Wiki Exploration right thumb EPL tendon, Help please!!!

[dsibley67]

I am not sure how to code this. Everything I have looked at is to repair, transfer or to lengthen or shorten the tendon. I don't see where he repaired anything, just looks like to me he just made sure that they wee intact and took them through range of motion. Can someone please help? Any advice will be greatly appreciated.

PREOPERATIVE DIAGNOSIS: Right thumb lack of extension.
POSTOPERATIVE DIAGNOSIS: Right thumb lack of extension.
PROCEDURE PERFORMED: Exploration right thumb EPL tendon

The patient was seen preoperatively, site was marked and
verified. Preoperative antibiotics had been given. She was taken back to the OR. Time-out was taken at
the beginning of the procedure. The arm was exsanguinated. The tourniquet was inflated. A small
incision was made at the thumb MP joint, carefully dissected down and identified the EPL tendon. We
isolated the tendon and used any retractor to attempt to move the tendon through range of motion. It
appeared intact. At this point, we proceeded with a second incision over the dorsal aspect of the wrist and
carefully dissected down. A small split was made in the retinaculum over the EPL tendon. EPL tendon
was then isolated and retracted. At this point, we verified that the tendon remained intact. The wounds
were irrigated. The retinaculum was repaired loosely with 3-0 Vicryl. The skin was closed. She was
placed back in a soft dressing and tolerated the procedure well

 

[amyjph]

Was the plan an EPL repair or reconstruction? What was on the surgery order and auth (if one was needed)? Maybe whatever the planned cpt was but now w/ a 52 mod because he did not have to complete it once he got in and saw it was not torn. Or, was he going in to "look" the whole time. This is not a fun one. Either that or unlisted I would go with.

 

[Orthocoderpgu]

I agree with Amy. My guess is that the patient had an injury and the provider was going to perform a restorative procedure but saw that it was not necessary since the tendon was intact with no tears, avulsions or adhesions.