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Thread: forearm and manipulation?

  1. #1
    Join Date
    Apr 2007
    Pensacola , Florida

    Default forearm and manipulation?

    AAPC: Back to School
    There is a lot to this one ... I am stumped fer sure'

    First question is two different docs did sx on this patient on the same day in the same facility - I have not ever dealt with this before ...is this going to cause problems getting paid ... i seem to remember somewhere that this cannot be done ? Am I wrong ? Please advise ...

    On this first one ... I don't even see a procedure in his notes ...I have some trouble when ?? these so I need some guns ...thanks!


    DESCRIPTION OF PROCEDURE: After discussion thoroughly about what we thought might be going on with him and getting consent, we took him into the fluoroscopy suite, placed him supine. He was Betadine scrubbed. His neck numbed with 2% lidocaine using the fluoroscope to identify the transverse process at C6. When I saw that I dropped down a 3.5-inch 25-gauge spinal needle to the transverse process withdrew a little back, ended up putting an 8 cc of 0.25% ropivacaine plus 40 mg of Kenalog in very small aliquots, checking frequently for blood and CSF making sure each aspiration was normal. I went ahead and put in the full 8 cc in. He tolerated the procedure overall very well. The pain immediately started to drop. He was able to move a little bit better after the block. He will be sent on to Bloomington Bone and Joint for physical therapy.

    IMPRESSION/PLAN: The patient is a 60-year-old white male with injury to the radius and ulna, left arm. We got a good stellate ganglion block on him today. We are going to move him. He has had a lot of burning pain at bedtime and I gave him some Neurontin to start to see how he tolerates that, maintain physical therapy in controlling of his pain as best as possible. He understands all these things. We will see him back. He can call me in a few days to let me how things are going. I will be glad to block him again if needed but hopefully he will be able to move forward with movement of the extremity.

    1. Contracture, left forearm distal radial ulnar
    2. Median neuropathy, left wrist.
    3. Complex regional pain syndrome.

    1. Limited left open carpal tunnel release.
    2. Manipulation of left forearm.

    OPERATIVE PROCEDURE: The patient was brought to the operating room and placed in the supine position. The extremity was sterilely prepped and draped in a normal fashion with DuraPrep. The arm was elevated and exsanguinated and the tourniquet above the brachium elevated to 250 mmHg. A carpal tunnel was blocked with 0.5% Marcaine and 1% lidocaine for postoperative pain control. A longitudinal incision was made in the palm in line with the radial border of the fourth ray. The sharp dissection was carried down through the skin and subcutaneous tissues. The palmar fascia was split under direct visualization in line with the skin incision. The distal extent of the transverse carpal ligament was identified by outpouching the fascia just proximal to the palmar arch and release completely at this level. At this point, the dilators from the security clip were placed starting with a #1, #2, and #3 pilot in a proximal and ulnarward direction. Once the ligament was isolated, curved Littler scissors were then passed up the ligament while the nerve was well protected posteriorly. After complete release of the transverse carpal ligament, the #1 pilot was then reintroduced to ensure there was complete release of the ligament from the level of the palmar fat into the forearm fascia. The carpal tunnel release once completed, the median nerve was quite hyperemic. There appeared to be diffuse scarring within the flexor tendons of the finger. After release of the carpal tunnel, we manipulated all digits and there appeared to be early fibrosis in the muscles of the forearm. The joint themselves were supple. After manipulation of the hand, we then manipulated the forearm. We were able to fully passively pronate and supinate the wrist. There was no crepitation at the distal ulna and radiographs obtained during the manipulation demonstrate no acute fracture and no loss of reduction from the wrist fracture. At this point, the carpal tunnel wound was closed. The 4-0 Prolene dry dressing splint was applied. The patient was transferred to the recovery room in stable condition.

    64721 354.0

    Thank you for you help !

  2. #2
    Join Date
    Apr 2007


    the issue of two seperate docs is not a problem. You will just code and bill each case seperately.

    NOW for those notes

    The first note APPEARS to be a stellate block.

    The second one...well I would burn it...lol just kidding.
    Carpal tunnel is well documented..so ok to 64721.

    The manipulation however is garbage (pardon my slang attitude today)...He states he manipulated all joints in the hand. Thats not going to get it. He needs to be more specific because the manipulation codes the the hand (IP joints) are for each joint which is potentially 15 codes (IP,PIP,DIP x 5 fingers..but good luck getting them all paid). I dont get the manipulation of the forearm...did he just massage the arm? there is nothing the forearm itself to manipulate, it had to be either at the elbow or the wrist...not somewhere in between. If its the wrist, then its probably going to bundle with the carpal tunnel, but you can check the CCI Edits.

    Good Luck!!
    Mary, CPC,COSC

  3. #3
    Join Date
    Apr 2007
    Pensacola , Florida


    Mary thanks so much for your insight !!
    and for giving me a great morning laugh ! I so agree

    Really, thank you so much !!

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