Answer Radial Shaft Fracture w/ Galeazzi Variant CPT

cclarson

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Hello Everyone, I wasn't sure whether this particular instance is better described as 25515 or 22525. No percutaneous fixation was performed so I'm not sure if 25525 qualifies, but there is a Galeazzi variant. Let me know what you think. Also, I'm coding the dx as a Galeazzi Fracture: S52.371A, would that be correct?

POSTOPERATIVE DIAGNOSIS:
Displaced right radial shaft fracture with Galeazzi variant.

OPERATION PERFORMED:

Open reduction and internal fixation right radial shaft fracture (Acumed).

INDICATIONS FOR PROCEDURE:
The patient is a 16-year-old male who injured his right arm in a football game last weekend. He is taken to the operating room today for surgical stabilization of his forearm. I have discussed the surgery with him and his mother. They understand and would like to proceed.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed in the supine position on the operating table. General anesthesia was administered without complication. The right upper extremity was prepped and draped in the usual sterile manner. The tourniquet was inflated to 250 mmHg pressure.

Standard anterior Henry approach was made to the right radial shaft. Dissection was carried down through the skin and subcutaneous tissues. Skin flaps were developed. The radial artery was identified and protected. The FCR fascia was opened and the radius was carefully exposed. Some of the FPL was released off of the radius so that the fracture in the shaft could be exposed. The fracture was reduced, held in a reduced position and an Acumed volar forearm plate was applied. Its position was checked with fluoroscopy and felt to be acceptable. A screw was placed proximally and distally and again positions all checked and felt to be acceptable. Multiple screws were placed above and below the fracture. Overall good reduction of the fracture and hardware was obtained. Final fluoroscopic images were taken and saved. The ulnar side looked good. The DRUJ was stable.

The wound was washed out vigorously. Skin closed with 4-0 Monocryl sutures, followed by Benzoin, Steri-Strips, 4x4s, Sof-Rol, and a well-padded sugar tong splint.
 

Orthocoderpgu

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There is no documentation that the DRUJ was reduced, so I would exclude 25525 from consideration. However you may want to query the physician and double check if the DRUJ was reduced or not. If yes and it's documented 25525 would be correct. As documented now 25515.
 

cclarson

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There is no documentation that the DRUJ was reduced, so I would exclude 25525 from consideration. However you may want to query the physician and double check if the DRUJ was reduced or not. If yes and it's documented 25525 would be correct. As documented now 25515.
That's what I thought, thank you. :)
 
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