karismithx
Contributor
I have an orthopedic op note here that I'm having some trouble with. I'll post the op note and write what I think it should be coded and then some questions at the bottom.
PATIENT NAME: *****
DATE OF SURGERY: *****
PREOPERATIVE DIAGNOSIS: Status post four-corner infusion with osteoarthritis of
the right wrist and stiffness.
POSTOPERATIVE DIAGNOSIS: Status post four-corner infusion with osteoarthritis
of the right wrist and stiffness. 715.93 & 719.53
PROCEDURE PERFORMED:
1. Dorsal incision with anterior interosseous neurectomy. 64708
2. Posterior interosseous neurectomy. 64708
3. Resection of supraretinacular nerves. ????
4. Neurolysis of the superficial nerve. 64704
5. Arthrotomy with partial carpectomy of the triquetrum. 25210 & 25100
6. Separate volar wrist incision with radial artery sympathectomy. 64821
7. Dorsal radial hand incision with dorsal branch radial artery sympathectomy.64821
8. Wrist manipulation. 25259
9. Wrist block. -
SURGEON: *****
ASSISTANT: *****
ANESTHESIOLOGIST: *****
ANESTHESIA: General.
COMPLICATIONS: None.
DRAINS: None.
SPECIMENS: None.
TOURNIQUET TIME: 56 minutes, 250 mmHg.
ESTIMATED BLOOD LOSS: 5 cc.
FLUIDS: Crystalloid 1 gm of Kefzol.
Page 2
INDICATIONS: Mr. ****** has had a previous scaphoid nonunion. This has failed
to heal. He subsequently went on to have four-corner infusion. He has done well for 13
years but has worsening pain. He is noted to have marked stiffness. The risks, benefits,
and options were discussed with him and it was felt that the best thing was for him to
have a wrist fusion which will solve all his problems. He wanted to have continued
motion that he had. He was noted to have 10 degrees dorsiflexion and 40 degrees volar
flexion preoperatively. The risks, benefits, and options were discussed with him and he
wished to undergo the procedure.
FINDINGS: There was noted to be a dorsal spur coming off the triquetrum dorsally.
This was opened up. This did seem to impinge on his wrist. Most of this was excised. He
was able to get up to 50 degrees of dorsiflexion. Volar flexion is done to 60 degrees for
manipulation.
There was noted to be scarring about the superficial nerve which was dissected. Branches
of the anterior osseous and posterior osseous nerve were resected. The radial artery had
sympathectomy performed over the 5 cm region and a 3 cm region over the dorsal branch
of the radial artery dorsally over the first web space.
PROCEDURE IN DETAIL: The patient was brought to the Operating Room. General
anesthesia was induced. All pressure points were well padded. Previous scars were
marked out. Surgical incisions were mapped out. The right arm was exsanguinated and
tourniquet inflated.
A longitudinal incision was then made just proximal to the previous incision over the
dorsal aspect of the wrist. Sharp dissection was carried out through the skin and blunt
dissection through subcutaneous tissue. Adequate hemostasis was obtained with
electrocautery.
Over the fourth dorsal compartment, the posterior osseous nerve was identified and
resected over 2 cm region.
In inner osseous septum and anterior osseous nerve was identified and resected.
Distally, resection was carried out above supraretinacular in order to prevent any
branches. Over the radial aspect, superficial nerve was identified. There was noted to be
involvement of the scar, mobilized off the scar elevated and any branches coming down
from deep were removed, and this was fully mobilized.
Digitally bluntly dissected over towards the volar radial incision.
Upon palpating this, this is noted to be a spur that felt to prevent dorsiflexion of the wrist.
Sharp dissection was carried down through the skin of the previous skin incision. Sharp
dissection was then carried out over the spur. This was just radial to the fourth dorsal
compartment. The periosteum and capsule were removed off the bone.
Page 3
This was then taken down and smooth with rongeur. The joint was entered this point.
