jhaleycoder
Networker
Coding help! Hands surgery. UHC has denied the CPT codes billed as not documented? I am lost? The codes billed are 26445, 64772, 25295. If someone could please give me second opinion. The operative report is below:
Postoperative Diagnosis
Left wrist retained hardware (volar plate and dorsal spanning plate); forearm, wrist, and hand stiffness (involving MCP and PIP joints of the fingers and MCP and IP joint of the thumb); and tendon adhesions involving the fourth dorsal compartment, EPL, FCR, FPL, and FDP to the index finger tendons with intraoperative nondisplaced left thumb proximal phalanx fracture
Operation
Left wrist removal of deep hardware x 2 (volar plate and dorsal spanning plate); forearm, wrist, and hand manipulation under anesthesia (involving MCP and PIP joints of the fingers and MCP and IP joint of the thumb for a total of 10 finger joints manipulated); and tenolysis of the fourth dorsal compartment (including index finger, long finger, ring finger, and small finger extensor tendons over the dorsum of the hand) and tenolysis of the EPL, FCR, FPL, and FDP to the index finger tendons at the level of the wrist, AIN and PIN neurectomies, with intraoperative nondisplaced left thumb proximal phalanx fracture
Findings
Uncomplicated removal of deep hardware including volar plate and dorsal spanning plate. Significant tendon adhesions involving all of the fourth dorsal compartment tendons at the level of the hand. Significant tendon adhesions involving the EPL, FCR, FPL, and FDP to the index finger tendons at the level of the wrist. Stable distal radius fracture. Following forearm manipulation, range of motion demonstrated -30 degrees of supination and full pronation. Following wrist manipulation, range of motion demonstrated 45 degrees of wrist extension and 45 degrees of wrist flexion. Following hand joint manipulation, range of motion was full at the MCP and PIP joints of the fingers and the MCP and IP joint of the thumb. Nondisplaced transverse left thumb proximal phalanx fracture sustained during manipulation of the thumb. This is a relatively stable fracture pattern and was not pinned.
Specimen(s)
None
Complications
Intraoperative nondisplaced left thumb proximal phalanx fracture
Technique
The patient identification, operative sites, and operative procedures were verified with the patient preoperatively in the holding area and again at the safety pause in the operating room. The anesthesia team administered a regional block to the left upper extremity in the preoperative holding area. The patient was transferred to the operating room in a supine position on a stretcher. She was then transferred to the operating room table and a safety strap was placed. All bony prominences were padded and a pillow was placed behind the knees. A well-padded tourniquet was placed on the left upper arm. The left upper extremity was subsequently prepped and draped using the standard sterile technique with Betadine. A timeout was performed and all were in agreement. The left upper extremity was exsanguinated with an Esmarch and the tourniquet was inflated to 250 mmHg. We began with the dorsal forearm, wrist, and hand. There was a 5 cm longitudinal scar over the dorsal aspect of the forearm overlying the proximal dorsal spanning plate, a 3 cm oblique scar over the dorsal aspect of the wrist along the course of the EPL tendon, and a 4 cm longitudinal scar over the dorsal aspect of the index metacarpal. We opened all three dorsal incisions simultaneously. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. There were significant adhesions between the scars and the subcutaneous tissues. These were carefully released. Proximally, we progressed in a plane between the dorsal forearm muscles to gain access to the plate. Distally, the plate was subcutaneous. The proximal and distal ends of the dorsal spanning plate were exposed and the screws were removed in the standard fashion. The plate was delivered out of the distal wound. A rongeur was used to remove the soft tissue and bony ingrowth into the recesses of the plate. We then turned our attention to the fourth dorsal compartment tenolysis. The two extensor tendons to the index finger, the long finger extensor tendon, the ring finger extensor tendon, and the two extensor tendons to the small finger were identified and released from the surrounding soft tissues using forceps and scissors. There were adhesions superficial to the tendons and deep to the tendons that were carefully released. Great care was taken to protect the juncturae. We used a Ragnell retractor to elevate the tendons out of the wound