kmuth
Contributor
I want to code 64718, 64719, and 69990, but my doc wants another CPT code for the anterior interosseous nerve transfer. Isn't it included or am I missing another code?
1.Right cubital tunnel release with anterior subcutaneous transposition of the
ulnar nerve.
2. Decompression of ulnar nerve and Guyon canal with anterior interosseous
nerve to motor branch of ulnar nerve transfer.
INDICATION:
history of severe right cubital tunnel
syndrome. He presents at this time for right cubital tunnel release with
transposition as well as anterior interosseous nerve transfer to the motor
branch of the ulnar nerve.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room on 01/04/2022, where he was first
given a block anesthetic. Next, his forearm, arm, and hand were prepped and
draped in normal sterile fashion. Next, after the appropriate time-out, his
right arm was elevated, exsanguinated with an Esmarch bandage and tourniquet
inflated to 250 mmHg. Next, incision was made in his distal arm and proximal
forearm with a 15 blade. Next, pickups and tenotomy scissors were used to
dissect through the subcutaneous tissue down to the brachial and antebrachial
fascia. Cutaneous nerves were identified and preserved throughout the entire
operation. Next, I identified the ulnar nerve just proximal to the medial
epicondyle, located there it and traced it proximally first, releasing the
brachial fascia. I removed the medial intermuscular septum. Next, I traced
the nerve distally into the flexor carpi ulnaris muscle. Care was taken not to
injure the branches to the FCU or to the FDP. Once the nerve was mobilized, I
could see that the nerve did have an area of constriction just distal to the
medial epicondyle and I suspect that this is where the problem with the nerve
was. I next designed a fascial flap based on the medial epicondyle, elevated
that flap and then placed the nerve beneath that flap and then sewed that flap
back down to where I harvested the flap from using interrupted 4-0 Vicryl. I
made sure the nerve was not kinked and glided nicely and the flap was not too
tight. Once that was done, I irrigated this wound, closed it with interrupted
4-0 Vicryl and staples in the skin.
Attention was then directed toward the nerve transfer. An incision was made
from the mid palm to the mid forearm. Skin was dissected. Subcutaneous tissue
dissected. Care was taken not to injure the cutaneous nerves. I identified
the ulnar nerve at the wrist, traced it proximally and distally. I traced it
distally so that I could find the motor branch. In order to do that, I had to
release the hypothenar muscle origin on the hook of the hamate. Once that was
done, I could see the motor branch. I then traced the motor branch proximally
to the mid forearm, so that I could identify the fascicular grouping
orientation. In the mid forearm, I could also see the origin of the dorsal
cutaneous branch of the ulnar nerve. Next, I identified the pronator quadratus
and could locate its proximal margin and could see the nerve to the pronator
quadratus in this area. I then divided the fibers of the pronator quadratus
about 50% distally. I then transected the nerve in this area and then brought
the microscope into the field. I then identified topographically where the
fascicular grouping of the motor branch that I could trace from distally to
proximal was and after making an epineural window, sewed the motor branch
end-to-side to the fascicular grouping of the motor branch. This was done with
interrupted 9-0 Ethilon suture on a BV 130 micrometer needle under the
microscope. was then used to reinforce this repair. I also used
theon the raw area of the pronator quadratus. Next, I then
irrigated the wound with copious amounts of saline and closed the incision with
interrupted 4-0 Vicryl and running 5-0 nylon in skin. Tourniquet was then
released. The patient was then placed in a dressing and splint. He tolerated
the procedure well and was sent to discharge area in stable condition. Total
tourniquet time was 1 hour and 58 minutes.
1.Right cubital tunnel release with anterior subcutaneous transposition of the
ulnar nerve.
2. Decompression of ulnar nerve and Guyon canal with anterior interosseous
nerve to motor branch of ulnar nerve transfer.
INDICATION:
history of severe right cubital tunnel
syndrome. He presents at this time for right cubital tunnel release with
transposition as well as anterior interosseous nerve transfer to the motor
branch of the ulnar nerve.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room on 01/04/2022, where he was first
given a block anesthetic. Next, his forearm, arm, and hand were prepped and
draped in normal sterile fashion. Next, after the appropriate time-out, his
right arm was elevated, exsanguinated with an Esmarch bandage and tourniquet
inflated to 250 mmHg. Next, incision was made in his distal arm and proximal
forearm with a 15 blade. Next, pickups and tenotomy scissors were used to
dissect through the subcutaneous tissue down to the brachial and antebrachial
fascia. Cutaneous nerves were identified and preserved throughout the entire
operation. Next, I identified the ulnar nerve just proximal to the medial
epicondyle, located there it and traced it proximally first, releasing the
brachial fascia. I removed the medial intermuscular septum. Next, I traced
the nerve distally into the flexor carpi ulnaris muscle. Care was taken not to
injure the branches to the FCU or to the FDP. Once the nerve was mobilized, I
could see that the nerve did have an area of constriction just distal to the
medial epicondyle and I suspect that this is where the problem with the nerve
was. I next designed a fascial flap based on the medial epicondyle, elevated
that flap and then placed the nerve beneath that flap and then sewed that flap
back down to where I harvested the flap from using interrupted 4-0 Vicryl. I
made sure the nerve was not kinked and glided nicely and the flap was not too
tight. Once that was done, I irrigated this wound, closed it with interrupted
4-0 Vicryl and staples in the skin.
Attention was then directed toward the nerve transfer. An incision was made
from the mid palm to the mid forearm. Skin was dissected. Subcutaneous tissue
dissected. Care was taken not to injure the cutaneous nerves. I identified
the ulnar nerve at the wrist, traced it proximally and distally. I traced it
distally so that I could find the motor branch. In order to do that, I had to
release the hypothenar muscle origin on the hook of the hamate. Once that was
done, I could see the motor branch. I then traced the motor branch proximally
to the mid forearm, so that I could identify the fascicular grouping
orientation. In the mid forearm, I could also see the origin of the dorsal
cutaneous branch of the ulnar nerve. Next, I identified the pronator quadratus
and could locate its proximal margin and could see the nerve to the pronator
quadratus in this area. I then divided the fibers of the pronator quadratus
about 50% distally. I then transected the nerve in this area and then brought
the microscope into the field. I then identified topographically where the
fascicular grouping of the motor branch that I could trace from distally to
proximal was and after making an epineural window, sewed the motor branch
end-to-side to the fascicular grouping of the motor branch. This was done with
interrupted 9-0 Ethilon suture on a BV 130 micrometer needle under the
microscope. was then used to reinforce this repair. I also used
theon the raw area of the pronator quadratus. Next, I then
irrigated the wound with copious amounts of saline and closed the incision with
interrupted 4-0 Vicryl and running 5-0 nylon in skin. Tourniquet was then
released. The patient was then placed in a dressing and splint. He tolerated
the procedure well and was sent to discharge area in stable condition. Total
tourniquet time was 1 hour and 58 minutes.