Hello, everybody. Welcome to today's TCAA Talk to the Hand webinar. I'm Kim Berry and I'm today's moderator, and we are happy that you have joined us, and we're excited to have our speaker, Mike Trilla, share his expertise and knowledge on the nuances of coding hand injuries. Mike's worked as a trauma registrar trauma analyst for 35 years. His experience spans many aspects of the trauma registry. He's worked for a registry vendor. He's worked in level one and level two adult and pediatric trauma centers. His clinical experience includes serving in the Air Force and firefighter paramedic rescue roles, and he's used these experiences to develop educational content in the trauma world, creating the basic and advanced trauma registrar course for a trauma education company. In addition to his current role at Brethren's Group as a director of trauma quality where he created the trauma tip cards for registrars to use, and I know I've shared these with my team, so he has some great information to share with everybody. A few housekeeping items before I pass this over to Mike. First, the disclosures are listed on one of the presentation slides as part of the TCAA requirements to offer when continuing education hour for today's webinar, and second, we're going to hold all questions until the end of Mike's presentation, but feel free to place your questions in the chat. I will be monitoring the chat and will make every attempt to present your questions to Mike at the end. So, now I will turn the spotlight over to Mike. Thanks, Kim. Just to let you guys kind of update you on what I, how I started out. When I started out, I was a trauma PA. I worked level one trauma at Barnes Hospital in downtown St. Louis, and I worked in the, in that area for seven years, and where I started out in the cardiothoracic OR, where I took the saphenous vein in the leg for cardiac bypass, and so from there, they trained, trained me to become a, everything from the neck down to do trauma, and so my background is I've worked in the ER, the OR, and the ICU as a trauma PA, and after burnout, I moved on to the trauma registry field, which I loved, and I've been doing it ever since. So, welcome to this presentation of Talk to the Hand, and just to let you know that I have no relevant financial relationship, neither does Kim, and so we will go on and start this off by really paying homage to the most famous hand of all time thing from the Adams family. So, just start off with that, and what I want to do is let's go back and kind of review some root operations that you deal with when dealing with hand injuries, and so, you know, we have to make sure that we have these down because they're just, you can tell they're written by some kind of legalese person, but with the excision, cutting out or off without replacement, a portion of the body part, resection is cutting out or off with, without replacement, all of a body part, extraction, pulling or stripping out or off all of a portion of a body part by the use of force, destruction, detachment, look at detachment, cutting off all or part of the upper or lower extremities. So, I just want to get you guys familiar again with these root operations because this is what you have to use as we go through and you start coding hand injuries. Looking at the one on transplantation, okay, putting in or on all or a portion of the living body part taken from another individual or animal to physically take the place and or function of all or portion of a similar body part. It's different than reattachment, putting back in or on all or a portion of a separated body part to its normal location or other suitable location. We have the reposition that I'm sure you're used to looking at and then I want to kind of go through kind of the procedures, the drainage, extirpation and fragmentation. So, these are not all of the root operations, but these are the ones that we really need to make sure that we understand as we start going through this area. So, starting out, what I want to do is we're going to cover the bones of the hand. So, we're going to start off the thing, but understand that hand injuries represent more than 12 percent of all trauma cases in the U.S. and are the most common type of injuries treated in the emergency departments. If you want to take notes, there are 27 bones in the hand. So, there's a lot of things that can get messed up and from the latest numbers that I could find about hand injuries is in 2017 there were approximately 18 million hand and wrist fractures. That's a lot. 2 million thumb amputations and 4 million non-thumb digit amputations worldwide. So, there is a lot of hand injury that goes on out there. So, let's start off and just understand the basic framework of the hand. So, what we want to do is I want to kind of zoom in on this area right here and let's talk about the phalanges. All right. Starting out, the phalanges are the bones of the fingers. The thumb has a proximal and distal phalanx. That's the only one that has just a proximal and distal, and the rest of them have a proximal, a middle, and distal phalanges. It's important to understand that because that's why surgeons need to document if the fracture was high, middle, or low. So, it's one of those things where we have to be able to make sure that the docs understand that's why we need to have it. Now, understand that the doctors, the surgeons don't have ICD-10 training or not as much as we do. Let's put it that way. So, just understand that those are the bones of the hand, the phalanges and the metacarpals, but let's go ahead. Let's take a look at the carpals. Now, these carpal bones are a group of