Wiki Need help with CPT code please

micki127

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Hello,

I am not sure what CPT code should be used for the following? Any suggestions please. I attached a portion of the op note.

POSTOPERATIVE DIAGNOSIS:
Right distal biceps joint adhesions and scarring.

PROCEDURES PERFORMED:
1. Wound exploration with right distal biceps tendon tenolysis.
2. External neurolysis of right antebrachial cutaneous nerve.

DESCRIPTION OF PROCEDURE:
The patient was identified correctly and IV access was established. He was given antibiotics IV rider preoperatively. He was brought to the operating theater and appropriate anesthesia was established. The operative extremity was prepped and draped in the usual sterile fashion after a well-padded tourniquet was placed on the proximal arm. The arm was exsanguinated, and the tourniquet was inflated to 250 mmHg. Tourniquet time of the case was less than 1 hour.

The previous incision was extended proximally in extensile fashion. The antecubital vein and antebrachial cutaneous nerve was identified and protected with vessel loops. The nerve was densely adhered to the scar tissue and an external neurolysis was performed. The biceps tendon was found to be thinned and scarred down to the brachialis and there were still fibers of the _____2.40_____ intact which were released. Incision was carried down through into the forearm with care taken to identify and protect neurovascular structures. The tendon was found to be in continuity and was resected down to the incision in the radial tuberosity. There was dense scar tissue in this area but the tendon fibers were found to be intact all the way down into their insertion upon the radial cortical bone. An extensive tenolysis was performed on the biceps tendon circumferentially, proximally and distally. The rest of the arc of motion was found to be intact biceps tendon with lifting of the tendon and normal hook test and with forearm pronation, appropriate excursion of the biceps tendon. So, at this juncture, after careful dissection around the incision again that there were intact fibers all the way down to the radial cortex and that reconstruction was not indicated as it appeared that the tendon was embedded in that scar tissue rather than ruptured. Decision was made to not perform the reconstruction of the tendon and the tendon was left intact. The tourniquet was then released. The wound was irrigated and meticulous hemostasis was obtained. The skin was closed in standard fashion. A sterile dressing was applied. The patient was then awakened and transferred to the recovery room in satisfactory condition.

The patient tolerated the procedures well. There were no intraoperative complications.

At the conclusion of the case, needle and sponge counts were correct.


Thank you in advance!
Micki
 
Micki-I would use 24310 for the tenolysis and 64708 for the external neurolysis. You need to check your encoder to see if they are bundled or not.

Penny
 
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