Hi, I would appreciate any input in the codes to use for this surgery - provider is trying to bill 25263 and 25130, but I do not think those codes are correct. I'm thinking 25295 for the tenolysis of the flexor carpi radialis tendon, but am totally lost with the debridement of the scaphoid and trapezium. TIA
PREOPERATIVE DIAGNOSIS:
1. Right wrist flexor carpi radialis tenosynovitis.
2. Right scaphoid nonunion of tuberosity.
POSTOPERATIVE DIAGNOSIS:
PROCEDURE:
1. Debridement right flexor carpi radialis tendon of distal forearm through the flexor carpi radialis tunnel at the level of the wrist.
2. Debridement of 55% attritional rupture of flexor carpi radialis tendon at level of the wrist to stable margins.
3. Excision of scaphoid tuberosity nonunion.
4. Debridement and partial excision of scaphoid tuberosity as well as trapezium to smooth margins.
SPECIMENS:
1. Excised nonunion sent for pathology.
2. Culture swabs were obtained of the surgical site.
COMPLICATIONS: None.
DISPOSITION: The patient was stable throughout the procedure.
OPERATIVE INDICATIONS: The patient is a very pleasant 36-year-old gentleman with persistent, recalcitrant volar radial wrist pain and swelling. MRI was consistent with tenosynovitis involving the flexor carpi radialis as well as increased signal within the distal scaphoid tuberosity consistent with probable nonunion of scaphoid tuberosity and tenosynovitis of the flexor carpi radialis tendon. After failing conservative management, he wished to proceed with surgical intervention. Risks, benefits, alternatives, complications were reviewed with him in detail. These included, but were not limited to the risk of infection; damage to nerves, vessels, tendons; failure to improve symptoms; worsening of symptoms; progressive symptoms; possible need for additional surgery; therapy and unforeseen complications. He understood and wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified in the holding area. The right wrist was identified as surgical site, was seen by Anesthesia, taken to the operating room and placed supine on the operating room table, underwent general anesthesia per Anesthesia department. All bony prominences were well-padded. A well-padded arm tourniquet was placed. The right upper extremity was prepped and draped in sterile fashion. Arm was exsanguinated, tourniquet inflated to 250 mmHg. Total tourniquet time was approximately one-half hour.
An incision was then created over the FCR tendon distally in the distal wrist, extended obliquely in a short oblique fashion across the volar radial aspect of the carpus, centered over the scaphoid tuberosity. Dissection was performed proximally to identify the flexor carpi radialis tendon, was mobilized distally. The palmar branch of the radial artery was suture ligated and released. The palmar cutaneous branch of the median nerve was identified just medial to the flexor carpi radialis sheath and preserved in the palmar flap. The release was taken through the flexor carpi radialis sheath distally. At this level, abundant amount of tenosynovitis was present, immediately encountered partial rupture of the flexor carpi radialis tendon. Tenolysis of the flexor carpi radialis was performed proximally to the level of the myotendinous origin, extended distally in the flexor carpi radialis tunnel. The flexor carpi radialis tendon was fully mobilized with the tunnel isolating the extent of the tendinous injury with wrist flexion. Estimated zone of injury was estimated at 50% to 60% of the tendon. Tendon was debrided to smooth margins. The tendon was retracted ulnarly. 25295
Attention directed toward the scaphoid tuberosity which was quite prominent and also prominence of the trapezium distally. The scaphoid tuberosity was isolated with an osteotome, and osteotome was used to remove the scaphoid tuberosity which was sent for pathology. A rongeur was then used to smooth scaphoid osteotomy site to smooth margins. There was prominence of the trapezium distally. In similar fashion, osteotome was used to smooth the trapezium distally in line with the osteotomy of the scaphoid tuberosity. A rongeur was used to smooth the margins down nicely. Bone wax was then applied.
Fluoroscopy was then brought in. AP, lateral, and multiple obliques under fluoroscopy were used to confirm removal of the scaphoid tuberosity. There was good stability to the remaining carpus.
The wound was thoroughly and copiously irrigated out. Bone wax was placed over the exposed bony surfaces. The flexor carpi radialis tendon was then placed back into the tunnel, was found to have no residual entrapment. The radioscaphocapitate ligament was visualized and preserved. Tourniquet was deflated. Meticulous hemostasis achieved with bipolar cautery. Local anesthetic infiltrated in soft tissues. Skin closed with nylon suture followed by a protective volar splint.
