Wiki Left first dorsal extensor compartment release, retinacular repair

klienhart

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Need help with this surgery. I think correct CPT code is 25000, however, provider wants to use 25275. Thank you!

Pre-op diagnosis: Left DeQuervain Tenosynovitis
Post op diagnosis: same

Procedure: Left First Dorsal Extensor Compartment Release, retinacular repair

Anesthesia: Local

Tourniquet time: * No tourniquets in log *

Procedure indications: Patient with recalcitrant radial sided pain consistent with DeQuervain stenosing synovitis. Conservative treatment including HEP, NSAIDs, braces and steroid injections have been tried and failed to provide long-lasting relief of pain. After Thorough discussion, the patient decided to proceed with surgical management. We discussed in detail surgical risks including scar, pain, bleeding, infection, anesthetic risks, neurovascular injury, need for further surgery, weakness, stiffness, risk of death and potential risk of other unforseen complication.

Procedure description:

Description of procedure: Patient was placed in the supine position and after appropriate time-out and side, site and procedure confirmed. Local anesthesia was infiltrated with Lidocaine 2% plain and 0.25% Bupivacaine plain.

A longitudinal incision was made over the first dorsal extensor compartment, blunt dissection was use, the dorsal radial sensory nerve was identified and protected, the 1st dorsal compartment was identified and release of the EPB and APL tendon sheath retinacular tissue was done on the dorsal third of the compartment to avoid volar dislocation of the tendons afterwards. Tendon demonstrated instability with flexion extension so decision was made to perform a retinacular repair, a figure-of-eight 4-0 Ethibond stitch was applied in loose fashion, after retinacular repair the tendons remained within the retinacular sheath. Wound irrigated and closure in routine fashion with 4-0 prolene suture and steristrips. Sterile dressing was applied
 
25000.
Can't take credit for structures repaired or closed if they were divided/released either partially or completely to do the case. "and release of the EPB and APL tendon sheath retinacular tissue was done on the dorsal third of the compartment to avoid volar dislocation of the tendons afterwards."
Also, 25275 would be incorrect either way, description states with free graft. No graft here.
 
25000.
Can't take credit for structures repaired or closed if they were divided/released either partially or completely to do the case. "and release of the EPB and APL tendon sheath retinacular tissue was done on the dorsal third of the compartment to avoid volar dislocation of the tendons afterwards."
Also, 25275 would be incorrect either way, description states with free graft. No graft here.
That was my thought also. I've been away from hand coding for about a year, so trying to get back to par with it, lol.
 
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