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How to code a non-union

jdibble

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Daytona Beach, FL
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I need some help in coding this surgery correctly. All help would be appreciated!

PREOPERATIVE DIAGNOSIS: Left humerus fracture delayed union with soft tissue interposition.

POSTOPERATIVE DIAGNOSIS: Left humerus fracture delayed union with soft tissue interposition.

OPERATION: Left humeral nail intramedullary fixation with open bone grafting
left humeral shaft delayed union with soft tissue interposition.


DESCRIPTION OF PROCEDURE: The patient was brought to the operative theater and placed supine upon the operating table. After satisfactory general endotracheal anesthesia was administered, a time-out was carried out confirming the operative site with the operative consent. The patient was brought to the semi beach chair position and a roll was placed between the shoulders. The C-arm was brought in to visualize the fracture in AP and lateral views. Once this was satisfactory, the left upper extremity was then prepped and draped in the usual meticulous sterile fashion for shoulder and upper extremity exploration. After meticulous sterile prepping and draping, an initial incision was then made obliquely from the anterolateral tip of the acromion approximately 2 cm in length and taken through subcutaneous tissue sharply. The deltoid muscle was split in the anterior middle raphe an the rotator cuff was identified. This was incised and split, allowing access to the proximal humerus, proximal to the greater tuberosity. This was then entered with a T-handled cannulated awl and a beaded-tip guidewire was then passed through the proximal fragment down to the level of the fracture site. At this point, an incision was then made just lateral to the biceps muscle and internervous plane and taken through subcutaneous tissues sharply. The incision was carried proximally to a deltopectoral position and dissection down to the bone was then accomplished using sharp and blunt dissection. The fracture site was significantly scarred with much soft tissue interposition and scarring that had to be taken down with care to protect the radial nerve. The end of the proximal fragment was identified and the beaded-tip guidewire end was utilized to pursue the proximal fragment. The proximal end of the distal fragment was then dissected and the intramedullary canal identified. With the scar tissue having been dissected and elevated, the beaded-tip guidewire was passed through the proximal end of the distal fragment and down to the level of the _______ spread of the humerus. This was then sequentially reamed to 8.5 mm. C-arm fluoroscopy was brought in to evaluate the reaming process to ensure that reaming was not eccentric. With the intramedullary canal having been reamed, a 7 mm x 22.5 cm AOS humeral nail was then brought through the proximal fragment, across the fracture site and distally. Excellent purchase of the distal fragment and the isthmus was noted. The impaction had reduced the fracture to near anatomic position. The wound was irrigated and then, utilizing decalcified cancellous bone graft, croutons were then placed into the fracture site. The wound was then closed with 0 and 2-0 Vicryl for the subcutaneous tissue and the skin reapproximated with subcuticular closure with 3-0 Prolene. Proximal wound was closed with the rotator cuff repaired with 0 Vicryl, the subcutaneous tissue closed with 2-0 Vicryl and the skin closed with subcuticular 3-0 Prolene. The wounds were then dressed with Xeroform and 4 x 4's. Throughout the case the C-arm was utilized to ensure that the fracture reduction was maintained and that no rotation occurred. The alignment of the forearm distal and proximal fragments was maintained throughout the case. The patient was returned to recovery, having tolerated the procedure well. Estimated blood loss was 150 mL.

I am not sure if this should be coded with 24516 or if I need to use the non-union codes of 24430 or 24435. I am confused on these codes since 24430 is without a graft, but he did an allograft and 24435 is with an autograft - not what he did! Is there another code that I am missing, or is it OK to code the ORIF code for a non-union.

I am totally confused and after researching this and not finding an answer, I am even more confused!! :)

Thanks for any help!
 
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Greetings and Salutations! I would code 24430 since the diagnosis is nonunion of a fracture. (24516 is treatment of an acute fracture and would require an "8" code and a date of injury). The reason why 24435 would not work is because it is including harvesting of an autograft (comes from the patient through a separate incision). In your scenario, the doc used allograft (does not come from the patient). When a doctor uses allograft, the allograft is provided by the hospital or surgery center. (In this case, it was cancellous bone croutons.) Since they buy it, they charge the patient for it. The only instance that I see where the physician can charge for allograft is when doing spine surgery (CPT codes 20930 & 20931). Hope this helps!
 
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