Wiki ORIF of distal radius with treatment of distal ulna

Deadpd

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Hey all,

I was wondering if any of you wonderfully brilliant people can help me with this:

PROCEDURE:
1. ORIF left distal radius, intraarticular, 3 parts 25609
2. Open treatment distal ulna, with excision of ulnar head 25240
3. Open treatment of distal radioulnar joint dislocation 25676

PROCEDURE IN DETAIL:
Patient was identified in the preoperative holding area prior to the induction of anesthesia and the operative extremity
was marked. The patient's numbness and weakness in the median nerve distribution had improved since her clinic visit.
The patient was then taken to the operating room and placed under GETA. The operative extremity was prepped and
draped in the standard sterile fashion. A timeout was performed verifying the correct patient, correct limb, and all
attendees were in agreement with proceeding.
The tourniquet was inflated to 250 mmHg. A standard trans FCR approach was performed, the fracture site was
identified and cleaned. The fracture was held in a reduced position and a 1.6 mm K wire was placed to the styloid into
the proximal intact radius. The above-mentioned implant was placed in the appropriate position. It was drilled and filled
in the standard fashion with excellent purchase and fixation. Attention was then turned to the distal ulna, and a direct
approach was performed with care to preserve the dorsal branch of the ulnar nerve. The ulnar head fragment was
dislocated near the volar lunate facet and was avoid of soft tissue attachments. Decision was made to excise this. The
ulnar styloid was intact and to preserve the relationship of the radius and the ulna a single 1.6 mm pin was placed
Quadra cortically across the DRUJ. The pin was cut and bent for later removal. Final fluoroscopic imaging confirmed safe
placement of all hardware, no injury to the scapholunate ligament, no radiocarpal instability. The tourniquet was
deflated, hemostasis was achieved. Palpable radial and ulnar pulses were present. Compartments are soft and
compressible. The wounds was irrigated with normal saline. A layered closure was performed. Sterile dressings were
applied along with a sugar-tong splint.

I'm thinking there is a code that bundles this all into one CPT; 25526:
Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex.
 
You cannot use a Radial Shaft fracture code on a Distal Radius, so 25536 is not appropriate.

This operative report does not show whether the fracture was intraarticular and so you cannot, from information given, choose between 25607/25608/25609. That is poor documentation by the surgeon and may get kicked back.

You can code 25240 for distal ulnar excision but would not code separately for stabilization of the DRUJ with a single removable wire. 25676 is the code for open reconstruction of the DRUJ, whereas the pin is part of the necessary procedure for stump stabilization after the Darrach.
 
Thank you for your quick response. I truly appreciate it Dr. Raizman. Those are the codes that were billed. The insurance paid but want their money back for the 25609.
 
Why do they want to clawback 25609? What do XR look like?

Someone should tell your surgeon that bad things happen to docs who don't understand the importance of their op notes...
 
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