nerver repair with wound exploration 64910 20103


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Physician wants to bill for nerve repair (64910) and wound exploration (20103) for this note. I feel as though the procedure started out as an exploration and FB removal but since he found a nerve that was lacerated and repaired that he should only bill for the nerve repair. The do not CCI out but I still don't feel right billing for both. Thoughts?

I first turned my attention to gently wrapping Esmarch around the hand and inflating the tourniquet to 200 mmHg. The more central portion of the wound was explored with a hemostat. A section of glass was quickly encountered, which was quite wide. An incision was made through skin and subcutaneous tissue at the level of the original injury down to fascia. This was spread bluntly and it demonstrated both a laceration of the radial artery in its entirety as well as laceration of a large nerve structure on the radial side, suprafascial, likely the lateral antebrachial cutaneous nerve. Upon dissecting further down through the fascia, the proximal portion of large piece of glass was encountered and this was removed with a tenotomy, found to be ab 7 cm in length and about 1 cm in total width. A small amount of granulation tissue without any obvious purulence was removed from the tunnel. This was thoroughly irrigated. A skin flap was then raised on the radial surface of this and both the proximal and distal ends of the lateral antebrachial cutaneous nerve were encountered. The central portions were significantly scarred and damaged and it could not be easily repaired without any due tension. Because of that, an interposition 1.5 mm X 1.5 cm nerve conduit was placed with a maximum gap of the nerve ends of approximately 1 cm. Each of the nerves were tucked within the nerve conduit and sutured in place with a 2 interrupted mattress 8-0 nylon sutures through the epineurium. A small skin flap was made on the radial service and this conduit was buried away from the wound so as not to create an infectious source. Packing was then placed into the wound itself, 1/2 inch iodoform gauze. It was left out through the wound. The tourniquet was then let down. Adequate hemostasis was obtained and the remainder of the incision was closed with interrupted nylon mattress sutures. Gauze and and ace bandage were placed at the end of the case. The patient was awoken from anesthesia without complication.

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