Can anyone help me with the coding of this one. Surgeon's office precerted 25628, another coder saying 25624 and I feel better with the unlisted 25999.
The patient and the surgeon marked the operative site. The patient was administered perioperative antibiotics. The patient was taken to the operating room and appropriate timeouts were taken. The patient was administered general anesthesia. The right upper extremity was sterilely prepped and draped. The extremity was exsanguinated and tourniquet was inflated. Landmarks were palpated and with fluoroscopic assistance a guidewire was placed in the scaphoid. The initial guidewire was not in optimum position so a second guidewire was placed and its position was felt to be quite good based on multiple orthogonal views with fluoroscopy. Guidewire was then measured. It was overdrilled and an 18 mm x 3.5 mm variable pitch Arthrex cannulated screw was placed with excellent purchase and compression. The guidewire was removed. Fluoroscopy confirmed good position of the screw and good compression at the fracture. The small stab wound was irrigated and closed. It was injected with Marcaine. Dressing and a splint were applied. The tourniquet was released. The patient was taken to the recovery room in stable condition. She tolerated the procedure well. There were no complications. There were no specimens. Findings included a stable fracture. Fluoroscopic images taken during the case confirmed good reduction of the fracture, good position of the screw
The patient and the surgeon marked the operative site. The patient was administered perioperative antibiotics. The patient was taken to the operating room and appropriate timeouts were taken. The patient was administered general anesthesia. The right upper extremity was sterilely prepped and draped. The extremity was exsanguinated and tourniquet was inflated. Landmarks were palpated and with fluoroscopic assistance a guidewire was placed in the scaphoid. The initial guidewire was not in optimum position so a second guidewire was placed and its position was felt to be quite good based on multiple orthogonal views with fluoroscopy. Guidewire was then measured. It was overdrilled and an 18 mm x 3.5 mm variable pitch Arthrex cannulated screw was placed with excellent purchase and compression. The guidewire was removed. Fluoroscopy confirmed good position of the screw and good compression at the fracture. The small stab wound was irrigated and closed. It was injected with Marcaine. Dressing and a splint were applied. The tourniquet was released. The patient was taken to the recovery room in stable condition. She tolerated the procedure well. There were no complications. There were no specimens. Findings included a stable fracture. Fluoroscopic images taken during the case confirmed good reduction of the fracture, good position of the screw