# Help with wrist arthroplasty



## cearley94 (Mar 12, 2018)

I am looking for suggestions on how this surgery should be coded. We have been coding with 25332, Arthroplasty, wrist; however, provider is not happy that 25240, ulna excision, is included. Is there a better code we should be using?

POSTOPERATIVE DIAGNOSIS: Rheumatoid arthritis, right wrist.
PROCEDURE:
1. Excision of distal ulna
2. Proximal row carpectomy
3. Excision of posterior interosseous nerve
4. Interpositioned soft tissue arthroplasty of wrist

DESCRIPTION OF OPERATION: The patient was brought to the Operating Room. After satisfactory anesthesia was confirmed and IV antibiotics were administered, the right
upper extremity was prepped and draped in the usual sterile fashion. A longitudinal incision centered over the radial shaft and the middle finger ray was created, dissection
carried down to the extensor retinaculum, which was exposed, mobilizing full thickness skin flaps. The third dorsal compartment was incised and the EPL tendon was reflected.
The second and fourth dorsal compartments as well as the fifth dorsal compartments were elevated in a subcompartmental, but extracapsular fashion. The distal radioulnar joint
capsule was then incised longitudinally and the distal ulna was harvested using a high speed sagittal saw. The arthrtomy was then continued transversely across the wrist joint
in order to expose the proximal carpal row. This was excised sharply and also with piecemeal using the rongeur to get out the remainder of the scaphoid. At this point, it
was evident that the carpus would sit appropriately on the lunate facet despite the fact that there was significant volar tilt to the distal radius. The articular surfaces as
expected however were destroyed and so therefore an interposition arthroplasty was performed. This was performed by harvesting the proximal head of the capitate as well as
hamate and the dorsal capsule was sutured using multiple Monocryl sutures in between the capitate, hamate and the radius. This resulted in very nice interposition flap and good
position of the hand which would not require any subsequent pinning temporarily. At this point, the DREJ capsule was reapproximated with the distal ulna placed in a reduced
position and the retinaculum was reapproximated. The skin was closed in layers. A bulky dressing incorporating a sugar tong splint was applied. She tolerated the procedure well
and was transferred to the Recovery Room stable and without evidence of intraoperative complication.


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## fish4codes (Mar 13, 2018)

Looking at the lay description (below), clearly states the ulna is included.  Also, 25240 is bundled (code 2 pair with 25332).  There are a lot of code pairs that my doctors and I think don't make sense, but it is what it is, unfortunately!  Where in the note is the documentation of the PIN excision, although these codes can be used together, I don't see documentation.

The *CPT Lay Description for 25332 *is as follows:
_
The physician performs an arthroplasty of the wrist. The physician makes a straight, dorsal, longitudinal incision centered over the wrist from the middle of the third metacarpal proximally. Skin and subcutaneous tissues are elevated off the fascia and retinaculum. The retinaculum over the fourth dorsal compartment is incised longitudinally and elevated medially and laterally. The extensor pollicis longus is freed, retracted radially, and left in the rerouted position at the end of the procedure. A longitudinal incision is made in the capsule. A capsular periosteal flap is elevated through the dorsal radioulnar ligaments. The distal radius is excised, as is the distal ulna if it is dislocated or severely involved. A cut is made through the hamate, capitate, trapezoid, and distal scapho-trapezoid area. The carpus is removed. The medullary canal of the radius is reamed. A fine awl is used to penetrate the base of the capitate and the shaft of the third metacarpal. The medullary canal of this bone is reamed. If using a double-stemmed component, an additional canal is prepared in the second metacarpal. Appropriate short canals are prepared in the carpal bones. With the wrist in 10 to 20 degree extension, the capsular-periosteal sleeves are repaired over the prosthesis. The extensor retinaculum may be used to reinforce the capsule, or may be repaired anatomically. The skin is closed over a deep and a superficial suction drain.

_Happy Coding!
Cindy


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## cearley94 (Mar 13, 2018)

Thanks! That is what I thought, I just wanted to make sure I didn't overlook anything. He has since amended the note to include the PIN excision.


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