Question Revision LRTI

[hcrochet]

Patient previously underwent an LRTI, so provider indicated that revision of LRTI was performed. Provider wants to bill 25448. I am wondering if this should just be billed as a tendon transfer since removal of the trapezoid/trapezium was already performed in the initial procedure. Description of procedure below:

An incision was made over the thumb CMC joint and extended into the dorsal radial forearm. This was carried out through the skin with a #15 blade. Littler scissors were utilized to dissect through the soft tissue. The first dorsal compartment was opened. The second most dorsal slip of the abductor pollicis longus was harvested as a distally based graft for later tendon transfer.
A hole was then drilled in the index finger metacarpal utilizing X-ray guidance. This was done with a 3.2 mm drill. The slip of the abductor was then passed across the index finger metacarpal and tied to the extensor carpi radialis longus utilizing 3-0 Supramid and 4-0 Ethibond sutures. X-rays demonstrate good restoration of metacarpal height of the thumb as well as good stability

 

[NRaizman]

1: This is a -shamefully poor- operative note. Someone, hopefully you, should tell your surgeon that he or she is documenting the work -so- poorly that it is leaving money on the table.
2: What your surgeon fails to document is opening up the capsule of the joint to access the base of the second metacarpal, confirming the loss of prior fixation, any debridement of the joint, any excision of scar tissue, any closure of the capsule. Any documentation of ANY of this would be sufficient for 25448, and GOOD documentation of difficulty and working through scar tissue and an altered surgical field due to revision would qualify you for a -22 modifier as well.

In this case, you are correct that the only thing -documented at current- is 26480.
However, I would ask your surgeon to addend or redictate the operative report in a more adequate way to qualify for 25448+22, which is what -should- have been coded for this procedure, but can't because of the inadequate documentation.

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