There is no evidence of any further spurring proximally. The wrist was then manipulated
to 50 degrees dorsiflex.
This was copiously irrigated. A 2-0 Vicryl suture was used in order to close the
periosteum over the bony fragment. Attention was then brought to the volar radial aspect
of the wrist. A longitudinal incision was made over the FCR. This was then dissected and
mobilized. The radial artery was identified with the venae comitantes.
De Bakery forceps were then used in order to mobilize the radial artery. Started
proximally, normal tissue then dissected distally. Sympathectomy was performed.
Bipolar was used in order go get adequate hemostasis. This was dissected down to the
scar. This did dive deep down into scar and left at that portion. A 5 cm sympathectomy
was performed.
Attention was then brought to the first webspace. A longitudinal incision was made over
the first web space. A sharp dissection was carried out through the skin and blunt
dissection through the subcutaneous tissues. Dorsal branch of the radial artery was
identified and then a 3 cm sympathectomy was performed around it circumferentially
using bipolar for adequate hemostasis.
The wound was copiously irrigated. The wrist was again placed in range of motion. Skin
incisions were closed with running Prolene stitch. A 6-0 nylon was used to pull out stitch
as the dorsal wrist incision did elongate in order to gain access to the capsule and
performed partial carpectomy.
Proximally wrist block was placed with 0.5% Ropivacaine. Bulky dressing was applied.
The tourniquet was released. The patient brought to Recovery Room in stable condition.
He tolerated the procedure without complications. The plan for him is to start active and
passive range of motion right away. There is ongoing stiffness. We will get him to hand
therapy next week for range of motion in order maximize the result and he notes that he
will not get full range of motion and also he may require wrist fusion.
After running the above codes through Encoder Pro I found that CPTs 25100 & 25259 would be bundled. So basically I have 2 questions.
1. I'm stumped on what CPT to use for #3 Resection of supraretinacular nerves.
2. Procedure #5 I've put 25210 for the partial carpectomy, but can I use this code if he doesn't remove the whole carpal bone??
Any help is appreciated!
Thanks
Kari
PATIENT NAME: *****
DATE OF SURGERY: *****
PREOPERATIVE DIAGNOSIS: Status post four-corner infusion with osteoarthritis of
the right wrist and stiffness.
POSTOPERATIVE DIAGNOSIS: Status post four-corner infusion with osteoarthritis
of the right wrist and stiffness. 715.93 & 719.53
PROCEDURE PERFORMED:
1. Dorsal incision with anterior interosseous neurectomy. 64708
2. Posterior interosseous neurectomy. 64708
3. Resection of supraretinacular nerves. ????
4. Neurolysis of the superficial nerve. 64704
5. Arthrotomy with partial carpectomy of the triquetrum. 25210 & 25100
6. Separate volar wrist incision with radial artery sympathectomy. 64821
7. Dorsal radial hand incision with dorsal branch radial artery sympathectomy.64821
8. Wrist manipulation. 25259
9. Wrist block. -
SURGEON: *****
ASSISTANT: *****
ANESTHESIOLOGIST: *****
ANESTHESIA: General.
COMPLICATIONS: None.
DRAINS: None.
SPECIMENS: None.
TOURNIQUET TIME: 56 minutes, 250 mmHg.
ESTIMATED BLOOD LOSS: 5 cc.
FLUIDS: Crystalloid 1 gm of Kefzol.
Page 2
INDICATIONS: Mr. ****** has had a previous scaphoid nonunion. This has failed
to heal. He subsequently went on to have four-corner infusion. He has done well for 13
years but has worsening pain. He is noted to have marked stiffness. The risks, benefits,
and options were discussed with him and it was felt that the best thing was for him to
have a wrist fusion which will solve all his problems. He wanted to have continued
motion that he had. He was noted to have 10 degrees dorsiflexion and 40 degrees volar
flexion preoperatively. The risks, benefits, and options were discussed with him and he
wished to undergo the procedure.
