cclarson
Guru
Hello everyone, I'm needing some help understanding how to code an extensor tenodesis of the left long finger to the left ring finger - EDC to EDC. Would this be coded as a tendon transfer even though the doctor is calling it a tenodesis? Thank you in advance! 
The codes I have so far for this case are 25240 for the Darrach, 26480 for the EIP to EDC tendon transfer, and 64772 for the posterior interosseous neurectomy mentioned in the body of the op note.
Here is the report:
POSTOPERATIVE DIAGNOSIS:
Vaughan-Jackson syndrome, left upper extremity.
OPERATIONS PERFORMED:
1. Darrach procedure, left ulnar hand.
2. Left extensor indicis proprius to left extensor digitorum communis of the small finger transfer.
3. Tenodesis of the left long finger extensor digitorum communis to left ring finger extensor digitorum communis.
DESCRIPTION OF PROCEDURE:
The patient was met in the holding area. The surgical site was marked and confirmed. Questions were answered. The patient underwent placement of a supraclavicular block by anesthesia attending under ultrasound guidance. Once block had been placed, she was transported to the OR in the supine position on the gurney. Once in the OR, she underwent induction of general anesthesia, followed by placement of a LMA. Once the LMA was secured, the bed was rotated to allow better access to the left upper extremity. Upper arm tourniquet was applied and the extremity was prepped and draped. After prep and drape, time-out was performed. After routine time-out, we proceeded with the procedure.
I exsanguinated the extremity with an Esmarch bandage and inflated the tourniquet to 250 mmHg. I made a straight longitudinal incision overlying the left wrist and centered at the DRUJ. Sharp dissection through the skin was followed by blunt dissection to expose the extensor mechanism, elevating full-thickness skin flaps and inadvertently lacerated a large dorsal vein. This was repaired using 6-0 nylon. After repair of the dorsal vein, I continued to mobilize full-thickness skin flaps of the extensor mechanism. I immediately was able to visualize ruptured extensor tendons, which I identified at the EDC to the small and ring finger by placing traction upon them.
I debrided these tendons, continued my dissection proximally, opening the fourth extensor compartment, identified the posterior interosseous nerve within the base of the wound. I then performed a posterior interosseous neurectomy. After performing a neurectomy, I performed capsulotomy of the ulnar carpal joint making a hockey stick-shaped incision to expose the ulnar head, which was high riding. I used a sagittal saw, cut the ulna at its neck, and resected the ulna head. We then then identified a large dorsal spur on the radius at the DRUJ. This was also resected using a rongeur. I irrigated the wound and then closed the capsule using 4-0 FiberWire, restoring fairly good alignment of the ulna and reducing the high riding ulnar stump. After creating the DRUJ capsule, I turned my attention to the tendon. I freshened the ends of the tendon using a #15 blade and then performed a Pulvertaft weave to tenodese the end of the ring finger tendon to the intact long finger extensor. After tenodesis of the ring finger to the long finger, I made an incision on the dorsum of the index finger MCP joint. Sharp dissection through the skin was followed by blunt dissection. I exposed the EIP tendon and transected it. Prior to this, I placed a 3-0 Ethibond between the two, EDC and EIP tendon to prevent subluxation of the remaining index finger and extensor. I pulled the EIP down into the wound and then rerouted over to the ring finger and small finger. I was unable to perform a Pulvertaft weave of the small finger EDC tendon to the EIP tendon. After multiple Ethibond placed, I put the fingers in maximal extension. The wound was irrigated. I closed the incisions using subcutaneous Monocryl. I then placed Steri-Strips to the skin followed by Xeroform, sterile 4x4s, sterile Webril, and a volar splint of plaster at the tips of the finger with the fingers extended to neutral and overwrapped with an Ace bandage. All digits were pink and viable at the conclusion. The patient was awakened, extubated, and taken to the recovery room. She arrived in the recovery room in stable condition still under the influence of general anesthesia. All counts were correct x2.
The codes I have so far for this case are 25240 for the Darrach, 26480 for the EIP to EDC tendon transfer, and 64772 for the posterior interosseous neurectomy mentioned in the body of the op note.
Here is the report:
POSTOPERATIVE DIAGNOSIS:
Vaughan-Jackson syndrome, left upper extremity.
OPERATIONS PERFORMED:
1. Darrach procedure, left ulnar hand.
2. Left extensor indicis proprius to left extensor digitorum communis of the small finger transfer.
3. Tenodesis of the left long finger extensor digitorum communis to left ring finger extensor digitorum communis.
DESCRIPTION OF PROCEDURE:
The patient was met in the holding area. The surgical site was marked and confirmed. Questions were answered. The patient underwent placement of a supraclavicular block by anesthesia attending under ultrasound guidance. Once block had been placed, she was transported to the OR in the supine position on the gurney. Once in the OR, she underwent induction of general anesthesia, followed by placement of a LMA. Once the LMA was secured, the bed was rotated to allow better access to the left upper extremity. Upper arm tourniquet was applied and the extremity was prepped and draped. After prep and drape, time-out was performed. After routine time-out, we proceeded with the procedure.
I exsanguinated the extremity with an Esmarch bandage and inflated the tourniquet to 250 mmHg. I made a straight longitudinal incision overlying the left wrist and centered at the DRUJ. Sharp dissection through the skin was followed by blunt dissection to expose the extensor mechanism, elevating full-thickness skin flaps and inadvertently lacerated a large dorsal vein. This was repaired using 6-0 nylon. After repair of the dorsal vein, I continued to mobilize full-thickness skin flaps of the extensor mechanism. I immediately was able to visualize ruptured extensor tendons, which I identified at the EDC to the small and ring finger by placing traction upon them.
I debrided these tendons, continued my dissection proximally, opening the fourth extensor compartment, identified the posterior interosseous nerve within the base of the wound. I then performed a posterior interosseous neurectomy. After performing a neurectomy, I performed capsulotomy of the ulnar carpal joint making a hockey stick-shaped incision to expose the ulnar head, which was high riding. I used a sagittal saw, cut the ulna at its neck, and resected the ulna head. We then then identified a large dorsal spur on the radius at the DRUJ. This was also resected using a rongeur. I irrigated the wound and then closed the capsule using 4-0 FiberWire, restoring fairly good alignment of the ulna and reducing the high riding ulnar stump. After creating the DRUJ capsule, I turned my attention to the tendon. I freshened the ends of the tendon using a #15 blade and then performed a Pulvertaft weave to tenodese the end of the ring finger tendon to the intact long finger extensor. After tenodesis of the ring finger to the long finger, I made an incision on the dorsum of the index finger MCP joint. Sharp dissection through the skin was followed by blunt dissection. I exposed the EIP tendon and transected it. Prior to this, I placed a 3-0 Ethibond between the two, EDC and EIP tendon to prevent subluxation of the remaining index finger and extensor. I pulled the EIP down into the wound and then rerouted over to the ring finger and small finger. I was unable to perform a Pulvertaft weave of the small finger EDC tendon to the EIP tendon. After multiple Ethibond placed, I put the fingers in maximal extension. The wound was irrigated. I closed the incisions using subcutaneous Monocryl. I then placed Steri-Strips to the skin followed by Xeroform, sterile 4x4s, sterile Webril, and a volar splint of plaster at the tips of the finger with the fingers extended to neutral and overwrapped with an Ace bandage. All digits were pink and viable at the conclusion. The patient was awakened, extubated, and taken to the recovery room. She arrived in the recovery room in stable condition still under the influence of general anesthesia. All counts were correct x2.