eight. Those eight carpal bones in there, they're organized in two rows. We have a proximal and a distal number of carpal bones to deal with. So, what I want to do now is we're going to go take a look at some x-rays and talk about some of the most common fractures and stuff that we see on hands. So, taking a look at this x-ray, what's encircled in red, that is your scaphoid fracture. Now, scaphoid is actually a Greek term that basically it means ship, and you can tell that that scaphoid kind of looks like a ship. And the scaphoid bone of the hand is the most fractured carpal bone, okay, typically by what's called a fuchs injury, and that is falling on outstretched hand. So, everybody's natural reaction when you fall forward is put your hand out, and what happens is the most common carpal fracture is of the scaphoid. Now, in a fracture of the scaphoid, the characteristic clinical feature is pain and tenderness, and what's called the anatomical snuff box. And to explain where that's at, take your hand, open up your hand, stretch it out, and at the base of the thumb you will find, the base of the thumb, you will find an indentation. And that is where that, this is called the anatomical snuff box, because back in the old days the people would put snuff right at that location and use it. So, the anatomical snuff box is the number one way to find out if there's a possible scaphoid fracture. And you can feel it's right above the radius, base of the thumb, there's an indentation, that's your snuff box. So, looking at this, what's interesting about the scaphoid is it is at a particular risk for what's called avascular necrosis, they call it AVN, and after a fracture because of the so-called retrograde blood supply. Now, in most cases, the blood supply starts at the proximal and goes to the distal end. In the scaphoid, it means what happens is the blood for that starts at the distal and works its way back down to the proximal side of the bone. And the problem is that the fracture to the middle, or what they call the waist of the scaphoid, may interrupt the blood supply to the proximal part, the one that sits on the radius. And from that, it will, that's where avascular necrosis comes from. Now, again, that main dorsal blood supply comes from the dorsal branch of the radial artery, and it enters the distal pole of the scaphoid and travels backwards. So, that's a scaphoid fracture. What's interesting about carpal fractures is that patients with a missed scaphoid fracture are likely to develop osteoarthritis in the wrist later on in life because there is a 27% misdiagnosis on these fractures. And when I worked in the emergency department as a trauma PA, we have people with suspected carpal fractures, and we take an x-ray and everything looks fine. But there is high suspicion that they may have a fracture. So, what we would do is we tell them, come back 24 to 48 hours later, we will re-x-ray that, and what we'll see is that's where we start to find a fracture line starting to form, especially in those, just those simple linear fractures that are not displaced. So, with the scaphoid, understand that 20% of the fractures happen at the distal, the top part of the scaphoid. 75% of the fractures happen at the waist, like it is on this x-ray. The fracture is dead across the waist of the scaphoid. And there's only 5% of fractures of the proximal pole, so the bottom part of that scaphoid. So, to understand those fractures, again, this is kind of an idea to kind of get you oriented to where the carpals are and the scaphoid. So, taking a look at that, let's go ahead and look at what's called a Bennett's fracture. Now, a Bennett's fracture, it's a fracture of the first metacarpal base, and it's usually caused by hyperabduction of the thumb. Usually, if you ever had your thumb caught on something and it pulls out, like, and you think you about break your thumb, well, that's the hyperabduction of a thumb. And this fracture extends into the first carpal metacarpal joint, and you can see in that picture right there, it's right at that joint, and that leads to instability and what they call subluxation of the joint. Now, as a result of a Bennett's fracture like this, it often needs a surgical repair. So, again, it's that hyperabduction of your thumb, and there goes, you have a good chance of getting a Bennett's fracture. Another very popular fracture that we see in the hand is a boxer's fracture. Now, a boxer's fracture, this can be taken care of simply by doing a closed reduction of the fracture, usually followed by a cast. So, if we look at the boxer's fracture, what that means is someone, and if you've ever taken martial arts, the first thing you learn is how to punch. And when you punch, you punch with these first two knuckles. And what that does, if you look at the x-ray, that your index finger, the physics is driving straight down, but you have a nice big radius bone that kind of impacts. It takes the force. When you punch the wrong way, and you catch the lateral side of your hand, you end up with a boxer's fracture. So, the moral of the story is, if you're going to throw a punch, make sure you throw it right. Okay? So, that's a boxer's fracture. Usually easy, just closed reduction, slap a splint on it, or a cast, a cast good for about six weeks. So, going on with that, let's take a look at these fractures here. And I'm going to highlight first these, this section. What we're looking at here, if you take a look at the ring finger, this is the left hand, the ring finger, and you see a fracture in that ring finger. Now, notice that is really, that fracture is quite a mess. Okay? If we're going to have to repair