Wiki Aptis DRUJ replacement

[cynthiag14]

Hello,

I am having trouble figuring out the appropriate CPT code for Aptis DRUJ replacement. The provider is requesting 25337 but I am thinking 25449-22. Thank you
The patient previously had an unconstrained distal radioulnar prosthesis placed with a bone growth matrix that ended up eroding into the distal radius.
"We had premarked and templated where we wanted to cut the prosthesis in terms of our DRUJ Aptis reconstruction and proceeded to use that. We then used a number of techniques including small K-wire drilling around the prosthesis to break up the bone ingrowth, which was extremely dense. Just removing the prosthesis itself took 1 hour. Care was taken obviously not to break the ulnar shaft. With the prosthesis finally removed, we then mobilized the ulna. We now exposed the distal radius.
The trial template for the Aptis was placed. As I anticipated, a fair amount for shaping of the radius was done, particularly because of the malformation caused by the abnormal prosthesis. With this done, the trial was placed. Once we were happy with the trial component, the main real component was placed. This was a #20 locking plate construct on the radius. We reamed to 6mm and a 4-inch extension. Again, fluroscopy was used liberally throughout to confirm position of the plate, to confirm the various shaping and confirmed that the rod was well contained within the ulnar shaft. With the prosthesis inserted and locked in, we now had full pronation and supination, and excellent stability of the DRUJ. At this point, the tourniquet had been let down.....
With this done, we proceeded to reconstruct the dorsal capsule using the capsule beneath the ECU tendon to protect the tendons. This fully closed the reconstructed distal radial ulnar joint. We now reconstructed the extensor retinaculum over the extensor tendons, which had been tenolysed reconstructing the extensor retinaculum."

Thank you.

 

[NRaizman]

This would be 25442+22, and 25250 for removal of the previous prosthesis.

25337 is in no way appropriate for a prosthetic replacement of the DRUJ.
Also, the surgeon apparently wants to cost his ASC/HOPD thousands of dollars and take a potentially profitable case and make it a money loser, as the APC for 25337 reimburses $6800 and 25442 reimburses $17000 (medicare rates). The Aptis prosthesis is extremely expensive and there is no way 25337 would cover it in an outpatient setting.

The surgeon should also be taught how to dictate an operative report that more adequately justifies the -22 modifier. This dictation barely denotes the extensive amount of work it takes to remove a well-fixed prosthesis and then do a very difficult contouring operation to make the notoriously finicky Aptis prosthesis fit.

 

[cynthiag14]

Thank you so much Dr. Raizman! There is some more documentation but I think I extracted what was necessary for this portion of the case. I initially did look at 25442-22 but because the provider mentioned this patient previously had an "unconstrained distal radioulnar prosthesis placed" I was looking at 25449-22 and leave out 25250 because of the CPT description for 25449-Revision of arthroplasty, incl removal of implant, wrist joint. What are your thoughts between 25442-22 & 25250 vs 25449-22? I appreciate your feedback!

 

[NRaizman]

25250 and 25442 are the better combo. One has to be careful separating out the wrist from the DRUJ. 25442 is definitely the correct code for the Aptis. 25449 does not encompass that work. 25250 distinguishes itself from 25251 for total wrist. Also, reimbursement to the facility is more appropriate with 25442 than 25449