Wiki 25609 ORIF distal radial intra-articular fx w/int fix of 3 or more fragments

[RebeccaMoney]

Insurance is denying 25609 as not documented. Would someone be interested in reading the op report attached and let me know what you think? I honestly can't tell how many fragments were repaired and need help determining that.
Thank you,

 

[NRaizman]

This op note is inadequate to prove that it was 3 or more parts.

Your options are to ask your surgeon to edit or amend the operative report to clarify, possibly resubmit with radiographs or CT scan confirming the number of articular fragments, etc.

I would educate your surgeon on the fact that they will routinely get denied for this unless they learn how to dictate their operative reports to the extent that they justify the appropriate code.

 

[RebeccaMoney]

This op note is inadequate to prove that it was 3 or more parts.

Your options are to ask your surgeon to edit or amend the operative report to clarify, possibly resubmit with radiographs or CT scan confirming the number of articular fragments, etc.

I would educate your surgeon on the fact that they will routinely get denied for this unless they learn how to dictate their operative reports to the extent that they justify the appropriate code.

 

[RebeccaMoney]

I was thinking that the op report wasn't clear enough. I'll talk to the physician.
Thank you,

 

[amyjph]

Agree. Just because it states there was extensive comminution, that is not enough. Even if the header stated intra-articular w/ 3 fragments (or more), if the body does not describe it properly it would not fly.

This was a very old link from AORN but helpful https://www.aorn.org/outpatient-surgery/article/2007-April-coding-billing

• Was the repair intra-articular or extra-articular?
• Did two or more than three fracture fragments require internal fixation?
• Operative documentation must detail whether the fracture is found outside of the joint (extra-articular fracture) or extends into the joint (intra-articular fracture). Descriptions should include the fracture fragments involved - (i.e.; radial styloid fragment, volar ulnar fragment, dorsal ulnar fragment) - and the fixation procedure