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.
- 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.