Wiki Cubital Tunnel Transposition w/ local fat pad flap

[RPowell]

Could anyone offer any feed back on how to code a cubital tunnel transposition w/local fat pad flap?
Provider wants to bill 15736. States that the surgeons who invented this procedure uses this code as well.
Please see procedure below. Thank you!

Cubital Tunnel Release with Transposition and Fat Pad FlapI then turned my attention to the elbow. I could feel the nerve subluxing with flexion so I drew my incision over the cubital tunnel with the arm in near extension to keep the nerve reduced. An incision was made with a fresh blade. Bipolar electrocautery was used for subcutaneous bleeders. I used blunt dissection to look for MABC branches. I found 2 branches to preserve. Further blunt dissection was performed to isolate the cubital tunnel retinaculum. I then incised the retinaculum and visualized the nerve underneath. It appeared swollen and compressed. Distally, I released the FCU fascia and bluntly split the 2 FCU heads along the course of the nerve. I did preserve the motor branches and articular branch I visualized. I then turned my attention proximally and bluntly dissected between the subcutaneous and fascial layers up the intermuscular septum until I reached the Arcade of Struthers. I used Metzenbaum scissors to open up the fascia over the nerve. I confirmed that the nerve was circumferentially released to the Arcade. I then examined the ulnar nerve for stability in the tunnel having completely released it. The nerve very clearly subluxed with any flexion past 90 degrees. Decision was made to perform transposition. I extended the incision proximally and repeated subcutaneous bipolar hemostasis. I bluntly dissected over the anterior aspect of the medial intermuscular septum to expose it 5 cm proximal to the epicondyle. I then incised it proximally in a transverse fashion for about 1 cm before continuing distally in a longitudinal manner and then eventually leaving a pedicle on the epicondyle to use as a sling for closure. I then started to create my fat pad flap. I went in between the vascular layers of the subcutaneous fat to create a pocket for the nerve in the anterior elbow. I transposed the nerve into the fat pad flap pocket. I was able to do this without disturbing any of the MABC or ulnar motor branches distally. There was no appreciable kinking, tension or compression on the nerve in its new transposed course throughout elbow range of motion. I then closed off the cubital tunnel using 2-0 Monocryl through the cubital tunnel retinaculum with attention to avoid incarcerating nerve branches. I also secured the nerve in the anterior fat pad pocket by using 2-0 Monocryl to suture the posteromedial subcutaneous fat, again with attention to avoid nerve branches. Lastly, I used the intermuscular septum pedicled on the medial epicondyle as a sling and sutured it to subcutaneous fat posterior to the nerve to further prevent the nerve from falling posteriorly. Tourniquet was then taken down after 72 minutes. Both sides of the flap demonstrated vascularity. The ulnar nerve showed some increased vascularity as well. Wound was then thoroughly irrigated with normal saline. Bipolar electrocautery was used for hemostasis prior to closure. Subcutaneous layer was closed with 2-0 Monocryl in a buried, interrupted fashion. Skin was then closed with a 3-0 Monocryl running, subcuticular stitch. Dermabond was placed over the incision. 0.25% Marcaine with epinephrine was infiltrated throughout the surgical wound bed. A soft, sterile dressing was then placed.

 

[nsteinhauser]

I'm thinking that creating the fat pad would be included in the 'transposition' for 64718. If it was documented as a lot of additional work, if you're coding PRO fees, you could add a -22.
Anyone else have any ideas?