Question

PREOPERATIVE DIAGNOSIS : Right long finger, trigger finger. Left subacromial bursitis.

POSTOPERATIVE DIAGNOSIS : Right long finger, trigger finger. Left subacromial bursitis.

PROCEDURES :

Right long finger trigger release. Injection of the left shoulder with Xylocaine, Marcaine and Celestone via anterior subacromial approach.

ANESTHESIA : General.

COMPLICATIONS : None.

ESTIMATED BLOOD LOSS : Minimal.

REPLACEMENT : Crystalloids.

DESCRIPTION OF PROCEDURE : The patient was taken to the operating room where he was given general anaesthesia. The right upper extremity was prepped and draped in the usual sterile fashion. While draping, the left shoulder was prepped with Betadine; and through an anterior subacromial approach, the left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. The patient tolerated the procedure well.
Meanwhile, the right hand had been prepped and draped. It was exsanguinated with an Esmarch bandage, and the tourniquet inflated to 250 mm. I made an incision over the A1 pulley in the distal transverse palmar crease, about an inch in length. This was taken through the skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. Care was taken to avoid injury to the neurovascular bundle. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. A clean dressing was applied. The patient was awakened and taken to the recovery room in stable condition.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

The CPT code for right long finger trigger release is 26055, and the CPT code for the injection procedure of the left shoulder is 20610. The corresponding ICD-10-CM codes are M65.311 for Trigger finger of the right finger, and M75.52 for Bursitis of the left shoulder.

Step-by-step explanation:

To report the CPT and ICD-10-CM codes for the surgical procedures described in this scenario, we must identify the procedures performed and the diagnoses associated with them. For the right long finger trigger release, a CPT code of 26055 would be used, which represents 'Tendon Sheath Incision (eg, for trigger finger)'. The shoulder injection procedure can be coded with 20610 which represents 'Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)'. In terms of ICD-10-CM codes, if we assume that there is no more specific information such as the severity or the cause of the condition, we would use M65.311 for 'Trigger finger, right finger' and M75.52 for 'Bursitis of left shoulder', respectively.