How To Use CPT Code 26121

CPT 26121 describes a surgical procedure involving the removal of fascial tissue in the palm. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 26121?

CPT 26121 is a code used to describe a surgical procedure in which the provider removes fascial tissue from the palm. This procedure may also involve other techniques such as Z-plasty, rearranging local tissue, or skin grafting. It is typically performed to address conditions like Dupuytren’s contracture, which is the abnormal formation of collagen fiber tissue beneath the skin of the hand or palmar region.

2. Official Description

The official description of CPT code 26121 is: ‘Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft).’ This code encompasses the surgical removal of fascial tissue in the palm, along with any additional procedures that may be performed during the same surgical session.

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The provider makes an incision over the affected region of the palm to access the fascia.
3. The fascial tissue causing contracture, such as in Dupuytren’s contracture, is carefully removed.
4. If necessary, the provider may perform additional techniques such as Z-plasty, rearranging local tissue, or skin grafting to restore normal function and appearance to the palm.
5. The surgical wound is closed, and appropriate post-operative care is provided.

4. Qualifying circumstances

CPT 26121 is typically performed on patients with conditions that require the removal of fascial tissue in the palm, such as Dupuytren’s contracture. The procedure is performed by a qualified healthcare provider who has the necessary expertise in performing fasciectomy and related techniques. The patient must meet the criteria for the specific condition being treated and must have exhausted conservative treatment options before opting for surgery.

5. When to use CPT code 26121

CPT code 26121 should be used when a provider performs a fasciectomy procedure on the palm, with or without additional techniques like Z-plasty, local tissue rearrangement, or skin grafting. It is important to accurately document the specific procedures performed during the surgery to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT 26121, the provider must document the following information:

• Patient’s diagnosis and the medical necessity for the procedure
• Details of the surgical procedure performed, including any additional techniques used
• Date of the procedure
• Any complications or unexpected findings during the surgery
• Post-operative care instructions and follow-up plans
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 26121, ensure that the procedure performed meets the criteria outlined in the code description. It is important to accurately document the specific procedures performed during the surgery to support the claim. Additionally, be aware of any bundling or unbundling rules that may apply to this code and any related codes. It is recommended to review the payer’s guidelines and seek coding guidance if needed.

8. Historical information

CPT 26121 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or revisions to the code since its addition.

9. Examples

1. A patient with Dupuytren’s contracture undergoes a fasciectomy procedure on their palm to release the contracture and restore hand function.
2. A provider performs a fasciectomy with Z-plasty on a patient with a severe case of Dupuytren’s contracture affecting their palm.
3. A patient with a history of trauma to the palm undergoes a fasciectomy procedure to address scar tissue formation and improve hand function.
4. A provider performs a fasciectomy with skin grafting on a patient with a large palm defect resulting from a previous surgery.
5. A patient with a recurrent case of Dupuytren’s contracture undergoes a fasciectomy procedure to address the contracture and prevent further progression.
6. A provider performs a fasciectomy with local tissue rearrangement on a patient with a complex palm deformity caused by a congenital condition.
7. A patient with a palm tumor undergoes a fasciectomy procedure to remove the tumor and restore hand function.
8. A provider performs a fasciectomy with Z-plasty and skin grafting on a patient with a severe palm contracture resulting from a chronic inflammatory condition.
9. A patient with a history of failed conservative treatment for Dupuytren’s contracture undergoes a fasciectomy procedure to address the contracture and improve hand function.
10. A provider performs a fasciectomy with local tissue rearrangement and skin grafting on a patient with a palm defect resulting from a traumatic injury.