sequentially and ensure all tendons were completely released. When pulling on the tendon with the Ragnell retractor, there was full extension of each digit. We then turned our attention to the manipulation under anesthesia for the fingers. Several cycles of firm pressure was provided to the MCP and PIP joints of the fingers. Full range of motion of the MCP and PIP joints was obtained and a passive composite fist was achieved. There was mild residual stiffness at the index finger DIP joint. We then identified the EPL tendon underneath the retinaculum at the base of the dorsal wrist wound. A 1 cm aperture was created in the EPL tendon sheath at the level of Lister's tubercle. A freer elevator was placed proximally and distally within the EPL tendon sheath to release the adhesions. The EPL tendon was delivered from the wound using a Ragnell retractor and the thumb was noted to have nearly full extension. We then turned our attention to the PIN neurectomy. A transverse incision was made parallel to the fibers of the fourth dorsal compartment retinaculum. A 2 cm aperture was created in the fourth dorsal compartment sheath. The tendons were retracted off the floor of the fourth dorsal compartment sheath using a Ragnell retractor. The PIN was identified in the floor of the fourth dorsal compartment and a 1 cm section of the PIN was excised. All of the dorsal wounds were then copiously irrigated. The apertures in the retinaculum were not repaired since there was no evidence of soft tissue or tendon herniation. We then turned our attention to the volar side. A 6 cm longitudinal scar was noted over the volar aspect of the wrist overlying the FCR tendon. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. There was significant scar circumferentially about the FCR tendon. This was carefully released with forceps and scissors. Great care was taken to protect the adjacent median nerve and radial artery. Once the FCR tendon was completely released, we progressed through the interval to the level of the volar plate. Significant adhesions were noted between the FPL and the FDP to the index finger tendons and the surrounding soft tissues. The FPL muscle was also noted to be adherent to the surrounding soft tissues. The adhesions were carefully released using forceps and scissors. A Ragnell retractor was used to ensure the tendons were appropriately released. When pulling on the FDP to the index finger tendon with the Ragnell retractor, there was full flexion of the digit. However, there was persistent stiffness in the thumb when pulling on the FPL tendon. We turned our attention to the thumb manipulation under anesthesia. Several cycles of firm pressure was provided to the MCP and IP joints of the thumb. Unfortunately, a transverse fracture was sustained at the base of the thumb distal phalanx. This fracture was extra-articular and nondisplaced and was noted to be relatively stable. We made the decision to avoid percutaneous pinning. Following manipulation, there was full range of motion of the thumb when pulling on the FPL tendon with the Ragnell retractor. We then turned our attention to removal of the volar plate. A #15 blade was used to expose the plate at the base of the wound and the soft tissues were elevated off the plate using a combination of a freer elevator and a key elevator. Once the plate was adequately exposed, the screws were removed sequentially in the standard fashion and the plate was delivered out of the wound. A rongeur was used to remove the soft tissue and bony ingrowth into the recesses of the plate. We then turned our attention to the AIN neurectomy. The AIN was identified entering the pronator quadratus in the interval between the radius and ulna proximal to the DRUJ. A 1 cm section of the AIN was excised. All wounds were then copiously irrigated. The tourniquet was released after a total of 95 minutes with immediate return of blood flow to the fingertips. A bipolar was used to maintain hemostasis. All incisions were closed with running 3-0 Prolene subcuticular sutures. This closure was reinforced with interrupted 3-0 nylon sutures in a horizontal mattress fashion. Steri-Strips were placed in between the nylon sutures for added strength. A dry sterile bulky nonadherent resting was placed over all incisions and around the thumb. This was reinforced with Coban and an Ace wrap. The procedures were complicated by the nondisplaced left thumb proximal phalanx fracture that was managed conservatively. The counts were correct. The patient tolerated the procedures well and was transferred to the PACU in stable condition.
Grafts/Implants
No implants were placed.
