The Upper Hand: Chuck & Chris Talk Hand Surgery

Listener Mailbag w Discussion on Surgical Coding

April 10, 2022 Chuck and Chris Season 3 Episode 13
The Upper Hand: Chuck & Chris Talk Hand Surgery
Listener Mailbag w Discussion on Surgical Coding
Show Notes Transcript

Season 3, Episode 13.  Chuck and Chris review several listener questions and comments and then discuss coding.  We discuss our views on coding, review some cases and incorportate our clinical practice, academia vs private practice and refer to two different manuscripts. 

Coding Practices in Hand Surgery and Their Relationship to Surgeon Compensation Structure
Ryan M. Coyle, MD, , Amr M. Tawfik, BA,  Anna Green, MD,  Brian M. Katt, MD, y Steven Z. Glickel, MD    Journal of Hand Surgery Global Online 3 (2021) 161e166

Use of a pedicled adipose flap as a sling for anterior subcutaneous transposition of the ulnar nerve.  Danoff JR, Lombardi JM, Rosenwasser MP.  J Hand Surg Am. 2014 Mar;39(3):552-5. 

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Charles Goldfarb:

Welcome to the upper hand, where Chuck and Chris talk hand surgery.

Chris Dy:

We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.

Charles Goldfarb:

Thank you for subscribing wherever you get your podcasts.

Chris Dy:

And be sure to leave a review that helps us get the word out.

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm doing great. How are you this fine Sunday morning?

Chris Dy:

Oh, well, I'm inside on a beautiful Sunday morning. But just finishing rounding. You know, it's interesting, we have this policy now, where, you know, we have to, you know, attending physician must see the patients seven days out of the week. And it's really nice to actually sit, not sit, but actually walk around with the resident and talk to the resident. I feel like that's probably the biggest perk that I've noticed, obviously, the patient care part of it too. But just a little downtime with with the residents is kind of fun.

Charles Goldfarb:

You know, I think that resonates with me on two counts. One, I totally agree. I don't love going into round. That's why I went to an surgery. So I didn't have to do that much. One of the reasons I went to hand surgery, but hanging out with the residents and getting in rounding is okay, and honestly, I don't think we're adding much to patient care. But occasionally we might. But the second resident point is you and I had been doing what we old school called the resident fellow clinic, and attending there. And I have to say that has been fantastic. I really enjoyed that. It's just a very different environment in the sense that the residents or fellows, quote, unquote, own the patients, I'm there for consultation, and I love that environment.

Chris Dy:

You know, I enjoyed the last time I was there, mainly because I brought snacks was great. I did that I remember I did that clinic as a fellow here. It is a very important part of my experience and one that I wouldn't trade for anything. And I think having some additional attending involvement in whichever way is useful to the trainees. You know, the residents, fellows do a fantastic job in that clinic. And they clearly show ownership and they value that you don't just be a small part of it again, it's nice. Rounding this morning, of course, all the things that happened when he round happened. So first patient we went to see had just gotten into the bathroom. Another patient that we're gonna go see, was literally getting transported as soon as we got to there. So I won't say it was the most efficient rounds. And then of course, somebody got added onto our list to see right at the end. So but it was fun. Joe Vivian is actually I think on your service right now and fantastic resident a lot of fun to work with. And yeah, that was it's a nice thing.

Charles Goldfarb:

Yeah, yeah, those are the frustrations of rounding. And when you're trying to, you know, take your time and be you know, teach and then you get stymied at every turn with a with a hiccup, it can get a little frustrating.

Chris Dy:

What do you been up to otherwise?

Charles Goldfarb:

You know, it's really this week has been reentry. I was fortunate enough to go away with the family on a wonderful vacation as I think you did as well and had a wonderful time and you know, come back and and just get back in the game. And it was a good week. Clinically, you know, very busy as you know, most of us are when we come back you get busy before you get busy after will take me a couple of weeks I think to catch up completely. Yeah, how was your your first week back?

Chris Dy:

It was good. Pretty much the same. was a little surprised by how refreshed I felt after traveling with children, young children. It's a bit of a hit or miss not exactly vacation, but it was there was some relaxation, and some recharging. So I felt pretty good coming back. So any interesting emails that you've received recently?

