Orthopedic Coding Alert

Hint: Compartment and debridement dictate the right code.

When treating compartment syndrome in the forearm, your surgeon’s work may include longitudinal exposures and incising the fascia to perform a fasciotomy, during which the surgeon inspects the muscle and nerve and excises any necrotic tissue. Applying the right codes depends on accurately retracing these procedure steps. Use the advice that follows to select the right compartment syndrome codes and never miss your deserved payment.

1. Confirm the Compartment

The orthopedic surgeon may work in the flexor, extensor, or both compartments. You will need to carefully read the operative note to know which incisions were used. These will help you to know which compartments were approached for the fasciotomies.

If your surgeon mentions specific tendons, you can look for the anatomy and function of each one to know if your surgeon worked in the flexor or extensor compartment, experts say.

2. Look for Debridement

Your surgeon will check the viability of both the muscles and nerves once inside the compartment(s). “The surgeon will confirm if the muscles have a good color and twitch, often with the use of an electrical stimulator. This is because the high pressures hamper conduction in both the muscles and the nerves and make them nonviable. In this case, your surgeon may do a debridement to remove the nonviable muscle,” says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C.

3. Select the Right Code

When coding for compartment syndrome, you first confirm if the surgeon worked on the flexor or extensor compartment or both. Next, you read further in the operative note to learn if any muscle or nerve debridement was done. Lastly, you should determine if the surgeon explored the brachial artery to improve blood supply in the limb. Once you’ve completed these steps, you’ll be better equipped for appropriate code selection from the list that follows for compartment syndrome services:

• 25020 (Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve)
• 25023 (Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve)
• 25024 (Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve)
• 25025 (Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerve)
• 24495 (Decompression fasciotomy, forearm, with brachial artery exploration).

Example: You may read in the operative note that the surgeon made a long longitudinal volar ulnar incision down the ulnar side of forearm from the antecubital fossa to the middle of the palm and performed a volar fasciotomy followed by another dorsal, linear, longitudinal incision between the mobile wad of Henry and the muscle bellies of the extensor digitorum communis to decompress the mobile wad and dorsal compartments where the pressures were more than 25 mm Hg.

“The mobile wad consists of the brachioradialis, extensor carpi radialis brevis, and extensor carpi radialis longus,” says Mallon. You confirm that both the flexor and extensor compartments were decompressed. Your surgeon may obtain pressure measurements of the volar compartment (20950, Monitoring of interstitial fluid pressure [includes insertion of device, e.g., wick catheter technique, needle manometer technique] in detection of muscle compartment syndrome), mobile wad, and dorsal compartments after the decompressions. “This is rarely done though,” says Mallon. You report 25024 as your surgeon does a fasciotomy in both the flexor and extensor compartments.

In a similar situation, you may further read that the surgeon inspected the muscle and evaluated the twitch to confirm that the muscle was not responding and then did a resection to remove the nonviable muscle. In this situation, you report 25025 since your surgeon is additionally doing a debridement to remove the nonviable muscle.