Answer CPT 25447 vs 25820 - Interposition Flap Arthroplasty of Radiocarpal

cclarson

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Hello, I'm trying to figure out which cpt code better fits for the treatment of a scapholunate tear w/ early SLAC wrist.

The doctor states that he did an interposition flap arthroplasty of the radiocarpal space. Typically I'd use 25447, but the radiocarpal space description has me unsure. I might just be overthinking. Any help would be deeply appreciated. He also performed a proximal row carpectomy and posterior interosseous nerve neurectomy, which I coded as 25215/64772.

Here is the body of the op note:

The patient was brought to the operating room and placed supine with the left hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. Timeout was performed and preoperative antibiotics were given.

A longitudinal incision was made over the wrist. We dissected down through the subcutaneous tissues to the extensor retinaculum and this was opened over the third compartment.

The EPL tendon was transposed. The posterior interosseous nerve was then identified and was compressed with a hemostat. We then resected approximately 2 cm of the nerve. We then performed a U-shaped capsulotomy off of the radius. This was elevated off of the proximal row. There was a complete tear of the scapholunate ligament with early arthritis of the radioscaphoid joint and the STT joint. At this point the decision was made to proceed with the proximal row carpectomy. A threaded K-wire was used and scaphoid osteotomy was performed with a saw and osteotomes. The bones were then able to be removed subperiosteally. We then released the lunate and the triquetrum intact and subperiosteal dissection. The wounds were irrigated and the capsule was interposed with 3-0 PDS sutures. There was some mild arthritis of the hamate and so the interposition flap was chosen.

Final fluoroscopic pictures were taken, confirmed good position of the capitate and the lunate fossa without evidence of ulnar translation.
The wounds were irrigated. The extensor retinaculum was repaired with the EPL transposed and then the skin was closed with interrupted nylon sutures. The dorsal wrist splint was applied. The patient tolerated the procedure well without complication.
 

Orthocoderpgu

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My question is how can you treat a schopholunte tear when they are both part of the "front row" and per your doc was removed?

Usually in 25447 the trapezium is removed and a tendon is cut and rolled up into the space where the bone was removed from.

From what I see in reading this he did a proximal row carpectomy. The PIN in these cases are performed for long term pain control so that would not be reported separately.

He says that he performed an interpositional arthroplasty, but it's not documented. He just said it was "chosen", but the procedure itself is not documented.

From what I am seeing the only billable code that is documented is 25215
 
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cclarson

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My question is how can you treat a schopholunte tear when they are both part of the "front row" and per your doc was removed?

Usually in 25447 the trapezium is removed and a tendon is cut and rolled up into the space where the bone was removed from.

From what I see in reading this he did a proximal row carpectomy. The PIN in these cases are performed for long term pain control so that would not be reported separately.

He says that he performed an interpositional arthroplasty, but it's not documented. He just said it was "chosen", but the procedure itself is not documented.

From what I am seeing the only billable code that is documented is 25215
Thank you for your input, it was very helpful. :) I'll talk to the doctor concerning this.
 

cclarson

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My question is how can you treat a schopholunte tear when they are both part of the "front row" and per your doc was removed?

Usually in 25447 the trapezium is removed and a tendon is cut and rolled up into the space where the bone was removed from.

From what I see in reading this he did a proximal row carpectomy. The PIN in these cases are performed for long term pain control so that would not be reported separately.

He says that he performed an interpositional arthroplasty, but it's not documented. He just said it was "chosen", but the procedure itself is not documented.

From what I am seeing the only billable code that is documented is 25215

The Doctor created an addendum to the report to further describe the interposition flap arthroplasty, which cpt code would best qualify for this?

"The interposition flap arthroplasty from the radiocarpal space, during the initial approach, the wrist capsule was elevated in a U-shape flap for possible interposition arthroplasty. At the end of the procedure there were arthritic changes of the hamate. So, at this point we elected to proceed with the interposition arthroplasty and so the capsule was then sutured with multiple 3-0 PDS sutures. These were then tied interposing the flap over the capitate and the hamate to the volar capsule. At this point the wrist was taken through a range of motion and was stable."
 
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