this, you're going to have to take them to the OR, because you can't put a pin in this, because you have kind of comminuted sections of that, of that bone. So, one of the things I love doing is, I loved working as a PA in the OR, because I was trained to do everything except their neurosurge. I could do, basically, if you work in the OR, you do one gallbladder, you've pretty much done them all. Well, as a traveling, as a rotating PA, I was able to work, one case would be general surgery, next case would be pediatric, next case would be orthopedics. Out of all the different areas of surgery, I loved orthopedics. It's, it's a guy's playground. We use black and decker drills, screwdrivers, screws. We use all sorts of neat machinery. And when we look at how we would fix this particular type of fracture, I want to talk about open reduction and internal fixation of the right phalanx. And what you see here, let's zoom in here, we see they had to go to the OR, and they had to actually put screws in. And we had to go above the fracture and below the fracture line, and it's really a plate that they put in, and because you have to go above and below the fracture to get it. So we're looking at an ORIF, open reduction, internal fixation of the right phalanx. So just to give you an idea, that's what it's going to look like after it's fixed. What I want to do now is go ahead and look at the closed reduction internal fixation. So looking at the upper left, this is a pretty ugly fracture. Okay, and easy to fix. What they'll do is they will drive pins using a drill. They will drive pins down the shaft after they reduce the fracture. They will drive pins down and maybe like you have lateral one across, but they'll drive pins down. And what we'll do, if you look at the bottom right here, we see that it is through the fracture. And notice it went above the joint too, because we need that fracture to heal. So we'll go above and below the fracture line. So you'll see that fracture line at the very top and how they put a closed reduction. First they do a closed reduction and then do an internal fixation with a nice long, either threaded or could be threaded or smooth, basically wire. That's what it is. So that will stay in there and then at some point they may go after it to get it out. They may leave it in there. It's up to the surgeon's discretion at that time dealing with orthopedics. So those are just really some ideas of closed reduction, internal fixation, and open reduction and internal fixation. But now we want to get to getting out the bones and get into the vascular supply of the hand. So what we're going to see here is we have two main arteries coming in. We have the ulnar artery coming up by the base of the thumb. I mean the radial artery coming up by the base of the thumb and ulnar artery coming up by the fifth digit. You have palmar loops right through your palm and when you cut those you've cut pretty deep and you are in some trouble. And then further up higher we get these common digital arteries. These are the arteries that usually come up from the radial artery and they branch out and they go all the way up to the through the fingers, through the phalanges. So these digital arteries are up there. So when you're working case in point, we're working on a gunshot wound. The doc came in. He was working deep inside. All of a sudden he yells, pulls out, and he just sliced through one of his fingers with a suit with the knife. And what happened was we had to take him to another room because not only did he lacerate his digital artery but he also lacerated his digital nerve. So we had to take him to another room and start working on him there. So the digital arteries are run up through there. So remember that you have basically the radial artery and the ulnar artery supplying most of the blood supply to your hand. Now what's interesting, and we will see this a little bit later, is when they re-implant fingers they will come in level one or two institutions. They may not do it in every place but there are a lot of places that will use leeches on the fingers once they re-implant the fingers. We'll talk more about that and what I'll do is before I get to anything that's going to be pretty nasty, I've got some basically we have some pretty gnarly pictures we have to look at today. I will warn you ahead of time before I show it to you and we will discuss it. So be prepared. I will try to warn you ahead of time. So now we want to look at the nerves of the hand and let's go ahead and talk about the nerves and take a look at the different nerves that are in here and notice how far up those nerves go. Now there are three main nerves in the hand. The median, the ulnar, and the radial nerve. Those are the three nerves. There are two main nerves that provide sensation to the hand. The median nerve and the ulnar nerve. Now the median nerve runs along the middle of the arm and it enters the hand through the wrist. That gives sensation to the thumb, index, and middle finger and half of the middle finger and I'll say half of the ring finger. So it does these four, these three, four. All right. The ulnar nerve runs along the inner side of the arm and it enters the hand through the wrist as well. Now that gives sensation to the little finger and part of the ring finger. Now I am living this right now. My little finger is completely numb. This finger is almost completely numb and this is partially numb. Somehow about three weeks ago I bagged something in C3, C4. I've got some disc compressing on a nerve and what I'm experiencing is I'm having just numbness. These are all numb and while it's coming through the ulnar