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ORIF radial FX

  1. Default ORIF radial FX
    Medical Coding Books
    Hello,
    Would you code the following report as: 25515-RT DX: 813.21

    Post and pre DX: Radius and ulnar shaft FX forearm
    Name of Operation: ORIF RT radial FX

    An anterior volar approach was used for the radial FX, and dissection was made through the SUB Q tissue, with the incision just radial to the flexor carpi radialis tendon and then dissection made through the sub Q tissue. Care was taken to retract and protect the radial artery and the superficial branch of the radial nerve. The FX was then easily identified and was exposed, and the flexor muscles were retracted ulnarward. Then,the FX was manipulated to an anatomic reduction and then while it was held reduced, it was transfixed with a 5 hole DCP plate, with 2 holes distally and 3 holes proximal to the FX. This afforded rigid fixation. At that point, the image intensifier was used to determine the reduction, and it was anatomic ( incomplete) and in fact, the ulnar FX was completely unreduced and was even not visible on the image intensifier. Since there was no separation and no displacement and the FX appeared to be quite stable on the ulnar side, it was not approached.

    Thanks!

  2. #2
    Location
    San Antonio, Tx
    Posts
    73
    Default
    I would use 25574 since you state that you have a Radius AND Ulnar FX and because the Ulnar was not approached. 25515 is for trearment of the Radius only. Dx should also be 813.33.



    Post and pre DX: Radius and ulnar shaft FX forearm
    Name of Operation: ORIF RT radial FX

    An anterior volar approach was used for the radial FX, and dissection was made through the SUB Q tissue, with the incision just radial to the flexor carpi radialis tendon and then dissection made through the sub Q tissue. Care was taken to retract and protect the radial artery and the superficial branch of the radial nerve. The FX was then easily identified and was exposed, and the flexor muscles were retracted ulnarward. Then,the FX was manipulated to an anatomic reduction and then while it was held reduced, it was transfixed with a 5 hole DCP plate, with 2 holes distally and 3 holes proximal to the FX. This afforded rigid fixation. At that point, the image intensifier was used to determine the reduction, and it was anatomic ( incomplete) and in fact, the ulnar FX was completely unreduced and was even not visible on the image intensifier. Since there was no separation and no displacement and the FX appeared to be quite stable on the ulnar side, it was not approached.
    Ray Galvez CPC

  3. #3
    Default
    How do you know it's an open FX (813.33)? 813.23 is Dx for closed Fx.

  4. #4
    Location
    San Antonio, Tx
    Posts
    73
    Default
    Then use the 813.23 if it is a closed Fx.
    Ray Galvez CPC

  5. Default reply
    Thanks! I was going to initially use 25574, but was uncertain if the ulnar was reduced as well.

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