Our hands may the the body part we most take for granted relative to their importance to our existence and our day-to-day activities. They are amazingly intricate and comprised of many different body systems and incur injuries and conditions that often demand the expertise from a number of surgical specialties including Plastic surgery, Orthopedic surgery, Vascular Surgery, Rheumatology, and of course Hand surgery. This assures that hand surgery is a constant challenge for coders.
Hand surgery goals
Because of the precision functioning of our hands, the generous allocation of nerves (and brain to control them), and delicate balance of the stability and movement, hand surgery is intended to ensure complete and secure skin coverage, correct alignment and smooth movement of the joints, and balanced pull of the tendons that move, and the ligaments that stabilize, the many joints that we have. Through injury, inflammation, and wear and tear, these mechanisms can be compromised. The surgeon’s goal is to keep everything running smoothly.
How do we code this in CPT?
With 26% of all of our bones in our hands, there are plenty of opportunities for Orthopedic mishaps with the hand, and consequently there are a number of CPT codes in the Musculoskeletal section 20100 – 29999. Any and all of the bones in the hand can be fractured, and as hands are the “feelers” to our external world, they are in fact often subjected to fractures. Are you comfortable with the eight different carpal bones and how to code the various types of fracture interventions that can be performed? No body part has quite the number of approaches and techniques for fracture treatment as the hands: closed, with and without manipulation, percutaneous, open. There is such a multitude of variation it is critical that we coders have a strong working knowledge of hand fracture care and the respective coding.
Tendons magically move our fingers in three dimensions almost effortlessly. Watch a pianist or even your own hands as you type and marvel at the precision with which the action occurs. Tendons are responsible for this amazing clockwork like movement. Tendons are subject to laceration, rupture, infection, triggering, and imbalance. Have a look around CPT 26350 – 26497 and you will see a surprising variation in the number of codes that pertain to tendon work. Do you know the difference between a tendon repair in No Man’s Land zone 2 or not? What the heck is an “opponensplasty”?
The joints and ligaments of the hand and fingers are the unsung heroes of keeping things strong and stable. Through acute injury or prolonged abuse, these structures can find themselves worn and imbalanced. Treatment includes reconstruction, release, replacement, or even fusion. The ligaments that comprise the joint capsules in the hand may be released in a capsulotomy or tightened up in a capsulodesis. The local ligaments can also be used to interposed inside the joint to create a new articular surface. There is no shortage of clever procedures that can be done to restore the hand and finger joints and ligament construct.
Finally, it is probably more critical on the hands than elsewhere on the body that the hands have good skin and soft-tissue coverage. With all the aforementioned structures, deep infection of the hand and fingers is an ominous risk. Also consider the need for the skin to move along with the bones, joints and tendons. Among the integumentary CPT codes 10004 – 19499 you will find many of the repair and skin graft codes include the hands in the “harder to do” sites with scalp, neck, feet, and genitalia. But there are several codes that are absolutely specific to the integument of the hand, including nail procedures 11719 – 11765 and some like filleted finger flaps which are completely specific to the hand. There is even a procedure to turn an index finger or toe into a thumb.
Ed O'Beirne, CCS, CHDA, CHPS, CDIP, PA, MHS
Documentation and coding audits are firmly in Ed’s skillset but educating coders is what really makes him tick. He is known for effectively integrating anatomy, physiology, pathophysiology, medicine, and detailed procedural descriptions into his coding education in all forms.