nerve. That's why these are, these three are numb right now. Now remember that the note that the median nerve runs through the middle of the wrist and comes out through the wrist and up into the hand. You see that ligament band, that white band right there? That laves over the median nerve. So that band ligamentous tissue lays right there. That's where your carpal tunnel comes in because that nerve also runs between bones too. So when they release a carpal tunnel they have to go in and open up that band to release the pressure off the nerve. And you may have to, you may code, you may find that coded in really severe hand injuries. They may have to go in and basically kind of reduce the the carpal tunnel inside coming up through the nerve. So that's where the carpal tunnel comes up from that middle of the hand. And since we talked about ligament, let's go over those ligaments. All right this is going to be a busy screen. This one's kind of busy so let's kind of walk through it here. All right we have tendons and we have ligaments. And tendons are white kind of flexible rope-like cords at the ends of muscles that attach muscle to bone. So they attach muscle to bone. The tendons that run down our fingers are held in place by a series of ligaments. And sometimes you'll hear orthopedic surgeons refer to them as a pulley. And they form stable arches over tendons. And they form a tunnel-like sheath. So you see in those, in the fingers, you see that you have some flexor tendon sheath up there. You have some ligaments through there. So that's what's so hard is if you slice open the finger and you get a ligament or a tendon. That's why we have to get those repaired. And the other thing about the tendons and ligaments, ligament is really just a fibrous tissue that helps bind together the joints in the hand. That's really all they do. And I will tell you that in the OR, when you open up and you see a tendon sheath or ligament, they're covered by a silver, almost like a silver skin. And when the OR light hits it just right, it's right enough to blind you. So you get through that sheath and there's your tendon and there's your ligament. Now there are four main ligaments in each finger. So understand there are four main ligaments. The extensor ligament, which extends the finger. The flexor ligament, which flexes the finger. And two interosseous ligaments, which cross between joints. And you'll see those crosses up there. You'll see the the crosses through the fingers. So there are, there is a lot of things that can go wrong with lacerating a hand. You'll, you're very easily, easily going to bag a tendon or ligament. And then that's going to require going in and getting set up in the OR. So those will have to be fixed. So we'll go through some of these here in a minute as we get to our exercise, but I want to cover all of these areas. Now we want to talk about something called degloving. And here's your first warning. This next picture I show is fairly graphic. Well not fairly, it is graphic. And we'll want to talk about degloving injuries because I saw these a lot. A degloving injury is really a type of injury where the skin is peeled away from the tissue underneath. That usually happens, something like this usually happens when they're caught in some kind of machinery or high-speed accident where it's pulled off. Now the skin may still be attached at the wrist, but the rest of the hand will be exposed along with the tendons and muscles. So everything will be right there. So the treatment for degloving injuries may also include surgery and skin grafts. I've had patients who got caught and they took their, degloved their hand like taking the glove off, and they came in with the skin hanging down. We basically just had to put it back on like a glove and suture it in a place. So degloving injuries are also very big. And this is kind of interesting because you'll see everything still intact underneath that. So you'll be able to see everything on the underlying structures. So that is the idea of a degloving injury. Again, usually we see that in places that have some kind of rollers on and that they get caught and handed a roller or something. I've seen it in car accidents too where they somehow get caught coming out and degloved the arm. So looking at that, we want to talk about the next one is amputation. Now this is a big one, and what I want to do is again warn you this is a graphic slide coming up. But looking at this reattachment, okay, we talk about reattachments here. It can take hours and hours and to complete. Usually there is a full team of orthoplastics hand teams that are in on that. Now I want to tell you something that happened to me. And I'll tell it the way it was told to me so you get the full benefit. I got called in when I was working trauma PA. I got called in about three o'clock in the morning. I needed to get in and get to the ER. So I got in the ER about 3 30 in the morning. And I live just inside the Illinois border from St. Louis. Downtown St. Louis is about 25 minutes from me. And so Barnes is a couple miles in. So I got there and I had no idea why I was paged. I get to the front desk and as I'm asking why my page up pulls an Illinois State Police. I understand Barnes is in St. Louis, Missouri. And up comes an Illinois State Police, lights and sirens on. And I'm sitting here looking like what's going on? Why is an Illinois State Police doing in Missouri? They come in with a cooler and they set the cooler down. And I open up the cooler and my knees buckle because there is an arm from mid humerus on down in that cooler. And I was just, I didn't, you know, you don't expect that