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CMC Joint Arthroplasty 25447

Camille Posted Thu 16th of January, 2020 13:46:53 PM
During Rt thumb CMC joint arthroplasty (CPT 25447), BUT thru a separate incision at the wrist, the surgeon performs FCR Tendon Transplant/Transfer (25310), EPB Tenodesis (25300), and APL Advancement (25280). I realize there isn't a bundling edit, but are these 3 subsequent procedures performed at a separate incision in the wrist included in CPT 25447-therefore not separately billable? Thank you!
SuperCoder Answered Fri 17th of January, 2020 05:55:39 AM

Hi Camille,

Arthroplasty of the intercarpal or carpometacarpal joint generally involves a ligament reconstruction and tendon interposition (LRTI) or Burton LRTI, a procedure in which the surgeon inserts a prosthesis or tendon tissue graft in a joint to reconstruct the joint and restore mobility of the joint. The surgery is primarily performed in a patient suffering from degenerative arthritis, traumatic injury, or infection.

Before the procedure the physician administers anesthesia. A dorsoradial incision is made along the line of first metacarpal joint and extended medially to the palm. The radial artery is dissected out carefully and protected to avoid injury. The capsule over the trapezium is opened up, and the thenar muscles are elevated from the trapezium and the first metacarpal (MC). The MC at the base of the thumb is then excised with a power saw. The interval between the slips of the abductor pollicis longus (APL) is developed. The trapezium is then excised, and the bone is carefully removed piecemeal without damaging the flexor carpi radialis (FCR). Drills are then used to make holes in the base of the metacarpal. A local graft is harvested from the FCR or APL tendon. Through a longitudinal incision or a series of transverse incisions, the tendon tissue graft is placed. A spacer is then made by putting longitudinal weaving sutures in the FCR remnant, rolling the tendon like an anchovy on itself and inserting it into the trapezium fossa. The EPB tendon is sutured to the shaft of the metacarpal. The metacarpal joint is stabilized, and the wound is closed with sutures and a thumb spica applied. For a stage III and IV arthritis, a Swanson silicon prosthesis replacement arthroplasty is performed where a stem is inserted into the first MC; a spacer in the gap left by the trapezium excision, and a functional elongation of first MC is performed.

Since, arthroplasty of CMC (25447) already involve the work on EPB, FCR and/or APL, then it is suggested not to bill these codes together. However, there is not CCI bundling between all the codes, so these can be billed with the support of strong medical necessity.

On the other hand, if these codes are not billed together, then modifier 22 (Increased Procedural Services) can be appended with the arthroplasty procedure code.

In order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:

  • Increased intensity
  • Additional time
  • Technical difficulty
  • Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician

Hope this helps!

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