Charles Goldfarb:

Yes, I got. I've gotten a couple of really interesting emails lately regarding the podcast. The first one is was from Andy Nelson, who is a hand society member, a listserv participant, and he wanted to follow up and discuss a little bit more about technique for arthroscopic TFCC repair, specifically foveal repair. And this was in response to our deep dive on surgical technique. And we had a good email conversation. And I have to say, you know, Andy is in, in New Britain, Connecticut. And while I've known him for a long time, I don't know him super well, but I was a happy he discovered the podcast and it's always, you know, it's just so interesting how this podcast is becoming more and more people are becoming more and more aware of it, but in very different time points. And second of all, that he became aware of it has a long commute. He's been enjoying listening to it and I love the fact that he followed up with questions.

Chris Dy:

Questions are always always welcome. So if anybody He has any questions, feel free to email them to handpodcast@gmail.com or leave them in a review. But yes, Andy, thanks for listening. And thanks for spreading the word on the listserv. I know that we've gotten a little buzz on there. And listserv is a fantastic resource for many, many practicing hand surgeons and trainees. So what was the question that Andy asked you about your TFCC repair.

Charles Goldfarb:

So I'm going to just quote him. And I kind of love all of this. He said, Chuck, I feel via the podcast I have come to know you, I enough to call you chuck with all the respect you deserve. Why don't have a deserve any respect, but I certainly welcome the first name basis. And then he said, First, I love the podcasts and just discovered and have binged on my 35 mile commute to and from work. I am working on a list of suggestions to come earlier. Thank you. We want suggestions. And we look forward to that list. And the question is, I don't think I understand exactly how you do your TFCC repair. And he has done an open repair, which sounds like it's pretty much like mine. And then we went back and forth on the technical. And I think that bears further emphasis. So there are sports hand surgeons out there. And Steve Shin is one of them. Steve is at Cedars Sinai in LA. Steve is clearly recognized as a sports surgeon, and I think you are going to or have just recently interviewed Steve for your podcast. But Steve does an open repair of TFCC injuries with a suture anchor for folio type repairs, and he has a slip technique and is very pleased with it. I really liked arthroscopic repair, I believe you get better visualization, I think you can be more technical with your suture placement. And so I think you could accomplish the same goals. And certainly, you know, surgeon comfort is incredibly important. It remains my preference to do these arthroscopically.

Chris Dy:

Do you consider your ulnar tunnel technique to be an arthroscopic repair.

Charles Goldfarb:

So that's super interesting. And that may tie into another conversation we have I consider an ulnar tunnel that is you know, drilling a short oblique tunnel through the ulna and bringing the sutures down and tethering the sutures to the bone to be an open assisted technique. So you know, the scope is in the joint the entire time, the scope and a probe are helping to assure exact placement of the sutures. But ultimately, this is an open repair technique. And so I think it actually checks both boxes. And the coding is interesting for it.

Chris Dy:

Yeah, well, that actually brings us to probably our topic of discussion for today. But I love that technique, mainly because I think you were doing it with more frequency when I was training with you, or you just started to do it more. And I really like it. And it's worked for me as well. And it's pretty intuitive. So perhaps one day, I should really sit down with you and kind of go through a true open technique. But if I'm in that kind of setting, I'm probably sending that patient to you anyway.

Charles Goldfarb:

Well, I appreciate that. You know, it's, I'm in the middle of a study. I don't think that fovea TFCC tears, and I guess I should broaden that the wide expanse of TFC pathology, I don't think it's super well understood. And maybe that's maybe it's not well understood by me. But I think it's taken me years to really feel like I totally own it. And I think I do. But my sense is that if you know, we took a couple of surgeons from WashU, and a couple of surgeons from elsewhere, and compared our assessment, it would not be the same. So that's what we're about to do. There's one study out there doing this at a Philadelphia we're going to do it on a little bigger scale. We have about 40 arthroscopic videos and we're going to compare and contrast and try to see what people think about the diagnosis because you can't make the diagnosis in a way that is mutually agreed upon by all then obviously, treatments can be very different. So anyways, understanding that TFCC tear is the first step and then surgeon choice on treatment thereafter.

