maljdcpc
Networker
Requesting help on coding bone graft for a delayed union fracture rt distal humerus. I got an unlisted procedure, humerus or elbow 24999 through 3M. The closest code I found was 24435- Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft) but this was performed for a delayed union (by definition, it is not a nonunion, but clinically, it is an impending/possible nonunion). Physician used an allograft bone graft to accelerate the healing and to limit the nonunion potential. Attached op report below for reference. Any help on this will be much appreciated. Thank you.
POSTOPERATIVE DIAGNOSES:
1. Retained painful hardware, right elbow, distal humerus.
2. Right elbow contracture, status post open reduction and internal
fixation of grade 2 open distal humerus fracture.
3. Delayed union right distal humerus.
PROCEDURES PERFORMED:
1. Removal of retained screw, right distal humerus.
2. Manipulation of right elbow under anesthesia.
3. Debridement and bone grafting for right distal humerus, medial column
delayed union.
Attention was turned to the right elbow. The previous incision was utilized.
Sharp dissection through skin was followed by blunt dissection through
subcutaneous tissues. Bleeding was controlled with Bovie electrocautery and
direct pressure. Care was taken to protect neurovascular structures
throughout the approach. There was significant adhesive tissue involving the
triceps through the zone of injury. Adhesions were released and tenolysis
performed and the triceps was carefully mobilized. The ulnar nerve was
palpated in its anteriorly transposed position. There was no significant
scarring or adhesions around the nerve through the visible and palpable
areas. It was stable in its transposed bed. The medial column plate was then
exposed at the apex of the epicondyle.
Preoperative evaluation showed that the third screw from the distal end was
the problematic screw with interference in the radiocapitellar joint. Once
this screw was fully exposed, it was removed without significant difficulty.
The elbow was taken through a gentle range of motion. Preoperatively, the
patient only had about 80 degrees of active flexion. I was able to achieve
nearly 110-120 degrees of flexion with gentle manipulation. Supination and
pronation also were improving from his preoperative status with nearly 70
degrees of achieved full supination. Adhesions were released and good motion
was achieved. No other releases were deemed necessary at this point. The
medial column was then further exposed and there was some bridging bone at
the area of the plate; however, there was gapping and fibrous union
developing along the more central aspect of the medial column. This was
carefully debrided with a curette.
The column was noted to be stable, and no other fixation was deemed
necessary. Evo3 bone graft was then placed into the bone void to help
promote further healing at this site. The elbow was taken through range of
motion again and noted to be stable. The wound was copiously irrigated. The
tourniquet was deflated. Hemostasis was achieved. The medial window at the
triceps was reapproximated with Vicryl suture, and the skin was closed in a
layered tension-free fashion. A sterile postoperative dressing was applied.
POSTOPERATIVE DIAGNOSES:
1. Retained painful hardware, right elbow, distal humerus.
2. Right elbow contracture, status post open reduction and internal
fixation of grade 2 open distal humerus fracture.
3. Delayed union right distal humerus.
PROCEDURES PERFORMED:
1. Removal of retained screw, right distal humerus.
2. Manipulation of right elbow under anesthesia.
3. Debridement and bone grafting for right distal humerus, medial column
delayed union.
Attention was turned to the right elbow. The previous incision was utilized.
Sharp dissection through skin was followed by blunt dissection through
subcutaneous tissues. Bleeding was controlled with Bovie electrocautery and
direct pressure. Care was taken to protect neurovascular structures
throughout the approach. There was significant adhesive tissue involving the
triceps through the zone of injury. Adhesions were released and tenolysis
performed and the triceps was carefully mobilized. The ulnar nerve was
palpated in its anteriorly transposed position. There was no significant
scarring or adhesions around the nerve through the visible and palpable
areas. It was stable in its transposed bed. The medial column plate was then
exposed at the apex of the epicondyle.
Preoperative evaluation showed that the third screw from the distal end was
the problematic screw with interference in the radiocapitellar joint. Once
this screw was fully exposed, it was removed without significant difficulty.
The elbow was taken through a gentle range of motion. Preoperatively, the
patient only had about 80 degrees of active flexion. I was able to achieve
nearly 110-120 degrees of flexion with gentle manipulation. Supination and
pronation also were improving from his preoperative status with nearly 70
degrees of achieved full supination. Adhesions were released and good motion
was achieved. No other releases were deemed necessary at this point. The
medial column was then further exposed and there was some bridging bone at
the area of the plate; however, there was gapping and fibrous union
developing along the more central aspect of the medial column. This was
carefully debrided with a curette.
The column was noted to be stable, and no other fixation was deemed
necessary. Evo3 bone graft was then placed into the bone void to help
promote further healing at this site. The elbow was taken through range of
motion again and noted to be stable. The wound was copiously irrigated. The
tourniquet was deflated. Hemostasis was achieved. The medial window at the
triceps was reapproximated with Vicryl suture, and the skin was closed in a
layered tension-free fashion. A sterile postoperative dressing was applied.