FINDINGS: There was noted to be a dorsal spur coming off the triquetrum dorsally.
This was opened up. This did seem to impinge on his wrist. Most of this was excised. He
was able to get up to 50 degrees of dorsiflexion. Volar flexion is done to 60 degrees for
manipulation.
There was noted to be scarring about the superficial nerve which was dissected. Branches
of the anterior osseous and posterior osseous nerve were resected. The radial artery had
sympathectomy performed over the 5 cm region and a 3 cm region over the dorsal branch
of the radial artery dorsally over the first web space.
PROCEDURE IN DETAIL: The patient was brought to the Operating Room. General
anesthesia was induced. All pressure points were well padded. Previous scars were
marked out. Surgical incisions were mapped out. The right arm was exsanguinated and
tourniquet inflated.
A longitudinal incision was then made just proximal to the previous incision over the
dorsal aspect of the wrist. Sharp dissection was carried out through the skin and blunt
dissection through subcutaneous tissue. Adequate hemostasis was obtained with
electrocautery.
Over the fourth dorsal compartment, the posterior osseous nerve was identified and
resected over 2 cm region.
In inner osseous septum and anterior osseous nerve was identified and resected.
Distally, resection was carried out above supraretinacular in order to prevent any
branches. Over the radial aspect, superficial nerve was identified. There was noted to be
involvement of the scar, mobilized off the scar elevated and any branches coming down
from deep were removed, and this was fully mobilized.
Digitally bluntly dissected over towards the volar radial incision.
Upon palpating this, this is noted to be a spur that felt to prevent dorsiflexion of the wrist.
Sharp dissection was carried down through the skin of the previous skin incision. Sharp
dissection was then carried out over the spur. This was just radial to the fourth dorsal
compartment. The periosteum and capsule were removed off the bone.
Page 3
This was then taken down and smooth with rongeur. The joint was entered this point.
There is no evidence of any further spurring proximally. The wrist was then manipulated
to 50 degrees dorsiflex.
This was copiously irrigated. A 2-0 Vicryl suture was used in order to close the
periosteum over the bony fragment. Attention was then brought to the volar radial aspect
of the wrist. A longitudinal incision was made over the FCR. This was then dissected and
mobilized. The radial artery was identified with the venae comitantes.
De Bakery forceps were then used in order to mobilize the radial artery. Started
proximally, normal tissue then dissected distally. Sympathectomy was performed.
Bipolar was used in order go get adequate hemostasis. This was dissected down to the
scar. This did dive deep down into scar and left at that portion. A 5 cm sympathectomy
was performed.
Attention was then brought to the first webspace. A longitudinal incision was made over
the first web space. A sharp dissection was carried out through the skin and blunt
dissection through the subcutaneous tissues. Dorsal branch of the radial artery was
identified and then a 3 cm sympathectomy was performed around it circumferentially
using bipolar for adequate hemostasis.
The wound was copiously irrigated. The wrist was again placed in range of motion. Skin
incisions were closed with running Prolene stitch. A 6-0 nylon was used to pull out stitch
as the dorsal wrist incision did elongate in order to gain access to the capsule and
performed partial carpectomy.
Proximally wrist block was placed with 0.5% Ropivacaine. Bulky dressing was applied.
The tourniquet was released. The patient brought to Recovery Room in stable condition.
He tolerated the procedure without complications. The plan for him is to start active and
passive range of motion right away. There is ongoing stiffness. We will get him to hand
therapy next week for range of motion in order maximize the result and he notes that he
will not get full range of motion and also he may require wrist fusion.
After running the above codes through Encoder Pro I found that CPTs 25100 & 25259 would be bundled. So basically I have 2 questions.
1. I'm stumped on what CPT to use for #3 Resection of supraretinacular nerves.
2. Procedure #5 I've put 25210 for the partial carpectomy, but can I use this code if he doesn't remove the whole carpal bone??
Any help is appreciated!
Thanks
Kari