Chris Dy:

I think your study is gonna be really interesting. I can't believe you're giving away all of your wonderful study ideas on the podcast.

Charles Goldfarb:

Hey, more power to the listener who can make this happen quickly. It you know, I'm all about other people jumping in. This is a tough one, though, to get good videos and and reviewers it's taken us some time.

Chris Dy:

I mean, there's there's some really interesting literature in parallel in the general surgery, education space along these lines, not necessarily grading and assessment, but also surgeons skill in terms of sending in videos of your laparoscopic cholecystectomy and seeing how efficiently move and having somebody else graded and they might have even incorporated something like that into their board certification process. I think it's super interesting and funny enough, somebody emailed us saying that we both say super interesting a lot. Just caught myself doing that. You've got your two things, and we both have our super interesting. But yes, yes. Super interesting space.

Charles Goldfarb:

Yeah, well, it's not just entertaining and super interesting. Um, I think that's fascinating. And we've had a brief discussion, I think early in the podcast about, you know, how do we continue to improve as surgeons, if we're not, you know, coached on surgical technique and individually assessed, and the your comment gets to the point of that, which is a whole nother level of discussion, but fascinating.

Chris Dy:

So, to continue with our mailbag theme for today's episode, there was a great email from Cal Shaw, who is a listen to podcast for a long time, and we appreciate that cow. And he emailed it was a little bit ago, but a question about coding. And he was talking about how we code potentially for a ganglion cyst? Do you code for an arthrotomy? Do you do anything for a capsule or fee? And then just in general, just some discussions about coding and thoughts. Do you have any thoughts on that? Chuck?

Charles Goldfarb:

Yeah, if I may, I think, you know, if this is something, then judge me if you must, that I enjoy. I think the coding process is interesting. It's certainly controversial. And I want to I know, we both want to touch on a recent study and JHSGO. But I think coding perspective, unfortunately, is colored a bit by practice setting. And probably honestly, not surprising to understand that. But surgeons who are reimbursed based on RVUs or collections code more aggressively, if that's the right word, and salaried surgeons are less likely to do so. And that, obviously, is not the way it should be. But I kind of understand it. I think, you know, you and I are certainly in an academic situation. But we are reimbursed based on collections and RVUs. And so we might be thrown into that latter group, although I think we both take this seriously. And code carefully. And certainly don't want to overdo it. So as before adopt jumped into this specific example, we can pick a few. What do you think about that general statement? Does that resonate?

Chris Dy:

Yeah, I mean, I think yes, it's really important for the listeners to understand our context. And you know, the fact that we have base salaries, and then we are additional compensation based on collections and our views, and you know, that kind of thing. I'll be honest with you, I don't pay attention to it as much as I probably should. I know I should. But I don't. And it's one of those things where I do the work, I dictate what I do. And I kind of just let the coders do their thing. You know, I probably should pay more attention to it. Like, for example, like when David Brogan and I do a plexus together, I trust him to tell me how we should split everything up because he knows all this stuff. Because either he is interested in it, or I think in his prior practice setting when he was at Mizzou, he paid closer attention to it. I honestly don't want to get into the weeds on that. Again, knowing that I should no more but there are many other things that I have going on in my head.

Charles Goldfarb:

So let's be clear for residents who might be listening and fellows who might be listening, even young. You know, attendings who might be listening, ultimately, you can have coders and many of us do. But ultimately, it is your responsibility to code correctly. And, you know, fraudulent activity, intentional or not intentional, intentional comes back on you. So Chris and I are very fortunate that we have a wonderful group of coders that are subspecialized. But I review my codes every month. And there's never major issues, but I would say 10% of the time I have a question or we have a subsequent discussion about coding, again, simply because I like it and want to get it right. I do. I do strongly feel that, you know, we as doctors, and we as surgeons, are entitled to reimbursement appropriate reimbursement for the work that we do, but no one's going to hand it to me. And so I have to be prepared to ask for it and get it. And I feel really strongly about that. And I think you know, this silly process of coding is is part of the game we play in it, it was a game.