Explants included the Biomet titanium dorsal spanning plate and screws and Biomet titanium volar distal radius plate and screws.
Postoperative Diagnosis
Left wrist retained hardware (volar plate and dorsal spanning plate); forearm, wrist, and hand stiffness (involving MCP and PIP joints of the fingers and MCP and IP joint of the thumb); and tendon adhesions involving the fourth dorsal compartment, EPL, FCR, FPL, and FDP to the index finger tendons with intraoperative nondisplaced left thumb proximal phalanx fracture
Operation
Left wrist removal of deep hardware x 2 (volar plate and dorsal spanning plate); forearm, wrist, and hand manipulation under anesthesia (involving MCP and PIP joints of the fingers and MCP and IP joint of the thumb for a total of 10 finger joints manipulated); and tenolysis of the fourth dorsal compartment (including index finger, long finger, ring finger, and small finger extensor tendons over the dorsum of the hand) and tenolysis of the EPL, FCR, FPL, and FDP to the index finger tendons at the level of the wrist, AIN and PIN neurectomies, with intraoperative nondisplaced left thumb proximal phalanx fracture
Findings
Uncomplicated removal of deep hardware including volar plate and dorsal spanning plate. Significant tendon adhesions involving all of the fourth dorsal compartment tendons at the level of the hand. Significant tendon adhesions involving the EPL, FCR, FPL, and FDP to the index finger tendons at the level of the wrist. Stable distal radius fracture. Following forearm manipulation, range of motion demonstrated -30 degrees of supination and full pronation. Following wrist manipulation, range of motion demonstrated 45 degrees of wrist extension and 45 degrees of wrist flexion. Following hand joint manipulation, range of motion was full at the MCP and PIP joints of the fingers and the MCP and IP joint of the thumb. Nondisplaced transverse left thumb proximal phalanx fracture sustained during manipulation of the thumb. This is a relatively stable fracture pattern and was not pinned.
Specimen(s)
None
Complications
Intraoperative nondisplaced left thumb proximal phalanx fracture
Technique
The patient identification, operative sites, and operative procedures were verified with the patient preoperatively in the holding area and again at the safety pause in the operating room. The anesthesia team administered a regional block to the left upper extremity in the preoperative holding area. The patient was transferred to the operating room in a supine position on a stretcher. She was then transferred to the operating room table and a safety strap was placed. All bony prominences were padded and a pillow was placed behind the knees. A well-padded tourniquet was placed on the left upper arm. The left upper extremity was subsequently prepped and draped using the standard sterile technique with Betadine. A timeout was performed and all were in agreement. The left upper extremity was exsanguinated with an Esmarch and the tourniquet was inflated to 250 mmHg. We began with the dorsal forearm, wrist, and hand. There was a 5 cm longitudinal scar over the dorsal aspect of the forearm overlying the proximal dorsal spanning plate, a 3 cm oblique scar over the dorsal aspect of the wrist along the course of the EPL tendon, and a 4 cm longitudinal scar over the dorsal aspect of the index metacarpal. We opened all three dorsal incisions simultaneously. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. There were significant adhesions between the scars and the subcutaneous tissues. These were carefully released. Proximally, we progressed in a plane between the dorsal forearm muscles to gain access to the plate. Distally, the plate was subcutaneous. The proximal and distal ends of the dorsal spanning plate were exposed and the screws were removed in the standard fashion. The plate was delivered out of the distal wound. A rongeur was used to remove the soft tissue and bony ingrowth into the recesses of the plate. We then turned our attention to the fourth dorsal compartment tenolysis. The two extensor tendons to the index finger, the long finger extensor tendon, the ring finger extensor tendon, and the two extensor tendons to the small finger were identified and released from the surrounding soft tissues using forceps and scissors. There were adhesions superficial to the tendons and deep to the tendons that were carefully released. Great care was taken to protect the juncturae. We used a Ragnell retractor to elevate the tendons out of the wound sequentially and ensure all tendons were completely released. When pulling on the tendon with the Ragnell retractor, there