Orthopedic Coding Alert

Question: Can you help with this scenario? The operative note has the following for diagnosis:

The procedures performed by our surgeon are as follows:

How can we report this condition?

New York Subscriber

Answer: The surgeon is repairing 3 flexor tendons (FCR, BR, and FDC) so report code 25260 (Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle) x3. You report the musculotendon junction repair as tendon repair.

You report the repair of the radial nerve with either 64856 (Suture of major peripheral nerve, arm or leg, except sciatic; including transposition) or 64857 (Suture of major peripheral nerve, arm or leg, except sciatic; without transposition) depending on whether or not the nerve is transposed.

If the traumatic wound was used as the surgical wound, no additional code is reportable for the wound repair as closure of the surgical wound is inclusive. If this was a separate traumatic wound, the appropriate wound repair code you will report will be 12005 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 12.6 cm to 20.0 cm), 12035 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 12.6 cm to 20.0 cm) or 13121 (Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm), 13122 (Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less [List separately in addition to code for primary procedure]) x3.

In addition, you can report the ICD-9 codes for the tendons as 881.20 (Open wound of forearm with tendon involvement) and for radial nerve injury as 955.3 (Injury to radial nerve).