Chris Dy:

So to quote you do things as mainly as questions but that's just wanted to get that do you think so put on your hat as vice chair now. Do you? What percentage of our surgical faculty do you think actually go through the process that you just described looking at your codes every month?

Charles Goldfarb:

Geez, I wonder if I should disclose this but I will say conservatively it is less than one in five, who do this every month, it is a again, we all choose different practice settings for different reasons. The protected environment of academia is no longer what it used to be. But some of it is. Some of it is we, you know, I just don't like dealing with this. I have lots of other things on my plate, but it's a minority of us who actually look at the coding and double check it prior to submission.

Chris Dy:

Yeah, I mean, there's incredible variability or heterogeneity and how we would code something, I've seen it at least I don't know how it goes in terms of the codes. But I've seen different for example, in peripheral nerves, I've seen different surgeons at our institution, how they list out their procedures, and I don't know, again, if they're all getting coded the way that they're getting listed in the OP note, but for nerve transfer, you know, listing out a neuro lyse an internal neuro lysis, in addition to the nerve transfer itself, in addition to decompressions, and all the other stuff. So I mean, there are a lot of ways you could do I mean, yes, technically, that is part of the work. But you know, ultimately, what is supposed to be included in that one single code for a nerve transfer.

Charles Goldfarb:

So great point, I want to emphasize two things. The first is that, you know, it may I think this is gonna make you feel better about your choice to not review this, but our coders read every word of every op note. It's unbelievable to me. It's not like they're reading what our procedure is, they're reading our procedure and making sure we justify it. I mean, it's awesome. The second is the hands society has a Global Services Guide, which I don't know the last time it was published. And maybe we should reevaluate it as a as an organization. But it is wonderful. So it takes every CPT code. So for example, let's say, one of your favorites, 64718. So ulnar nerve decompression or transposition, and it lists out what's included in that code and what's excluded in that code. And, again, for those of you starting out in practice, it's really helpful to have that as a resource to make sure you understand that you're not unbundling, and you're coding maximally appropriately, to get what's due to you.

Chris Dy:

So I never got to get to my second point of my gopher thing. So of the you said, you know, there may be 10% of cases or something that you review that maybe there are some questions on how it was coded? What are the usually the issues that come up? Are there any common themes?

Charles Goldfarb:

Yeah, I think they're, they're, well, what's, again, I don't want to keep referring to paper we're going to discuss but, you know, there are certain percentage of codes that are super straightforward. You know, although maybe not as straightforward as I thought, but but like carpal tunnel, release 64721. No problem. We all know what that is. I think it's when we get to the unusual things. And in your example of a plexus procedure, or nerve transfer procedure, it is certainly one of those. That's when things get a little hairy. So for me, it's when I do a procedure that we none of the six about to be seven of us do on a regular basis. That's a little outside the box that just needs clarification. And sometimes I question it, and I'm wrong. Because of coders to have thoughtfully considered everything. And sometimes, I'm right, the other issue or unlisted codes. And so that might be a CMC arthroscopy or, you know, there are codes for small joint arthroscopy, but those things are are not coded regularly. So you need to find comparison codes, etc, etc.

Chris Dy:

So Cal asked about common surgeries and how you would code them. So how would you code a sub muscular ulnar nerve transposition?

Charles Goldfarb:

Yeah, and then let we all answer this one, I want you to answer this No, no, let's go back to the dorsal root ganglion or risk ganglion of his original question. So for a sub muscular ulnar nerve transmission, I would code 64718. That's the addressing the ulnar nerve and I would code lengthening of the flexor pronator, mass 24305. And so I happen to do as the lengthening of the mass, but we're cutting and repairing the flesh burning mass to me, merits different code. I don't code for anything else. Any other atoms I don't really think others do. And this one, I'm sure I'm wrong. I'm sure there's some people who would hopefully will comment, but those are the two basic codes for me. What about you?

Chris Dy:

How frequently, well, first, I mean, how frequently do you think you get the reimbursement for the for the Z lengthening code?

Charles Goldfarb:

Isn't that a fascinating question as much as I mentioned in this, I do not know, but the coders continue to agree with that approach. I am assuming shame on me. That they agree because they know we do get reimbursed for both codes. I don't know the answer to that question.