was full extension of each digit. We then turned our attention to the manipulation under anesthesia for the fingers. Several cycles of firm pressure was provided to the MCP and PIP joints of the fingers. Full range of motion of the MCP and PIP joints was obtained and a passive composite fist was achieved. There was mild residual stiffness at the index finger DIP joint. We then identified the EPL tendon underneath the retinaculum at the base of the dorsal wrist wound. A 1 cm aperture was created in the EPL tendon sheath at the level of Lister's tubercle. A freer elevator was placed proximally and distally within the EPL tendon sheath to release the adhesions. The EPL tendon was delivered from the wound using a Ragnell retractor and the thumb was noted to have nearly full extension. We then turned our attention to the PIN neurectomy. A transverse incision was made parallel to the fibers of the fourth dorsal compartment retinaculum. A 2 cm aperture was created in the fourth dorsal compartment sheath. The tendons were retracted off the floor of the fourth dorsal compartment sheath using a Ragnell retractor. The PIN was identified in the floor of the fourth dorsal compartment and a 1 cm section of the PIN was excised. All of the dorsal wounds were then copiously irrigated. The apertures in the retinaculum were not repaired since there was no evidence of soft tissue or tendon herniation. We then turned our attention to the volar side. A 6 cm longitudinal scar was noted over the volar aspect of the wrist overlying the FCR tendon. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. There was significant scar circumferentially about the FCR tendon. This was carefully released with forceps and scissors. Great care was taken to protect the adjacent median nerve and radial artery. Once the FCR tendon was completely released, we progressed through the interval to the level of the volar plate. Significant adhesions were noted between the FPL and the FDP to the index finger tendons and the surrounding soft tissues. The FPL muscle was also noted to be adherent to the surrounding soft tissues. The adhesions were carefully released using forceps and scissors. A Ragnell retractor was used to ensure the tendons were appropriately released. When pulling on the FDP to the index finger tendon with the Ragnell retractor, there was full flexion of the digit. However, there was persistent stiffness in the thumb when pulling on the FPL tendon. We turned our attention to the thumb manipulation under anesthesia. Several cycles of firm pressure was provided to the MCP and IP joints of the thumb. Unfortunately, a transverse fracture was sustained at the base of the thumb distal phalanx. This fracture was extra-articular and nondisplaced and was noted to be relatively stable. We made the decision to avoid percutaneous pinning. Following manipulation, there was full range of motion of the thumb when pulling on the FPL tendon with the Ragnell retractor. We then turned our attention to removal of the volar plate. A #15 blade was used to expose the plate at the base of the wound and the soft tissues were elevated off the plate using a combination of a freer elevator and a key elevator. Once the plate was adequately exposed, the screws were removed sequentially in the standard fashion and the plate was delivered out of the wound. A rongeur was used to remove the soft tissue and bony ingrowth into the recesses of the plate. We then turned our attention to the AIN neurectomy. The AIN was identified entering the pronator quadratus in the interval between the radius and ulna proximal to the DRUJ. A 1 cm section of the AIN was excised. All wounds were then copiously irrigated. The tourniquet was released after a total of 95 minutes with immediate return of blood flow to the fingertips. A bipolar was used to maintain hemostasis. All incisions were closed with running 3-0 Prolene subcuticular sutures. This closure was reinforced with interrupted 3-0 nylon sutures in a horizontal mattress fashion. Steri-Strips were placed in between the nylon sutures for added strength. A dry sterile bulky nonadherent resting was placed over all incisions and around the thumb. This was reinforced with Coban and an Ace wrap. The procedures were complicated by the nondisplaced left thumb proximal phalanx fracture that was managed conservatively. The counts were correct. The patient tolerated the procedures well and was transferred to the PACU in stable condition.
Grafts/Implants
No implants were placed.
Explants included the Biomet titanium dorsal spanning plate and screws and Biomet titanium volar distal radius plate and screws.