at 3 30 in the morning. And so I asked the cop, I said, where's the rest of the person? And that's what I was told that that person was flown in or about 45 minutes earlier. And I said, you know, this arm should have gone with the patient. And the state patrol said, well, we couldn't find the arm. It was dark. Driver was driving. And this is my pet peeve. People who hang their arms out the driver's door, the left arm, when they're driving and just let it dangle. This guy was doing that in the middle of the night in a minivan, the right, the left front tire blew, and he rolled into a field. And that's how he amputated mid humerus. And it was a clean amputation, luckily. And so they got to the scene, they called for a helicopter. And during that time, they were trying to find the arm. And at some point, the helicopter's like, we got to get this guy in, you find the arm, bring it in. It wasn't, it was maybe 45 minutes from St. Louis in the country in Illinois. So I asked the cop, I go, so what happened? They said, they took off. And we started a search grid trying to find other people had stopped at the accident. They were enlisted in trying to find this arm. And they said, at some point, someone said that they saw someone pick something up, put it in their car, and they drove off. So when the police went after, they caught the guy a few miles down the road. Lo and behold, the guy had the arm in the back seat. And I'm like, what'd you guys do? He goes, we charged him with armed robbery. Seriously, all the groaning you're doing, it's exactly how they got me. So what I did then is I took that cooler, and I went up to the OR, and I scrubbed in. And 12 and a half hours later, we got the arm reattached. So if you think about what you have to do first, you have to revascularize the arm. So we had a lot of hand and also vascular surgeons working on that. And while they're doing that, they can be doing several different things at the same time. So usually you don't see a big amputation like that, but you will see finger amputations. And finger amputations accounted for an estimated, I'm going to read it here, 234,304 emergency department visits from 2010 to 2019. Most of the patients were male, about 79%. No big surprise there. And identified as white, which is about 46.2%. The most implicated products overall were power saws and other related power tools, followed by doors. Interesting. Car doors was the number one cause of finger amputations. And then lawnmowers. So there's a lot of things that go on with these finger amputations. Now understand that just because you have a clean, the thing is you really need to have a clean cut. If it's jagged nine times out of 10, they won't waste the time to try to do this, to try to re-implant it. So what they'll do is also look at your preexisting conditions. Those also determine whether or not they're going to try to re-implant the digits. Think about this. The patient has diabetes, peripheral artery disease. If they are a smoker, that will complicate and probably not allow the digit to re-implant it to survive. So your preexisting conditions can cause you not to have a re-implant done. So one of the things about doing finger re-implants, and I will tell you of all of the slides that my wife saw when she looked at this presentation, this is the one that gave her the creeps the most because they still do it. And she got kind of queasy. So here's another warning. Another kind of graphic picture. But they will use leeches on your picture, on your on your finger. And you can see that they have a pin at the end of this finger here, which means they've re-implanted it. And he's got actually got two leeches. Now interesting thing about that is that the leech saliva contains hirudin. And that's really an anticoagulant and an antiplatelet agent that works to prevent blood clots and reduce the amount of congested blood in the tissues. So what they'll do is other chemicals in the leech saliva keeps the blood flowing in the damaged area even after the leech is detached. And that allows time for the new veins to grow and the existing ones to widen and accommodate more blood. So really what's cool about this is as a bonus the treatment is painless because when the leech bites they release a naturally occurring anesthetic which numbs the area. That's why people if you've seen in movies or you ever had it done in real life you come out of the water and you're like you look down and it's like there's a leech on me. I didn't even feel it because it's an anesthetic. It took a while for me to remember the code for using leeches. F08F5ZZ which is wound management treatment of integument integumentary system upper extremity using physical agents. Now I will tell you that to me these don't bother me. When I worked as a PA I would get calls from the nurses especially in the ortho step-down unit. They did not want to touch them and so they would usually call me and I go up and I would take the leeches off. Now some patients it was interesting how patients reacted to leeches on their fingers. You know the cones you put on animals to so they can't get to a wound. They made cones for a hand so they didn't have to look at the leeches that they were on there. Others kind of freaked me out as I go in and they're talking to their leeches. They even named their leeches. So one nurse called me one day and she goes I need you to come up and get rid of these leeches. I can't touch them. I'm like okay. So I got up there and I said go get me a specimen cup of some with some water in it. She came in and gave it to me. I took the leech off and I dropped it in and it foamed up and over all