Chris Dy:

Now I've heard through the grapevine through our trainees that I have converted you to doing a subcutaneous transposition with a The fat pad flap that Mel Rosenwasser originally described. When you do that surgery, you can't build for the flexor pronator lengthening because you're not doing a sub muscular. You're doing a subcutaneous transposition, are you just 64718 there? Or do you think that our coders are adding anything else for that pedicle that up the fascial flap that you're creating pocket to put the nerve in.

Charles Goldfarb:

So first of all, hats off to you and Mel, I have become a-

Chris Dy:

Not me, just Mel. That's Mel's technique, I just

Charles Goldfarb:

Well, you converted me though. Hats off, like it. because I really like it. And it doesn't work for every patient and based on the volume of subcutaneous tissues and adipose cutaneous tissue. It is fantastic. It is a game changer for me. And maybe you should talk through it a little bit. Just to reinforce it. I absolutely love it. I never love The Eaton flap, which is the dense fascia which, you know, was described many, many years ago, 50 years ago. The problem with the Eaton flap, in my humble opinion, is that it is a kind of rigid structure against a nerve. The exact positioning of that flap is dependent on the repair into the subcutaneous tissue. So it can theoretically be compressive if you're not careful. And it also tends to medialize, the nerve, and if you're not careful can put the nerve up against bone which the nerve doesn't like. So for those three reasons, I don't like it. This adipocutaneous flap is fantastic. And that's a very long answer to your question. I only billed 64718. Unless you are going to tell me I should be building something else. But that just do a simple 64718.

Chris Dy:

I mean, in theory, it is it is pedicled. And it's adipocutaneous adipofascial. It's how I describe it. I'll be honest with you, if I list it as that I have no idea whether it gets coded or not. I feel so bad that I don't know. Because you're like, looking at your codes every month. I'm like, Well, I'm just like.

Charles Goldfarb:

Well, you know, I mean, you we got to I think I listen, I hope there are listeners who will help us and tell us what they do in this code? And that's a great question. And again, I am grateful. Do you want to give a one minute description of exactly how you tackle this? Because you know, I know you want to talk about nerve?

Chris Dy:

Well, I guess the first thing I'd say is I probably should email our coding team. And they are fantastic. Just asking them. That would be my homework. And then there are probably our private practice that surgeons are like, these academics are such dopes, at least that Dy guy. I liked that I liked that technique. You know, it's there. It's based on an article from Mel Rosenwasser at Columbia. And instead of doing whatever version of a fascial sling, you're taking that very nice pocket of fat that sits basically right on top of the intermuscular septum and extends a little bit distally. Now you got to be careful about your MADC in that area, because it does tend to cross obliquely right around there. But I elevate as wide of a pocket of that as I can. And depending on the anatomy of the patient, I either split that layer longitudinally, like you're opening, cutting into a bagel, and you're opening it up and put the nerve in there. Or if the anatomy doesn't allow for that, I will take that layer of fat, and then sew it to the posterior soft tissue. And after bringing the nerve to the front, and that's how I keep it I mean, so the important part, there is just a really wide wide pillow for that nerve to sit in. You know, it really depends on the patient's anatomy, I think that you know, knowing how to do an Eaton sling or whatever, whatever type of sling you need to do is important just because you never know what's going to be available to you in a revision or a revision of a revisions. So I you know, whenever we do these, I tell our trainees that you got to know how to do every type of transposition, just because you never know what you're gonna have to do. Because like, for example, I won't go so muscular, if one of our partners or I am doing a elbow contracture release at the same time because I don't want all that swelling and inflammation from the joint to be right on the nerve. And then you have to tuck the nerves somewhere else. So I digress. I can't believe you let me talk about nerve for even a little bit during this coding episode.

Charles Goldfarb:

No, it was self interested. So thank you. We I maybe you can send me the exact article and I can put it in the show notes.

Chris Dy:

Yeah, absolutely. So let's get back to the ganglion question.

