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Code This!

Scenario Week of August 01, 2013:
View Current Scenario

Assign the correct ICD-9-CM, ICD-10-CM diagnosis and CPT 2013 procedure codes for the following inpatient coding scenario:

Diagnosis: Dupuytren disease right hand and fifth finger
Procedure: Excision Dupuytren disease
Complications: None
Blood Loss: Minimal
Anesthesia: Bier block with monitored anesthesia

Indications: The patient is a 51-year-old male with a history of Dupuytren’s disease causing contractions. This is painful for the patient, and he is in obvious discomfort. The risks and benefits of surgery have been discussed with the patient and he wishes to continue with the excision.

Procedure: The patient was supine on the procedure table. A bier block was administered to the right upper arm by the anesthesiologist. The right hand and wrist were prepped and draped in sterile fashion.

A zig-zag incision was made on the palmar surface from the distal finger to the mid palm area. Skin flaps were elevated. Dupuytren contracture (palmar fascia) was dissected from the undersurface of the skin flaps. Two proximal neurovascular bundles were identified. The Dupuytren fibrous band was resected proximally with tissue restoration. Palmar fascia was dissected from the neurovascular bundles from the palmar flexor tendon sheath continuing to the right fifth finger PIP joint. The wound was irrigated. Inspection of the neurovascular bundles showed no evidence of injury or residual Dupuytren disease. Incisions were closed with interrupted 5-0 nylon sutures. A dry dressing was applied.

The patient tolerated the procedure well and will be monitored until discharge. He is to return to the office for wound check and suture removal.

Assign the appropriate ICD-9-CM, ICd-10-CM, and CPT 2013 diagnosis and procedure codes.

Coding Answers

ICD-9-CM Diagnosis Code
728.6 Contracture of palmar fascia

The index main term “Dupuytren’s” is referenced. The subterms “disease (muscle contracture)” and “contraction” refer the user to 728.6. This is verified in the tabular list where Dupuytren’s contracture is listed below the code description. The disease and contraction are reported with the same code, so only one code is reported.

ICD-10-CM Diagnosis Code
M72.0 Palmar fascial fibromatosis [Dupuytren]

The index main term “Dupuytren’s contraction or disease” refers the user to M72.0. There are no subterms under this main term. Alternately, the main term “disease” and subterms “Dupuytren’s (muscle contracture)” may be referenced and also refer to the same code, M72.0. Lastly, the main term “Contraction(s), contracture, contracted” and subterm “Dupuytren’s” refer to the same code. Code M72.0 is confirmed in the tabular list. This example illustrates that often a term may be found using multiple main terms and subterms.

CPT Procedure Codes
26123 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft);

The index includes a listing for Dupuytren’s fasciotomy (26040); however, the procedure describes excision of the fascia. The index main term “excision” and subterm “fascia” instruct the user to see “fasciectomy.” The main term “fasciectomy” and subterm “palm” refer the user to 26121–26125. By referencing the codes, it is determined the appropriate code is 26123 as it describes the fasciectomy of the palm and one digit.

CPT Assistant, October 2010 confirms that code 26040 would be incorrect and also instructs the user to see 26121–26125. The June 2011 issue also addresses Dupuytren’s contracture and states, “If a palmar fasciectomy is performed to include the fingers, a code from the 26121–26125 series would be reported.”

Bier block is the administration of a regional anesthetic. If the surgeon had administered the bier block it would be separately reported. The surgical package as defined by the CPT book indicates that local, metacarpal/metatarsal/digital blocks are included. It does not indicate that regional blocks, such as a bier block, are included. The CPT Assistant November 2004, updating a previous article, indicates that bier block should be reported with code 64999. In this instance, however, as the block was administered by an anesthesiologist, the surgeon would not code for this service.

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