# Hand/Wrist - Need help ASAP!



## jmkitchen (Feb 14, 2011)

One of our surgeons did an arthroscopically aided CMC Arthroplasty with implant.  He insists there is a CPT code for this but I believe I need to bill as CPT-29999.  Can someone please PLEASE help me??

OPERATIVE FINDINGS: The patient is a 52 year-old female with a long history of pain in the basal joint. Preoperatively she had point tenderness over the structure. She had failed nonoperative management. She was admitted for the previously mentioned procedure. Examination under anesthesia revealed that there was no hyperextension of the metacarpophalangeal joint. There was crepitance with passive range of motion and circumduction motion of the basal joint.

OPERATIVE PROCEDURE: The patient was identified as XXXXXX on the Operating Room table. Prior to doing so the risks and benefits of the procedure were again reviewed at length with including bleeding, infection, risk of the anesthetic from nausea to death, need for more surgery, loss of motor or sensory function, damage to nerves and vessels, chance she would be no better perhaps worse, stiffness, weakness, rejection and other potential complications. She understood the risks and benefits and wished to proceed. She was induced with a General anesthetic per Anesthesia. The right upper extremity was prepped with a Betadine solution and draped in the usual sterile fashion. She received 600 mg. of Clindamycin prior to beginning the procedure. Under satisfactory General anesthetic a small incision was made just ulnar to the abductor pollicis longus to establish the one U portal. The #11 blade was utilized just to divide the skin. A Hemostat was utilized to spread bluntly down directly to the capsule. The arthroscope was then introduced directly into the basal joint and confirmed using the C-arm. Once that was established we made a second portal trans thenar in nature. The portal was localized using a #22 gauge spinal needle. A similar technique was utilized to establish the portal. Next a probe was placed in the basal joint and a diagnostic arthroscopy was performed. There was Grade IV damage to the base of the metacarpal. There was also Grade III damage to the trapezium with fibrillation. There was a significant amount of hypertrophic synovial tissue that required debridement. There was redundancy in the beak ligament and that ligament itself was quite attenuated and loose. Next an aggressive arthroscopic joint debridement was performed removing and debriding the loose segments of articular cartilage from each bony structure. A synovectomy was performed debriding the hypertrophic synovial tissue. Attention was then directed to the beak ligament. A standard Arthrotec heat probe was passed through the thenar portal. The CAP ArthroCare Wand was utilized to heat the collagen in the beak ligament until bubbles were visualized. This confirmed shrinkage of this tissue. A paint brush technique was utilized to completely the shrink the beak ligament and hopefully obliterate excessive motion of the joint and thereby eliminate hyperlaxity. Next the Xylos Seculrian graft was opened on a back table. A strip of 2 x 4 cm was cut using scissors. It was folded lengthwise and then it was folded over upon itself twice. It was then secured using a #3-0 nylon suture. Next an #0 PDS was passed through the graft so as to create a mattress type affect. The thenar portal was then dilated. The graft was then introduced into the basal joint and a very stout and anatomic fit was achieved. Next attention was directed to fixation. Given that the hyperlaxity had been eliminated with the heat probe, it was felt that the implant would be secure simply by passing the PDS sutures through the beak ligament and out through an accessory portal. Therefore an accessory portal was made just distal to the thenar portal. It was deepened through the subcutaneous tissue and was bluntly spread down to the capsule. We then utilized a curved needle to pass the free ends of the suture from the thenar portal deep to the thenar musculature and through the beak ligament and then exiting out the accessory portal. Tension was applied to the sutures and the graft was then translated volarly and secured deep to the beak ligament. A snug slip lock knot was then tied directly on the capsule. The knot was then cut and we inspected the construct arthroscopically and a very stout reconstruction was achieved. It should be noted that the patient had been placed in 12 lbs. of traction via application via a clamp and the traction was released and a very stout reconstruction was achieved. All wounds were then copiously irrigated with normal saline solution. The tourniquet was dropped and minimal bleeding was encountered. There was a 2+ radial pulse. Each of the portals were then reapproximated with nylon sutures in a mattress configuration. The wound was thoroughly cleaned and sterile dressing was applied consisting of antibiotic ointment, Adaptic, 4 x 4s, ABD and a well padded thumb spica splint. She tolerated the procedure well and had brisk refill in her thumb upon completion of the procedure.


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## moodymom (Feb 15, 2011)

I cannot find a cpt code for this procedure.. I feel the unlisted code is the best.


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## twosmek (Feb 15, 2011)

He may be thinking of the 25447 code. Sometimes my docs think there is a code for what they do but don't realize that if they use a different approach then one code is not good any more.  I would think that you would need to use the unlisted code or a modifer on the 25447 code. 

But then again don't know how to modify an open to an arthroscopic procedure.


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