Billing for hand procedures is among the most complex types of orthopaedic coding. Here, we highlight eight frequently encountered errors when coding hand procedures and how to fix them.

1. Lack of specificity in documentation of tendon repair and fracture management

Current Procedural Terminology (CPT) includes references to specific locations in the forearm, wrist, hand, and fingers for reporting flexor and extensor tendon repair codes. Codes are selected based on the location of the repair, not the site of tendon insertion. In particular, zone 2 flexor tendon repairs in the hand are important, as a separate CPT code is used to describe such procedures.

Location specificity also is essential in fracture management reporting. An example is distal radius fractures, which require documentation of whether the fracture is extra- or intra-articular. If intra-articular, the operative note must specify the number of fragments (one to two or three or more). Be consistent when creating the operative note procedure list and documenting operative detail within the note body.

2. Incorrect reporting of first CMC excisional arthroplasty and associated services

Hand surgeons use a range of techniques for first carpometacarpal (CMC) excisional arthroplasty. Whether excisional arthroplasty is performed with an interposition tendon graft, tendon suspension, or allograft tightrope, all methods are reported with CPT code 25447, Arthroplasty, interposition, intercarpal or carpometacarpal joint.

When a flexor carpi radialis tendon graft is harvested in the forearm for arthroplasty stabilization, the American Society of Surgery for the Hand (ASSH) has instructed its members to utilize code 26480 for reporting Transfer or transplant of tendon, carpometacarpal area or dorsum of hand without free graft, each tendon based upon directives published in “CPT Assistant.” This code represents the location of the tendon placement, not the location of harvesting. Because there is no National Correct Coding Initiative (NCCI) edit between codes 25447 and 26480, it is not necessary to use modifier 59 for this code combination. Multiple procedure modifier 51 would be used with code 26480 because it has a lower relative value than 25447.

Removal of the trapezium or trapezoid is included in CPT code 25447. If a second carpal bone is fully or partially excised, use of CPT code 25210 also is supported, but the code must be appended with modifier 59 to explain that the provider is not using it to report the first carpectomy, thus unbundling the arthroplasty service.

3. Insufficient documentation to support tendon lengthening in conjunction with submuscular transposition of the ulnar nerve

CPT code 64718 is used to describe Transposition and/or neuroplasty of the ulnar nerve at the elbow. This code is used commonly to report simple decompression of the ulnar nerve, such as anterior transposition or subcutaneous transposition. Instead, surgeons may perform a submuscular transposition, which also is reportable as 64718. If the physician performs tendon lengthening as a component of the submuscular transposition, a secondary CPT code may be reportable: 24305, Tendon lengthening, upper arm or elbow, each tendon. The operative note must contain clinical justification and clear documentation of techniques, such as z-lengthening of the flexor pronator mass or lengthening of the flexor pronator fascia, in addition to dissection of the muscle and/or fascia, placement of the ulnar nerve in a submuscular location, and resuturing of the muscle. Because there is no NCCI edit between codes 24305 and 64718, it is not necessary to use modifier 59 for this code combination. Multiple procedure modifier 51 would be used with code 26418 because it has a lower relative value than 24305.

4. Billing for débridement when it is inclusive to the procedure

Per CPT: “Débridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when débridement is carried out separately without immediate primary closure.” For example, separate reporting of débridement from the 11042–11047 series of CPT codes would not be allowed in conjunction with an open wound with a tendon laceration, unless the criteria above are met and well documented in the operative report. CPT does allow separate reporting of excisional débridement from the 11010–11012 series of CPT codes in conjunction with open fractures or dislocations with appropriate documentation of medical necessity.

5. Billing separately for fluoroscopy or splint/cast application with surgical procedures

The fracture reduction codes include the use of fluoroscopy to assess fracture reduction; CPT code 76000 is not separately reportable. Moreover, application of the initial splint or cast is part of the surgical dressing and is not separately reportable.

6. Use of nerve code 64772 for AIN and/or PIN without a supporting diagnosis

When transection or resection of the anterior interosseous nerve (AIN) or posterior interosseous nerve (PIN) is performed, be sure to include an appropriate supporting pain diagnosis. When it is performed in conjunction with other hand procedures, it cannot be assumed that the service is medically necessary. Clear documentation in the operative record of indications for nerve service is mandatory.

7. Unbundling wound explorations

CPT code 20103 is reported for wound exploration, which includes extension of wound, débridement, removal of debris, and exploration of the wound to assess integrity of structures, if no structure is repaired. We see CPT code 20103 incorrectly reported in addition to the repair of a structure (tendon, nerve, etc.), but such exploration is included in the structure repair codes. Report one or the other, not both.

When CPT code 20103 is supported, we often find that surgeons also code for débridement from the 1104X series of codes, or nerve neurolysis (647XX) for nerve explorations. Note that CPT code 20103 is defined as a “separate procedure” code; thus, the maneuvers are included in code 20103 and are not separately reportable.

8. Unbundling and insufficient documentation of amputation services

CPT codes 26951 and 26952 include débridement and irrigation, so billing 1104X and 1101X with the amputation codes is not appropriate and will be denied. It also is considered unbundling to report codes 14040 and 1313X in addition to code 26952 for amputation closure with flap (e.g., V–Y). The correct way to report each of these examples is with the appropriate amputation code alone.

“A flap was used to close the amputation” is insufficient documentation to report code 26952. The physician must clearly describe the flap (e.g., incisions made, nature of flap). Moreover, use of the term volar flap (i.e., undermining the volar tissues) does not support use of code 26952. The volar (and dorsal) tissues are mobilized in straightforward amputation closure (code 26951); don’t report these maneuvers separately when reporting code 26951.

Sarah Wiskerchen, MBA, CPC, is a senior consultant with KarenZupko & Associates, Inc. She has more than 25 years of coding, reimbursement, and practice management experience and is a developer and instructor for the AAOS national coding and reimbursement series. Ms. Wiskerchen also provides education for ASSH.

Raymond Janevicius, MD, is a plastic and hand surgeon and president of Janevicius Consulting Corp. A nationally recognized coding and reimbursement expert, he has more than 30 years of experience, including participating in the creation of numerous CPT codes and revising several sections of the CPT book. He is the author of more than 350 articles on accurate, ethical coding. Dr. Janevicius’ on-demand hand coding courses are available at karenzupko.com.