Wiki Radical Resection Help

Thomasville, NC
Best answers

I am coding for an orthopedic oncologist that has performed a radical resection of a soft tissue sarcoma located in the right forearm that I am needing some advice on. The surgeon resected the sarcoma as well as part of the ulna that was underneath the sarcoma. My first thought was to code this as CPT 25078 (over 3 cm) but I am wondering if CPT 25170 is more appropriate due to a portion of bone being taken out or should i code the bone removal separately? He also performed an ORIF of the proximal ulna that i have coded as 24685. The surgeon wants to bill for an allograft due to the gap in the ulna after the resection, can i bill separately for the allograft? The operative note shows :

1. Radical resection of soft tissue sarcoma right forearm
2. En bloc resection of cortical bone from right ulna
3. Open reduction internal fixation right ulna with bone graft
4. Bone graft right ulna

The patient was brought to the operating room and after establishing adequate general endotracheal anesthesia the patient was placed in the left lateral decubitus position and appropriately padded and the right arm was prepped and draped in a sterile fashion with a tourniquet in place in the upper arm. The arm was prepped free so as to allow for maximum mobility. We first addressed the volar aspect of the forearm where the palpable tumor was evident and was marked out on the skin with a skin marker. A generous 3 cm margin was marked out circumferentially around the palpable tumor and marked on the skin. The tumor measured approximately 3 x 4 cm and the defect after excision measured 10-1/2 x 11 cm. No local anesthetic was used due to the preoperative nerve block. A skin incision was made in the skin with a tourniquet inflated in a circumferential fashion and taken down through the subcutaneous tissues. All bleeding was controlled with electrocautery. We dissected down through the subcutaneous tissues and fatty tissues down to the underlying muscular fascia in a circumferential fashion. We then dissected through the muscular fascia into the muscle in a circumferential fashion staying widely away from the palpable tumor. Proximally and distally this dissection quickly took us down onto the ulna and then dorsally down through the musculature and down towards the lower deeper portion of the ulna. On the volar surface a similar dissection continued through the muscular tissue down onto the deeper portion of the ulna affecting a wide radical resection of the entire area.

We then addressed the ulna and created osteotomies in the ulna using a drilling device along the distal margin and then on the dorsal surface along the dorsal margin and then along the proximal margin and then again down on the volar surface of the ulna in order to take an en bloc resection of the cortical surface of the ulna only with the specimen. The screw holes were connected using the drilling device and then using an osteotome and mallet the fragment of cortical bone was elevated up and off of the underlying ulna attached to the specimen and the specimen was then removed affecting an en bloc radical resection with attached ulna on the deep margin. The specimen was oriented with a long suture on the volar surface and a short suture proximally and sent for permanent section.

Next after ensuring hemostasis and irrigating with normal saline a fibular bone strut was fabricated with a saw to fit in the defect and then was screwed in place with 4 screws.

Any advice help is greatly appreciated!!

Tiffany B, CPC-A
I would bill them separately, it looks like he removed the tumor, then removed a portion of the bone. So after looking at the NCCI edits on medicare, I am showing 24685, 25170, 25078-XS