over the place and this nurse screamed and ran out of the room. The patient and I were laughing. What she had done is she gave me a specimen cup with hydrogen peroxide in it and since the leech is full of blood as soon as they hit that hydrogen peroxide foam everywhere. So these are still in use and there's the code for you F08F5ZZ. If you have if you work in a place and they still use leeches. They will use leeches on finger re-implants. They also use leeches plastics will use leeches on muscle flap muscle flap transfers because again allowing all that blood to get back into that portion of the anatomy. All right let's go and start the coding hand injury exercise. Now I will warn you this next picture is graphic also. So let's take a look. All right so what we're looking at here is kind of three different pictures. One is the hand you see on the left. The middle is a skeletal x-ray and then there's the 3d imaging that they that they made and this is on a an injury that we're going to use this as our basis for doing an exercise. So I want to go through a little poll first. Presented with this injury what would be the first thing the surgeon would do before taking to the OR? Do they do an extended H&P? Do they call ortho or hand? Or do they order an arteriogram of the hand? Go ahead and put in your answers and let's see how you all do. We'll give it a little bit of time. All right, let's close that. The answer is arteriogram. Correct. 56% of you got arteriogram as the the answer. Think about this. If there is no blood supply going to the hand, why would I even start working on it first? So we want to make sure that there's blood supply going up there so we know what we have to work with. So the first thing they'll do is they'll order an arteriogram of the hand to see how things are going and they'll be able to see where things are messed up. So that's the first one. Let's take a look at the second poll. And what diagnosis code would you use for this type of injury? Is this going to be a crush, an amputation, a degloving, or a vascular injury? Go ahead and throw your thoughts in on that. We'll give it a couple of seconds here. I will tell you the answer was in the actual slide if you saw it. All right, let's take a look and see. Correct. This is a thumb. I'm sorry, a crush injury. Now, let's go ahead and take a look. Again, first things first, we want to make sure there is blood flow to the hand. And this was a crush injury and you see there's partial degloving. We see tendons there. We don't see fingers. And we kind of see what looks like could be part of a thumb. Look at the dark, look at the dark red on the right side of that hand. So is there blood flow to the hand? So the first thing we'll do is we'll take a look at the blood flow to the hand. So the first thing we're going to do is look at coding an arteriogram with the right hand. And that would be your BP2N1ZZ CTA right hand with low osmolar. So that would be a way to look at that particular first things first. We want to make sure there's blood supply going in. There's no sense in us trying to trying to save things if there's no blood supply. So let's see what we've got going there first. Let's take a look at coding the injury to the right thumb. So we don't see a whole lot of thumb left. So we take a look. There is no tissue to salvage, first of all. There are amputation of fingers and thumbs and the thumb. So let's take a look at what we would do. Now 0X6L0Z0 detachment at right thumb complete open approach. Because remember there's only two sections to the thumb. We have proximal and distal. Okay, so it's detachment of the right thumb. We may have to complete the amputation. If there's nothing left, we're not going to, there's no way to rebuild tissue around that. So we're going to look at the code. If they can talk about detachment of right thumb high open approach, same code except Z1. Another is detachment at right thumb mid open approach and detachment at right thumb low open approach. So a lot of times patients will come in with these devastating hand injuries and all we can do is just pretty much just trim it up and get rid of everything. Patients come in with just a piece of skin hanging, keeping the digit on and there's nothing we can do because the digit is so far gone. So we will do a detachment. That's of the right thumb. Let's take a look at the right index finger. Again another devastating injury. There's no tissue to salvage. So here's where we get again the overall one detachment at right index finger but also we can look at here if we know there's a high mid or low approach. But as you can see but as you can see there's nothing left of that finger. So I'd more be be more inclined to look at 0x6N0Z0. That would be the my one that I would use for that particular code. Next one we're looking at the middle finger. Again a devastating injury. No tissue to salvage again. Same thing. I have an overall detachment at right middle finger. Complete open approach. I will trim that up. Again I can have high mid and low codes to go with it. And I don't know if you guys can may hear it. I've got a mosquito humming around my microphone. So again we're looking at 0x6Q0Z0. So we're looking at detachment where we're going to trim that up and just detach the rest of that. Let's take a look at the open reduction that we have of the fingers and metacarpals. So my ORIF is I'm going to go in there and I may do an open reduction internal fixation especially since we have so many things going on in that finger. The open approach and again the same code the OPST04Z can also use reposition right metacarpal with the internal fixation