This is a 42 yr old male who accidentally injured his left index finger while working on a broken shutter at home in his garage, the patient sustained a jagged laceration over the dorsal radial aspect of the index finger at the proximal interphalangeal joint, the wound was deep involving the joint capsule, extensor tendon and collateral ligament, the bone was also involved, especially at the base of the middle phalanx into the apical surface.
Procedure: Marcaine was used a local anesthetic digital block, the hand was prepped and draped in the usual manner, tourniquet than was placed at the base ofthe fingers, the wound was then debrided , the minute loose bone and articular surface had to be removed, some skin debrided aslo was removed, the joint capsule and extensor tendon then were repaired with 5-0PDS suture material, the radial collateral ligament also was repaired with same suture material, the skin then was carefully approximated with 5-0 nylon. dressing was applied, the tourniquet was released and there was good perfusion throughout the fingers, an aluminum splint was placed, Assign the correct codes and modifier for this encounter
To assign the correct codes and modifier for this encounter, we need to break down the procedure and identify the specific services provided. Based on the provided information, the following codes may be applicable:
1. Digital block anesthesia: Typically coded with a CPT code in the range of 64400-64450. However, the specific code would depend on the anesthesia technique used and the anatomical location. To accurately assign the correct code, more specific information is needed.
2. Wound debridement: The debridement of the wound involves removal of loose bone and articular surface, as well as some skin debridement. Depending on the extent of the debridement, the appropriate code would be selected from the CPT code range 11010-11012. Again, more specific information is needed to assign the correct code.
3. Repair of joint capsule, extensor tendon, and collateral ligament: The repair of the joint capsule, extensor tendon, and collateral ligament is coded using CPT code 26356. This code covers the repair of a deep wound that involves the joint capsule, ligaments, and tendons.
4. Repair of the skin: The skin was approximated using 5-0 nylon sutures. The appropriate CPT code for simple wound closure with sutures would be 12002 if a single-layer closure was performed.
Modifier: Based on the provided information, it is unclear if any modifier would be necessary. However, if there were any special circumstances or unusual circumstances that required the procedure to be modified, a modifier might be applied. A commonly used modifier in this case might be modifier -25, indicating significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day as the procedure.
Please note that the information provided is limited, and additional specific details would be required to accurately assign the codes and modifier for this encounter. It is recommended to consult an appropriate coding resource, such as the Current Procedural Terminology (CPT) manual, and consider seeking the assistance of a qualified healthcare professional for accurate coding.