Charles Goldfarb:

So to me, and again, I hope our listeners aren't totally rolling their eyes. A ganglion excision is straightforward. And yes, you are doing a capsule ectomy and some might even do a post interosseous nerve neurectomy for a dorsal ganglion. I hope not because I don't think it merits that but that's aggressive. For a ganglion excision, it is a 25111 For me, whether it's a dorsal ganglion or a volar wrist ganglion, and that's it, nothing else. What Yeah, I guess in my naive academic brain, I

Chris Dy:

Now say you're doing a volar? And it's because I've about you? think that it all evens out in the end. And so some of these encountered this, I've done a revision or of recurrence or whatever, and the cyst is literally plastered on the radial artery. Is that like an arterial lysis code? Or what? I don't know if that exists, but there's quite a fair bit of work will be super simple, and super fast, and others will be a that sometimes comes with getting a cyst off the artery if you choose to do that, and some don't. But. little more challenging and will require arterial lysis, so to speak. There is however, as you know, a separate code for a recurrent or a vision ganglion excision 25112. But, yeah, I, for me, it's very simple one code. And for carpal tunnel, you know, it's one code. I think other people might do some different things based on this article, you want to you want to briefly discuss the article. Yeah, sure. I mean, so this, this article is, let's pull it up here is in JHSGO, and it was last year. It's, it's from the group at NYU. Steve Glickel, the senior author. first author is Ryan Coyle. So thank you, Ryan, and Steve, for bringing us this article. It's called coding practices in hand surgery and their relationship to surgeon compensation. So sent out a survey to hand society members and they got out of over 4000 invitations, they got a 9% response rate, which is actually pretty reasonable. And then they, they asked them how they would code a thumb CMC surgery, trapeziectomy and a distal radius case. And then they looked at how the surgeons were compensated and whether they did their own coding, etc. And it made a difference. You know, so if you are a collections based surgeon or an RVU based surgeon, you definitely code differently than if you were, if you're salary. And then I guess that's not surprising. You know, I think we kind of talked about

Charles Goldfarb:

Yeah, yeah, I don't think it's surprise. It's, that early on. um, it's not appropriate. This should be different. But it's, it's not surprising. Let's go through these. So the first was carpal tunnel release. All right, yeah. And the CPT code that the vast majority of people provided was 64721, which I think you and I would totally agree upon. But there are others included, some of which surprise me synovectomy was given as one that might be included, I was always taught that if you do perform a synovectomy, that supersedes the carpal tunnel, and you don't build both internal neurolysis. Gosh, I didn't think anyone was doing that anymore, based on McKinnon and Gelberman separate work showing that that wasn't necessary. So people add on different codes. And I just have never done that.

Chris Dy:

That's very clear anybody listening as a trainee, you should not be doing an interim analysis of the median nerve if you're doing a primary carpal tunnel release. So maybe there are some situations like a revision or something like that, where you actually do need to do an internal neurolysis, but not in a primary carpal tunnel release. I was told always that I do a lot of local. And I was told you're not allowed to bill for that local. But it looks like there are some people here that are billing for the local anesthesia that's provided either I don't know whether that means that they're doing it as part of their will on like beforehand, or whether they're doing that as part of maybe like a post op and administration of anesthetic.

Charles Goldfarb:

My education was the same as yours that we are not, you know, the anesthesia is incorporated as part of the of the code. Getting back to that global services. 64721 includes anesthesia, pre and post I think, again, correct us if we're wrong. Interesting.

Chris Dy:

Yeah, yeah. So that the next one that they looked at was distal, radius, fracture fixation. And there were all sorts of codes that were included. I mean, most people went with 25607, you know, with which is, you know, treatment of an extra articular distal radius fracture. I think that there are many ways to justify intra articular involvement, based on whether it's, many of these fractures are really metaphyseal base, but do extend into the radiocarpal joint, I've seen some people justify extension into the sigmoid notch as an intra articular fracture. So I think maybe there's some room for interpretation there. Another code that was often billed and I want your thoughts on this was the fluoroscopy. You know, I know that that's one point that you are feel strongly about. And then the other application of cast, which I think is interesting.