device open approach OPSP04Z. So I may have to do the phalanx and the metacarpal. You can see down at the metacarpal is fractured. You may have to do several ORIFs to get that fixed. Now after we go through and we kind of clean up what we got, we have to look for any nerve repair if possible. If we can do any nerve repair. So if you ever get to a point where you have to do nerve repair you want to look at the dorsal digital nerve and their palmar cutaneous nerve. So those are the codes that you would use for the digital nerve 0x01Q60ZZ or if it's napalm if they especially a broken glass a lot of times a broken glass if you're holding it it will cut if you're holding it it will cut through your palm is 01QSQ50ZZ. Now you're also going to want to document any tendon or ligament repair. So any document any tendon ligament repair of the right hand OLP70ZZ and any skin closure or skin graft that's done for skin graft of the split thickness skin graft the right hand 0HRFX74 will bring out about the split thickness skin graft. Because after these things are taken out we we remove the bones then we have to cover that. So they're going to get so they're going to get skin grafts. So that's kind of the the view kind of going through the major things we see in these pictures. Now let's talk about the hand specialist. According to the American College of Surgeons level one and two trauma centers both adult and peds need to have some kind of hand surgeon. A plastic surgeon that can do microvascular work will also work in that area. And also you have to have a vascular surgeon because at that level you are dealing with the all the amputations all the the devastating crush injuries finger amps and stuff like that. And I luckily I lived in my last hospital I worked at was at was at Marshfield Clinic in Marshfield Wisconsin. Lived right next to me with new plastic hand surgeon that came in. So I was talking to him all the time we had a really good relationship and you know since a lot of farming things out there he had a lot of stuff to do from farm injuries that included the hands getting cut tendons ligaments nerves everything. So as a level one or two you're required to have some kind of hand specialist and for both both adult and peds. Now what I did is I took I took some extra time and created for you guys a tip card and Kim talked about those tip cards ahead of time. This is a tip card that we give out and these are the codes that you can use and we can make sure that I will send this tip card over to Deb and we'll see if we can get it out to everybody who who wants to have one. But this is a nice tip card to have that will show you those codes the procedure codes for the things that we looked at. So in the meantime as we close remember keep calm talk to the hand and I do want to thank you for participating in this webinar for TCAA and I will see if we have any questions that we need to do. Thank you so much Mike that was amazing and those tip cards I tell you it's been loaded in our our registry education folder and they they use it all the time it was the it's been super helpful. So yes absolutely a great great tool. As far as questions the audience is saying you did a great job they don't have a lot of questions I do have a question for you. So when they re when they have to do a re-implantation or replantation of a hand or a finger when you're coding can you just code that they replanted or do you have to do all of the minutiae the arteries the veins the nerves? That's a good question that's a real good question we'd normally have to look at everything that's done as long as they document that because again they will they'll get in and they will do stuff and sometimes they won't include everything a good hand or plastic surgeon will document the re-implant they will also connecting of the vessels kind of in a re-implant the first thing they do is they have to make sure that there's salvable tissue. The guy who had his mid humerus that I worked on for 12 and a half hours he actually left the hospital with his arm intact. Now he had the first thing we had to do we had vascular working to reconnect the vessels we had other people were the orthopedic guys were in there looking at reattaching any kind of nerves. Now those nerves will take longer to heal but as long as it's documented we can go and look at all those different things. So again it matters on if they document it we can code it and that's kind of the frustrating part about this is that we have to deal with the documentation so that's what makes it kind of hard at times. Fantastic so there is a quick question for you in the chat and this comes from Jennifer can you clarify on a complete amputation of a finger did you include all three amputation codes for proximal medial and distal how do you how do you address the coding? At that I would just pick the general overall code because if they have a section of that of that finger amputated they can re-implant that so if they say a mid digit re-implant then we'll know that came through the mid section. So usually they won't a lot of times what I've seen they won't do re they won't tell what section they re-implant it and I still work I'm still an active registrar I work a couple hours helping out Brooke Army Medical Center in San Antonio so if you're on there's your toot toot and I've I've done a couple re-implants and I've not seen them be so specific so you probably have to use the overall general code of reattachment of a finger again if it's not documented we have to go with the overall code. You got a shout out there too yay BAMC fantastic fantastic hey so because you've done this at