jhaleycoder
Networker
Hi-- If anyone could please help me. Aetna has denied the surgery as Operative Report does not support. All CPT codes have been denied. The operative report below was sent to Aetna. I am not sure if I am missing something.
The CPT codes billed are 25295/59, LT (2 units), 26445/51,F1, and 26440/F1. I didn't code the removal of hardware or the MUA because that would be included.
Any insight would be greatly appreciated. Thank you!
Postoperative Diagnosis
Left wrist retained hardware (dorsal spanning plate and volar plate), left wrist FCR/FPL/FDP to index finger tendon adhesions, left wrist stiffness, left hand EIP/EPL tendon adhesions, left index and long finger MCP joint stiffness
Operation
1. Left wrist removal of deep hardware: Dorsal spanning plate
2. Left wrist removal of deep hardware: Volar plate
3. Left index finger EIP and EDC tenolysis
4. Left wrist FCR tenolysis
5. Left wrist FPL tenolysis
6. Left wrist FDP to index finger tenolysis
7. Left wrist manipulation under anesthesia
8. Left index finger MCP joint manipulation under anesthesia
8. Left long finger MCP joint manipulation under anesthesia
Findings
Significant tendon adhesions to the EIP/EPL/FCR/FPL/FDP to index finger tendons. Full range of motion of the fingers following manipulation. Wrist extension to 55 degrees and wrist flexion to 55 degrees following manipulation.
Technique
The patient identification, operative sites, and operative procedures were verified with the patient preoperatively in the holding area and again at the safety pause in the operating room. The anesthesia team provided a regional block to the left upper extremity in the preoperative holding area. The patient was transferred to the operating room in a supine position on a stretcher. She was then transferred to the operating room table and a belt was placed. All bony prominences were padded. The anesthesia team administered a general anesthesia. The left upper extremity was extended onto an arm table and a well-padded upper arm tourniquet was placed. The operative extremity was subsequently prepped and draped using the standard sterile technique with Betadine. A timeout was performed and all were in agreement. The left upper extremity was exsanguinated with an Esmarch and the tourniquet was inflated to 250 mmHg. We began with the dorsal spanning plate removal. 4 cm longitudinal incision lines were marked over the existing scars. The dorsal forearm and dorsal index metacarpal incisions were opened simultaneously. A #15 blade was used to incise the skin. Blunt section was used to pass down through the subcutaneous tissues. Superficial neurovascular structures were identified and protected. The dissection proceeded to the level of the hardware. A #15 blade was used to divide the scar overlying the hardware and a freer elevator was used to expose the plate. The screws were removed sequentially in the standard fashion and the plate was delivered from the distal wound. We then used a rongeur to smooth the dorsal index finger metacarpal as well as the dorsal radius and remove the soft tissue ingrowth into the recesses of the plate. We then turned our attention to the index finger EIP and EDC tenolysis. These tendons were identified and the adhesions were released using forceps and scissors, taking care to protect the dorsal neurovascular structures as well as the juncturae. We then performed a manipulation under anesthesia for the index and long finger MCP joints. Several cycles of gentle firm pressure were used to regain full passive flexion and extension of all fingers. These wounds were then copiously irrigated. We turned our attention to the volar side. A 6 cm longitudinal incision was marked over the existing scar. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. Significant scar was immediately identified. We proceeded carefully to the level of the FCR tendon. The reconstituted FCR tendon sheath was opened and significant tendon adhesions were noted surrounding the FCR tendon. These were carefully released using forceps and scissors. The FCR tendon was then mobilized and we proceeded the to the level of the pronator quadratus. The quadratus and the overlying scar were divided over the volar plate using a deep #15 blade. A Freer elevator was used to expose the plate and the screws were removed sequentially in the standard fashion. The plate was delivered from the wound. We then used a rongeur to smooth the volar distal radius and remove the soft tissue ingrowth into the recesses of the plate. We then noted significant adhesions to the FPL and FDP to the index finger tendons. These adhesions were also released carefully using forceps and scissors until there was full excursion of both digits. All wounds were copiously irrigated. The tourniquet was released with immediate return of blood flow to the fingertips. A bipolar was used to maintain hemostasis. The subcutaneous tissues were closed with 4-0 Vicryl sutures and the skin was closed with running 4-0 Stratafix sutures. The skin was cleansed and a Dermabond Prineo dressing was placed. This was followed by a bulky sterile dressing, Coban, and an Ace wrap. The procedures were uncomplicated and the counts were correct. The patient tolerated the procedures well and was transferred to the PACU in stable condition.