Charles Goldfarb:

Yeah. So application of cast is not is not something we should be doing for that's part of the global services. And then the other one I think is release of the brachioradialis is incorporates tenotomy So BR release again, to me, I that that is, I guess, in my mind less egregious than billing for a cast application, but it's just part of the procedure, it also takes 10 seconds. Now, someone who sees this process differently will say, we are doing this, we should be compensated for it. And that's just a difference in philosophy. However, I think if you use a mini C-arm, then it is very appropriate to bill for that and collect for it. So I don't, we don't own the mini C-arm machine, but we can bill for the professional fee. And actually, our radiologists agree with that, even if they review them later, because this is in that it would be inappropriate for me to consider a radiology partner 12 hours later reviewing and billing for an inter operative, you know, C-arm assessment. So I think is very appropriate there. You have their rules and regulations and how you do it, you have to dictate dictate a separate note talking about the views you obtained and talk about what you saw, but I do feel strongly that that is very appropriate.

Chris Dy:

Yeah, I mean, I, I dictate a separate note for her a portion of the of the operative note for the fluoroscopy interpretation. And then in the clinic, I'll also put a separate note in for the mini C-arms. I mean, I don't know, it's obviously not a ton from an RVU perspective, but as you've mentioned, it adds up over time.

Charles Goldfarb:

It does, it does. Yeah, it's usually 25-35 bucks or something. But given our hand surgeon professional is something we do regularly.

Chris Dy:

So did you want to talk about either the trapeziectomy one or the scaphoid case, before we wrap up?

Charles Goldfarb:

This scaphoid, I think it'd be super easy. I think most of us for scaphoid nonunion will bill 25440 Which does incorporate bone grafting. So again, it's one of those where I'm a little surprised there are other codes being included.

Chris Dy:

Like a bone graft code?

Charles Goldfarb:

Like a bone graft code. The other one you can't you can't include not that was done here is if it's a non union, and you take out a screw, and then you're revising fixation with bone graft. You can't bill for that screw removal, but you can't bill for bone graft here. The interesting one, as you mentioned, is that trapeziectomy. And that in we in the hand society actually knows this, we're all over the map on how we bill and that's what this paper does demonstrate. And you and I have had to modify how we think about it. Because we are generally using a suspension plasty with a internal brace or wherever you want to call it. And so previously, I used and fcr kind of the classic procedure, Burton and Pellegrini style, and I used fcr. And I did bill for that, that 25310. But now I you know, I am doing something that I think is better and more patient friendly. And I'm billing less, I'm doing less work, and I'm billing less and so I just bill 25447 How do you

Chris Dy:

I think the same way. I mean, I think that, yes, we're think about it? all over the map on coding, because we're all over the map on what to do. There's no right treatment for this. And yes, we probably should, you know, be billing less because we're doing less work. And this is supposed to be you know, relative value and it's at work. So yeah, I think it's fair

Charles Goldfarb:

Excellent. Excellent. Well, I this is fun. As you know, I like this and I like listener questions and I hope and think we're gonna get some feedback on this one because this will resonate with many so fun topic.

Chris Dy:

Yeah, please tell us how we can code better. Maybe I'll start paying more attention.

Charles Goldfarb:

Yeah, what's your I'm going to take your role here. What's your win for the week?

Chris Dy:

My win for the week is opening get, actually the kids getting in the pool and me paying way too much to heat the pool in this weather. But uh, yes, the pool is sitting a lovely it'll be a lovely 80 degrees by the end of the afternoon.

Charles Goldfarb:

My win is vacation. You know, it is indescribable and mandatory. And it's felt like a long time coming. And I was really good. This vacation. First of all, I was grateful that my entire family could could join us. And I really didn't open the computer much. And it was great.

Chris Dy:

I'm sure you snuck away at 4:30am to check your email.

Charles Goldfarb:

Once in a while.

Chris Dy:

If they don't know about it, it didn't happen. Right. Have a good rest of your day?

Charles Goldfarb:

Yeah, you do the same. Take care. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy:

Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb:

Mine is @congenitalhand. What about you?

Chris Dy:

Mine is @ChrisDyMD spelled dy. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your podcasts.

Chris Dy:

And be sure to leave a review that helps us get the word out.

Charles Goldfarb:

Special thanks to Peter Martin for the amazing music and remember keep the upper hand come back next time.