the bedside working clinically with the surgeons in your PA role do you have any fabulous tips for getting us to get all of our providers to document with greater detail? Yep one of my things I found out starting out as a registrar it took me quite a while before I felt good about approaching a surgeon and saying we need to be more specific now again they may not they may not well they may or may not know the ICD-10 codes and how to code everything properly so a lot of times a lot of our registrar role we have to be an educator we have to educate maybe ED staff, APPs, PAs, MPs all those people because a lot of times they don't know the specifics that we have to code so I've always found that if I were to show them the why this is why we need to code it this way this this makes it much easier I always tell people as a registrar when you approach a physician a surgeon with a question about documentation I always tell them look I'm not here this is not personal what I'm about to I'm about I need to ask you a question it's not personal it's data the data has brought me to ask this question why did you why did you document this instead of this and a lot of times once you come about that way saying look I'm not trying to tell you how to do your job but the data has asked me to ask you this question they'll be glad to explain and then you can sit down say okay here's why we needed you to be more specific and I just very quickly say because ICD-10 they're looking for these three things if I have my book with me I show it and I and they're like oh I didn't know so that's kind of the idea about working as a registrar with your surgeons and even you know sending a query out saying hey you know radiology in the body of their of the radiology report they said this particular fracture was like this in the summary they don't mention that so sometimes I'd go to the surgeon and say look my favorite is multiple rib fractures oh my god if I see another multiple rib fractures I'm going to scream and I would go in and I would see a surgeon would see me coming at him in the hallway and they duck close like bow their head and they go what I missed and I go no nothing radiology says that they fracture ribs you know one through eight you documented multiple rib fractures could you please go and document fractures one through eight and they're like no problem so that's kind of the idea is that registrar you're always having to kind of query the surgeons and the nurse practitioners and the PAs and say can you code it this way and here's why and that really helps out a lot. Do you have any recommendations for the registrars who are now working in the remote environment because we all know surgeons do not read their emails any tips for for that? Well usually the TPM is in there and it's always good to to be able to go in and say hey look you know we have I'm having issues with the surgeons documenting this properly could you please explain this next time you sit down with them and I'm always a big proponent of I've had several times where I've been working with the hospital and the medical director gets on with us the trauma medical director gets on with us and allows us to talk remotely and so I've done that several times which really seems to work pretty well. Another way to do it is I would simply put out a we track a spreadsheet and in that spreadsheet I would list all those things that we need you know could you document this instead of this and then I'd send it to the to the trauma program manager say please have the surgeon fill this out and get it back to me if I'm remote and that's another way to do it too is if you have to put to put it down on a spreadsheet send it to the TPM and say can you have them look at this and please get back to me with it. Yeah one of the other things that that some of my colleagues do other trauma program managers is they started using for those of you who use EPIC you can use the in basket because they they do look at their EPIC in baskets that I do know so that's another another approach. Really quick we have two minutes left so before we shut down there is one more question and it's it's a it's a good one so Robin was asking why do you why did you code the hand angiography to bone is this because there isn't an option in the upper artery section of ICD-10? I didn't know we couldn't find one we looked I had several people look with me like okay guys help me out I I know I'm old I'm blind you know and the other one other thing I would tell people don't be afraid to reach out and phone a friend when you got questions that code for the leeches I could remember what it was I had to talk to three different people and we all got one call and we all beat our book to death before we found it and you know it's always good to phone a friend that's why if there's anybody who needs any and have any questions you have I don't my screen is still up but you can see the my contact information ask me any question and I'll get back with you. Fantastic thank you well we are at the top of the hour Mike I really want to thank you for everything this was a great great presentation I love the the refresher on all the anatomy and physiology that's fantastic and then to tie that in with coding so on behalf of TCAA I want to thank you all for joining us today for this webinar and I want to encourage you all to give us some feedback if you are so inclined and Mike once again thank you very much and have a great day everybody. Thanks for having me everybody have fun out there.

hand injuries

trauma registries

root operations

hand anatomy

fractures

vascular supply

nerves

amputation

coding tips