupted 4-0 nylon quite nicely."

Thanks!!!

Medical Billing and Coding Forum

Hand coders please do me a favor, tell me which codes are proper to submit please

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The following was done to the left middle finger. Please tell me which codes that you think are correct to submit. All procedures were performed on the same tendon through the same incision.

26433 Repair of extensor tendon, not in Zone II
26445 Tenolysis of extensor tendon (performed through same incision)
20660 K wire insertion through the DIP joint to hold joint in place
76000 Fluoroscopy

This is for physician education

Medical Billing and Coding Forum

Hand Coding

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One of my hand surgeons and I have a difference of coding opinion on the following OP report:

A sterile marking pen was then utilized to mark out a curvilinear incision overlying the ulnar
border of the thumb MCP joint. An Esmarch was utilized to exsanguinate the upper extremity
and the tourniquet was inflated to 250 mmHg. A #15 blade was used to incise the skin.
Meticulous hemostasis was obtained in subcutaneous plane with bipolar cautery. Several
superficial branches of the radial sensory nerve were identified and protected throughout the
procedure. The sagittal band was then released off of the ulnar border of the extensor pollicis
longus leaving a 2mm cuff of the band attached to EPL for later repair. A longitudinal
capsulotomy of the MCP joint was performed along the ulnar border of the joint line. This
allowed for excellent exposure of the underlying ulnar collateral ligament injury and the
proximal phalanx fracture. The patient had a complete avulsion of the ulnar collateral ligament
off of the proximal phalanx with an associated bony avulsion fracture. The proximal phalanx
fragment was very small and multi-fragmented. As such, the proximal phalanx fragments were
carefully excised. The ulnar collateral ligament was then carefully unfolded and brought back
out to length. The ulnar corner of the proximal phalanx was completely devoid of cortical bone
at the native footprint for the collateral ligament. As such, two Keith needles were advanced
from the ulnar corner of the proximal phalanx in an anterograde and radial direction to exit along
the radial border of the thumb proximal phalanx.
Two 2-0 prolene sutures were then passed through the ulnar collateral ligament in a running,
non-locking fashion. The prolene suture tails were then passed through the Keith needles and the
Keith needles were pulled through the proximal phalanx to shuttle the suture tails through the
bone. The suture tails were then passed through a layer of Xeroform and gauze followed by a
polypropylene button along the radial border of the proximal phalanx. The thumb MCP joint
was then carefully reduced and held in a semi-flexed posture while each set of suture tails were
sequentially tightened and tied to reduce the ulnar collateral ligament down to the proximal
phalanx.
Tensioning of the repair was then checked with the MCP joint in both full extension as well as
30 degrees of flexion. All testing demonstrated excellent restraint against apex ulnar deviation
stress at the level of the thumb MCP joint. The repair was then further reinforced by retensioning
the ulnar MCP joint capsule with 3-0 vicryl sutures (capsulodesis). The ulnar sagittal
band and the adductor aponeurosis were then repaired with 3-0 vicryl sutures to re-centralize the
EPL tendon.

He feels that CPTs: 26540, 26437, 26235 and 26516 are all warranted..

I believe that 26540 and 26437 are the only CPTs that should be billed.

Just was wondering if a diferent set of eyes could help!

Thanks
Heather

Medical Billing and Coding Forum

Hand, Foot and Mouth Disease

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Hi, could anyone help me with the icd code for hand foot and mouth disease?

We got B08.4 (Enteroviral vesicular stomatitis with exanthem), but my doctor says that this code seems to reflect mostly on the stomatitis, but not the actual condition of the disease. Any better coding for this (systemic virus infection with manifestation on hand, foot and mouth)

Thank you.

Bamboo

Medical Billing and Coding Forum

Need CPT for exploration and irrigation of puncture wound hand and forearm

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Can anyone suggest a code for the below procedure?

Patient was attacked by a cat and sustained a puncture wound of right wrist and multiple scratches. She was treated and given course of antibiotics but conditions worsened and she was admitted and given intravenous antibiotics. After multiple days int he hospital she still had swelling in her hand and an MRI showed evidence of tenosynovitis. She also exhibited significant pain over the puncture wound site. Op notes: A laterally based flap was drawn on the hand to include and expose the puncture site and the course of the extensor tendons to the middle and ring fingers over the dorsum of the hand. The flap was incised and raised. Dissection was carried down over the tendon sheath to expose the distal tendon. There was no purulence noted. Cultures were taken. Dissection was then continued into the proximal area and completely exposed the site of the puncture wound. A small collection of clear fluid was found under the fascia. This was cultured for both aerobic and anaerobic organisms. Then, the tendon sheath and the puncture would were irrigated copiously with a solution of bacitracin, polymyxin and saline. Hemostasis using the bipolar electrocautery was performed, wound was irrigated with anitbiotic solution and skin was closed with interrupted 4-0 nylon.

thank you for any and all suggestions. We tried unlisted procedure code 26989 but Medicare denied and the decision is not able to be appealed. We must correct and resubmit.

