SavCoder
Contributor
Hey my fellow coders! I am needing your help! I'm thinking the CPT is 25275 but it seems the provider did more work then just a tendon sheath repair. Would this be a reconstruction, 25320?
Preop Dx: Right ulnar wrist pain
Postop Dx: 1. right extensor carpi ulnaris longitudinal tendon tear
2. right extensor carpi ulnaris tendon instability
Procedure: 1. Debridement, right extensor carpi ulnaris tendon tear
2. Right extensor carpi ulnaris stabilization with a retinacular flap
Indications: The patient has a long history of the above complaints.
Description of Procedure: The arm was prepped and draped in a normal sterile fashion. The arm was exsanguinated and the tourniquet was inflated. A longitudinal incision made over the extensor carpi ulnaris. Hemostasis obtained. Blunt dissection carried down the level of the extensor retinaculum. The cutaneous nerve branches were protected. The retinaculum was released off the most volar ulnar aspect. There was obvious subsheath tear. There was significant synovitis which was debrided. The tendon itself had significant fraying distally and a longitudinal split involving approximately a quarter of the tendon. I excised the core of the tendon longitudinally and removed any damaged areas distally. The subsheath itself was not repairable. At that point, I proceeded to do a stabilization procedure. I transposed the tendon dorsally and it appeared stable without too much tension. At that point, I isolated the central third of the extensor retinaculum and a radially based flap was created off of the 4th/5th compartment septum. I transposed the tendon and I wrapped the fascial flap over the tendon and secured it more proximally to the proximal 3rd of the retinaculum. This stabilized the tendon nicely. I then repaired the subsheath tissue and the remainging two-thirds of the extensor retinaculum. This stabilized the tendon through full supination and pronation. The area was copiously irrigated. The subcutaneous tissues closed with vicryl, skin with nylon. A long-arm splint in pronation was applied.
Any thoughts on this would be greatly appreciated!
Thank you
Preop Dx: Right ulnar wrist pain
Postop Dx: 1. right extensor carpi ulnaris longitudinal tendon tear
2. right extensor carpi ulnaris tendon instability
Procedure: 1. Debridement, right extensor carpi ulnaris tendon tear
2. Right extensor carpi ulnaris stabilization with a retinacular flap
Indications: The patient has a long history of the above complaints.
Description of Procedure: The arm was prepped and draped in a normal sterile fashion. The arm was exsanguinated and the tourniquet was inflated. A longitudinal incision made over the extensor carpi ulnaris. Hemostasis obtained. Blunt dissection carried down the level of the extensor retinaculum. The cutaneous nerve branches were protected. The retinaculum was released off the most volar ulnar aspect. There was obvious subsheath tear. There was significant synovitis which was debrided. The tendon itself had significant fraying distally and a longitudinal split involving approximately a quarter of the tendon. I excised the core of the tendon longitudinally and removed any damaged areas distally. The subsheath itself was not repairable. At that point, I proceeded to do a stabilization procedure. I transposed the tendon dorsally and it appeared stable without too much tension. At that point, I isolated the central third of the extensor retinaculum and a radially based flap was created off of the 4th/5th compartment septum. I transposed the tendon and I wrapped the fascial flap over the tendon and secured it more proximally to the proximal 3rd of the retinaculum. This stabilized the tendon nicely. I then repaired the subsheath tissue and the remainging two-thirds of the extensor retinaculum. This stabilized the tendon through full supination and pronation. The area was copiously irrigated. The subcutaneous tissues closed with vicryl, skin with nylon. A long-arm splint in pronation was applied.
Any thoughts on this would be greatly appreciated!
Thank you
Last edited: