Orthopedic Coding Alert

When a patient presents for wrist arthrodesis, discerning which CPT^® code you should use is often the most challenging aspect of the claim.

Jessyka Burke, BSHA, CPC, COSC, CASCC, coder, biller, and mentor, has coded many wrist arthrodesis claims. Below are two clinical examples from Burke, along with the CPT^® and ICD-10 codes you should use for each scenario.

Can you make the right decisions on the following two scenarios? (These are not complete operative reports. For brevity, some of the notes have been edited.)

Case 1

Indications: He has posttraumatic arthritis involving his right wrist secondary to a scapholunate ligament injury. He has a stage III scapholunate advanced collapse. He has associated severe carpal tunnel syndrome as per my EMG study.

Partial procedure portion of note: A longitudinal incision was made overlying the dorsal midline aspect of the wrist extending distally over the 3rd metacarpal. The subcutaneous tissue was dissected sharply. Hemostasis was obtained. The extensor retinaculum was identified and divided through the 3rd compartment. The EPL tendon was reflected radially with the contents of the 2nd extensor compartment. The EDC tendons in the 4th compartment were retracted ulnarly. The PIN was identified at the base of the 4th compartment and was cauterized and excised. A longitudinal incision was made in the wrist capsule. The carpus was exposed. There was significant arthritis in the radiocarpal and midcarpal joints. The dorsal prominence of the distal radius was removed with an osteotome and cancellous bone was harvested from the distal radius. The remaining articular cartilage was removed from the surfaces of the midcarpal and radiocarpal joints. The joint surfaces were prepped with a burr to remove the subchondral bone.

The surfaces were then drilled with a K-wire to puncture the prepared surfaces. The harvested bone graft was packed between the articular surfaces. The scaphoid and lunate were reduced and held to the distal radius with a K-wire. An Acumed neutral wrist fusion plate was positioned on the dorsal surface of the wrist. The distal plate was secured to the 3rd metacarpal with a non-locked screw. The plate was reduced to the distal radius and secured in compression with a non-locked screw. The position of the hardware and wrist fusion was confirmed using fluoroscopy. The remaining screws were inserted into the plate. The K-wires were removed. An additional Acutrak mini screw was placed from the distal radius, across the scaphoid and into the capitate. Final intraoperative fluoroscopy confirmed position of the hardware and wrist.

Case 1 Coding

For this encounter, you’ll report the following codes:

• 25800 (Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)) for the wrist arthrodesis
• Modifier RT (Right side) appended to 25800 to indicate laterality
• M19.131 (Post-traumatic osteoarthritis, right wrist) appended to 25800 to represent the patients wrist arthritis
• 64721 (Neuroplasty and/or transposition; median nerve at carpal tunnel) for the carpal tunnel release
• Modifier 59 (Distinct procedural service) appended to 64721 to show that the carpal tunnel release is a separate service from the arthrodesis
• Modifier RT appended to 64721 to indicate laterality
• G56.01 (Carpal tunnel syndrome, right upper limb) appended to 64721 to represent the patient’s carpal tunnel syndrome

Case 2

Indications: Longstanding history of radial-sided wrist pain that has been gradually worsening over the past year. It is painful on a daily basis. He has pain with any gripping or lifting activities. He tends to have some numbness in his right hand, however, his EMG study showed no evidence of carpal tunnel syndrome. His wrist range of motion is limited. On x-ray and CT scan, he has a stage II SNAC wrist with a chronic scaphoid nonunion.

Partial procedure portion of note: The scaphoid nonunion was identified. The proximal pole was necrotic. The scaphoid was excised saving the distal portion for bone graft. Care was taken to preserve the radioscaphocapitate ligament. The articular cartilage was intact between the lunate and radius. The residual cartilage was removed within the midcarpal joint. The subchondral bone was removed using a burr to expose bleeding cancellous bone. Two 0.045” K-wires were then placed into the proximal pole of the capitate and driven distally out the dorsal aspect of the hand. The midcarpal joint was packed with cancellous bone harvested from the distal scaphoid that was excised. The midcarpal joint was reduced and the K-wires were then passed across the midcarpal joint into the lunate. Intra-operative fluoroscopy confirmed position of the K-wires and the midcarpal joint. A small incision was made over the ulnar aspect of the wrist. The subcutaneous tissue was dissected bluntly. A K-wire was placed across the triquetrum and into the hamate and capitate. The position was confirmed using fluoroscopy. individually, each K-wire was measured and over-reamed. A mini Acutrak II screw was placed down each K-wire. The position of the screws and joint were confirmed using fluoroscopy. There was good compression across the midcarpal joint. None of the screws entered the articular surface. Additional cancellous bone was packed into the midcarpal joint.

Case 2 coding

For this encounter, you’ll report the following codes:

• 25825 (Arthrodesis, wrist; with autograft (includes obtaining graft)) for the wrist arthrodesis
• Modifier RT (Right side) appended to 25825 to indicate laterality
• S62.021K (Displaced fracture of middle third of navicular [scaphoid] bone of right wrist, subsequent encounter for fracture with nonunion) appended to 25825 to represent the patient’s wrist fracture.