Medical Billing and Coding Forum

Carpal Tunnel Release and 10 Compartment fasciotomy of the hand

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Can someone please help me with the following?? I have come up with 26037, but it does not seem to cover what all was done. Any and all help is appreciated!

PREOPERATIVE DIAGNOSIS: Right hand compartment syndrome.

POSTOPERATIVE DIAGNOSIS: Right hand compartment syndrome.

PROCEDURE PERFORMED: Right carpal tunnel release and 10 compartment fasciotomy of the hand.

TYPE OF ANESTHESIA: General.

ESTIMATED BLOOD LOSS: There was minimal blood loss.

COMPLICATIONS: No complications.

TOTAL OPERATIVE TIME: 30 minutes.

INDICATIONS FOR PROCEDURE: The patient is a 51-year-old woman who was assaulted in her home. She I think lost consciousness, I am not entirely sure of the situation, but she is actually deaf on admission from head injury. She has pretty banged up and her right hand is intensely swollen. The immediate thought process is that when she lost consciousness, her hand was severely bent underneath her and lost vascularity for a pretty time and then when she woke up, the hand regained vascularity and this is a revascularization phenomenon with intense swelling. She clinically cannot moving her fingers. Her hand is ballooned out intensely, it is almost rock-hard and is correctly assessed emergently in the emergency room that this was a compartment syndrome. She was emergently brought up. I was called in as the attending and assessed her and I do believe this is a compartment syndrome. So therefore on a clinical basis, we are taking her to the operating room for a compartment least
and carpal tunnel release. Her sister is there as next of kin for consent as she is head injured and not doing very well and signed the consent for her. I would like to add that she has quite severe rhabdomyolysis and her kidneys are being affected. Therefore, she is in the intensive care unit for hydration and management of that as well.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in supine position. General anesthesia was induced by the anesthesiologist. The right upper extremity was prepped and draped in usual sterile fashion with the proximal arm tourniquet in place. After elevation for 15 seconds, the tourniquet was put up to 250 mmHg. A 2 cm incision was made to the base of palm aligned with radial aspect of the ring finger and the ulnar aspect of the palmaris longus tendon. It was taken down to the superficial tissues down to level of transverse carpal ligament. The transverse carpal ligament was incised perpendicular to its fibers distally until palmar fat was seen and an adequate decompression was verified. Under direct vision, the thickest portion of fibers of the ligament were incised and then the last centimeter of the distal forearm fascia was incised through until there not being any palpable compression. Once that was done, I moved on to the other
compartments of the hand. We made an incision over the thenar eminence and this muscle was white. It looked like the color of a chicken breast. It had no real color to it and no rebound blood flow. I went over the hypothenar eminence and made an incision over there and that had the same white appearance to the fibers. Over the first dorsal interosseous space, made an incision there and that tissue also had that dysvascular appearance. We then made incisions over the dorsal interspaces and this tissue looked a little better. The muscle looked a little bit more pink and that was between 2 and 3; 3 and 4; and 4 and 5. Once that was all done, the tourniquet was let down and I sat and watched the compartments for a while and over about 10-15 minutes, we did slowly get some bleeding from the edges. As the pressure was relieved, we manipulated the fingers to get the pressure down even more by getting rid of swelling. There was intense swelling around the dorsal aspect of the
hand and we released that just with massage through the wounds. The only wound that I closed was a carpal tunnel wound and the rest I covered with Xeroform. I worked diligently to get this into an intrinsic plus position, getting the MP joints down to 90 degrees, the PIP joints perfectly straight, DIP joints perfectly straight, wrist at 20 degrees and the thumb with a good first webspace distance. This was done with multiple burn dressings and wraps, all for edema and hand position. A splint was provided to keep her in this position. She tolerated everything well. She was awoken from general anesthesia and transferred to the intensive care unit.

Medical Billing and Coding Forum

Technology and hand hygiene compliance

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Lutheran is among the healthcare organizations nationwide that in recent years decided to try hand hygiene monitoring technology in the hopes it could improve hand hygiene compliance—and in the process reduce the number of infections and avoid citations from accrediting organizations like The Joint Commission, which in January put stricter enforcement in place.

HCPro.com – Briefings on Accreditation and Quality

S63.055- Code once or multiple times for same hand?

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I recently came across a chart where the doctor wrote this code 3 times because he was going to treat several fingers on the same hand. I think it should only be listed once and the CPT code would reflect the multiple sites. I thought this because the diagnosis code covers the whole hand so there only needs to be 1 code. Any clarification would be great.

Medical Billing and Coding Forum