Any advice would be greatly appreciated. I code for an ASC and am looking at CPT codes 25405 vs 25390, due to the nonunion and the use of the auto graft I am thinking 25405 however the case was originally authorized as 25390
The Patient initially sustained a left distal radius fracture with ORIF and then hardware removal. Patient then underwent Left pisiform excision and left ulnar shortening osteotomy with open triangular fibrocartilage complex repair. The most recent procedure in question is
POSTOPERATIVE DIAGNOSIS: Left ulnar shortening osteotomy nonunion.
PROCEDURES PERFORMED: 1. Left revision ulnar shortening osteotomy with distal radius bone graft qualifying for the 22-modifier given the increased time and effort and revision nature of the procedure. 2. Deep cultures. 3. Interpretation of intraoperative fluoroscopy.
INDICATIONS: The patient presents with prominent screw and evidence of a nonunion of his ulnar shortening. The patient elects to proceed with revision ulnar shortening osteotomy. Risks, benefits, and alternatives were discussed with the patient, and he elects to proceed. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine with the left hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. A timeout was performed, and preoperative antibiotics were given. An incision was made over the left ulna in line with his previous incision. This was extended slightly, and we dissected down through the subcutaneous tissues to the subcutaneous border of the ulna, and the previous osteotomy plate was identified. There was a prominent screw, and multiple screws on the plate seemed to be slightly loose. The screws and the plates were removed, and the nonunion was visible on the x-ray, but seemed to be partially healed. The osteotomy was taken down with a scalpel and osteotomes. A drill and a curette were used to freshen up the edges. An incision was made over the dorsal radius over the Lister tubercle. We dissected down through the subcutaneous tissues, and the Lister tubercle was removed. A curette was used to harvest the distal radius autograft, and this was then inserted into the nonunion site. We then selected the Synthes 2.0 T-plate, which was contoured and was provisionally fixed distally to the ulnar head. We then compressed at the osteotomy site and then the plate was fixed proximally. We had good compression and fixation of the bone. The wound was irrigated, and our cultures had been taken previously. We then placed demineralized bone putty around the osteotomy and to fill up the bone graft harvest site. The capsule was closed with 2-0 Vicryl sutures as well as the extensor retinaculum. The subcutaneous tissue was closed with Vicryl and the skin was closed with nylon. Final AP and lateral radiographs were taken confirming good alignment of the osteotomy and position of the plate and screws without evidence of complications. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
The Patient initially sustained a left distal radius fracture with ORIF and then hardware removal. Patient then underwent Left pisiform excision and left ulnar shortening osteotomy with open triangular fibrocartilage complex repair. The most recent procedure in question is
POSTOPERATIVE DIAGNOSIS: Left ulnar shortening osteotomy nonunion.
PROCEDURES PERFORMED: 1. Left revision ulnar shortening osteotomy with distal radius bone graft qualifying for the 22-modifier given the increased time and effort and revision nature of the procedure. 2. Deep cultures. 3. Interpretation of intraoperative fluoroscopy.
INDICATIONS: The patient presents with prominent screw and evidence of a nonunion of his ulnar shortening. The patient elects to proceed with revision ulnar shortening osteotomy. Risks, benefits, and alternatives were discussed with the patient, and he elects to proceed. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine with the left hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. A timeout was performed, and preoperative antibiotics were given. An incision was made over the left ulna in line with his previous incision. This was extended slightly, and we dissected down through the subcutaneous tissues to the subcutaneous border of the ulna, and the previous osteotomy plate was identified. There was a prominent screw, and multiple screws on the plate seemed to be slightly loose. The screws and the plates were removed, and the nonunion was visible on the x-ray, but seemed to be partially healed. The osteotomy was taken down with a scalpel and osteotomes. A drill and a curette were used to freshen up the edges. An incision was made over the dorsal radius over the Lister tubercle. We dissected down through the subcutaneous tissues, and the Lister tubercle was removed. A curette was used to harvest the distal radius autograft, and this was then inserted into the nonunion site. We then selected the Synthes 2.0 T-plate, which was contoured and was provisionally fixed distally to the ulnar head. We then compressed at the osteotomy site and then the plate was fixed proximally. We had good compression and fixation of the bone. The wound was irrigated, and our cultures had been taken previously. We then placed demineralized bone putty around the osteotomy and to fill up the bone graft harvest site. The capsule was closed with 2-0 Vicryl sutures as well as the extensor retinaculum. The subcutaneous tissue was closed with Vicryl and the skin was closed with nylon. Final AP and lateral radiographs were taken confirming good alignment of the osteotomy and position of the plate and screws without evidence of complications. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.