PREOPERATIVE DIAGNOSIS:
1. Right wrist flexor carpi radialis tenosynovitis.
2. Right scaphoid nonunion of tuberosity.
POSTOPERATIVE DIAGNOSIS:
PROCEDURE:
1. Debridement right flexor carpi radialis tendon of distal forearm through the flexor carpi radialis tunnel at the level of the wrist.
2. Debridement of 55% attritional rupture of flexor carpi radialis tendon at level of the wrist to stable margins.
3. Excision of scaphoid tuberosity nonunion.
4. Debridement and partial excision of scaphoid tuberosity as well as trapezium to smooth margins.
SPECIMENS:
1. Excised nonunion sent for pathology.
2. Culture swabs were obtained of the surgical site.
COMPLICATIONS: None.
DISPOSITION: The patient was stable throughout the procedure.
OPERATIVE INDICATIONS: The patient is a very pleasant 36-year-old gentleman with persistent, recalcitrant volar radial wrist pain and swelling. MRI was consistent with tenosynovitis involving the flexor carpi radialis as well as increased signal within the distal scaphoid tuberosity consistent with probable nonunion of scaphoid tuberosity and tenosynovitis of the flexor carpi radialis tendon. After failing conservative management, he wished to proceed with surgical intervention. Risks, benefits, alternatives, complications were reviewed with him in detail. These included, but were not limited to the risk of infection; damage to nerves, vessels, tendons; failure to improve symptoms; worsening of symptoms; progressive symptoms; possible need for additional surgery; therapy and unforeseen complications. He understood and wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified in the holding area. The right wrist was identified as surgical site, was seen by Anesthesia, taken to the operating room and placed supine on the operating room table, underwent general anesthesia per Anesthesia department. All bony prominences were well-padded. A well-padded arm tourniquet was placed. The right upper extremity was prepped and draped in sterile fashion. Arm was exsanguinated, tourniquet inflated to 250 mmHg. Total tourniquet time was approximately one-half hour.
An incision was then created over the FCR tendon distally in the distal wrist, extended obliquely in a short oblique fashion across the volar radial aspect of the carpus, centered over the scaphoid tuberosity. Dissection was performed proximally to identify the flexor carpi radialis tendon, was mobilized distally. The palmar branch of the radial artery was suture ligated and released. The palmar cutaneous branch of the median nerve was identified just medial to the flexor carpi radialis sheath and preserved in the palmar flap. The release was taken through the flexor carpi radialis sheath distally. At this level, abundant amount of tenosynovitis was present, immediately encountered partial rupture of the flexor carpi radialis tendon. Tenolysis of the flexor carpi radialis was performed proximally to the level of the myotendinous origin, extended distally in the flexor carpi radialis tunnel. The flexor carpi radialis tendon was fully mobilized with the tunnel isolating the extent of the tendinous injury with wrist flexion. Estimated zone of injury was estimated at 50% to 60% of the tendon. Tendon was debrided to smooth margins. The tendon was retracted ulnarly. 25295
Attention directed toward the scaphoid tuberosity which was quite prominent and also prominence of the trapezium distally. The scaphoid tuberosity was isolated with an osteotome, and osteotome was used to remove the scaphoid tuberosity which was sent for pathology. A rongeur was then used to smooth scaphoid osteotomy site to smooth margins. There was prominence of the trapezium distally. In similar fashion, osteotome was used to smooth the trapezium distally in line with the osteotomy of the scaphoid tuberosity. A rongeur was used to smooth the margins down nicely. Bone wax was then applied.
Fluoroscopy was then brought in. AP, lateral, and multiple obliques under fluoroscopy were used to confirm removal of the scaphoid tuberosity. There was good stability to the remaining carpus.
The wound was thoroughly and copiously irrigated out. Bone wax was placed over the exposed bony surfaces. The flexor carpi radialis tendon was then placed back into the tunnel, was found to have no residual entrapment. The radioscaphocapitate ligament was visualized and preserved. Tourniquet was deflated. Meticulous hemostasis achieved with bipolar cautery. Local anesthetic infiltrated in soft tissues. Skin closed with nylon suture followed by a protective volar splint.