Grafts/Implants
Explants:
Biomet Crosslock titanium volar distal radius plate and screws
Biomet titanium dorsal spanning plate and screws
The CPT codes billed are 25295/59, LT (2 units), 26445/51,F1, and 26440/F1. I didn't code the removal of hardware or the MUA because that would be included.
Any insight would be greatly appreciated. Thank you!
Postoperative Diagnosis
Left wrist retained hardware (dorsal spanning plate and volar plate), left wrist FCR/FPL/FDP to index finger tendon adhesions, left wrist stiffness, left hand EIP/EPL tendon adhesions, left index and long finger MCP joint stiffness
Operation
1. Left wrist removal of deep hardware: Dorsal spanning plate
2. Left wrist removal of deep hardware: Volar plate
3. Left index finger EIP and EDC tenolysis
4. Left wrist FCR tenolysis
5. Left wrist FPL tenolysis
6. Left wrist FDP to index finger tenolysis
7. Left wrist manipulation under anesthesia
8. Left index finger MCP joint manipulation under anesthesia
8. Left long finger MCP joint manipulation under anesthesia
Findings
Significant tendon adhesions to the EIP/EPL/FCR/FPL/FDP to index finger tendons. Full range of motion of the fingers following manipulation. Wrist extension to 55 degrees and wrist flexion to 55 degrees following manipulation.
Technique
The patient identification, operative sites, and operative procedures were verified with the patient preoperatively in the holding area and again at the safety pause in the operating room. The anesthesia team provided a regional block to the left upper extremity in the preoperative holding area. The patient was transferred to the operating room in a supine position on a stretcher. She was then transferred to the operating room table and a belt was placed. All bony prominences were padded. The anesthesia team administered a general anesthesia. The left upper extremity was extended onto an arm table and a well-padded upper arm tourniquet was placed. The operative extremity was subsequently prepped and draped using the standard sterile technique with Betadine. A timeout was performed and all were in agreement. The left upper extremity was exsanguinated with an Esmarch and the tourniquet was inflated to 250 mmHg. We began with the dorsal spanning plate removal. 4 cm longitudinal incision lines were marked over the existing scars. The dorsal forearm and dorsal index metacarpal incisions were opened simultaneously. A #15 blade was used to incise the skin. Blunt section was used to pass down through the subcutaneous tissues. Superficial neurovascular structures were identified and protected. The dissection proceeded to the level of the hardware. A #15 blade was used to divide the scar overlying the hardware and a freer elevator was used to expose the plate. The screws were removed sequentially in the standard fashion and the plate was delivered from the distal wound. We then used a rongeur to smooth the dorsal index finger metacarpal as well as the dorsal radius and remove the soft tissue ingrowth into the recesses of the plate. We then turned our attention to the index finger EIP and EDC tenolysis. These tendons were identified and the adhesions were released using forceps and scissors, taking care to protect the dorsal neurovascular structures as well as the juncturae. We then performed a manipulation under anesthesia for the index and long finger MCP joints. Several cycles of gentle firm pressure were used to regain full passive flexion and extension of all fingers. These wounds were then copiously irrigated. We turned our attention to the volar side. A 6 cm longitudinal incision was marked over the existing scar. A #15 blade was used to incise the skin. Blunt dissection was used to pass down through the subcutaneous tissues. Significant scar was immediately identified. We proceeded carefully to the level of the FCR tendon. The reconstituted FCR tendon sheath was opened and significant tendon adhesions were noted surrounding the FCR tendon. These were carefully released using forceps and scissors. The FCR tendon was then mobilized and we proceeded the to the level of the pronator quadratus. The quadratus and the overlying scar were divided over the volar plate using a deep #15 blade. A Freer elevator was used to expose the plate and the screws were removed sequentially in the standard fashion. The plate was delivered from the wound. We then used a rongeur to smooth the volar distal radius and remove the soft tissue ingrowth into the recesses of the plate. We then noted significant adhesions to the FPL and FDP to the index finger tendons. These adhesions were also released carefully using forceps and scissors until there was full excursion of both digits. All wounds were copiously irrigated. The tourniquet was released with immediate return of blood flow to the fingertips. A bipolar was used to maintain hemostasis. The subcutaneous tissues were closed with 4-0 Vicryl sutures and the skin was closed with running 4-0 Stratafix sutures. The skin was cleansed and a Dermabond Prineo dressing was placed. This was followed by a bulky sterile dressing, Coban, and an Ace wrap. The procedures were uncomplicated and the counts were correct. The patient tolerated the procedures well and was transferred to the PACU in stable condition.
Grafts/Implants
Explants:
Biomet Crosslock titanium volar distal radius plate and screws
Biomet titanium dorsal spanning plate and screws
