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Question: I have a surgical note with the following listed as the procedure:

1. Debridement right flexor carpi radialis tendon of distal forearm through the flexor carpi radialis tunnel at the level of the wrist.

2. Debridement of 55 percent attritional rupture of flexor carpi radialis tendon at level of the wrist to stable margins.

3. Excision of scaphoid tuberosity nonunion.

4. Debridement and partial excision of scaphoid tuberosity as well as trapezium to smooth margins.

The procedure description also includes 鈥淭enolysis of the flexor carpi radialis.鈥� The preoperative diagnoses are listed as right wrist flexor carpi radialis tenosynovitis and right scaphoid nonunion of tuberosity. The provider attempted to bill 25263 and 25130, but I鈥檓 not sure those codes are correct.

What procedure codes should I report for the surgery?

Alaska Subscriber

Answer: Code 25130 (Excision or curettage of bone cyst or benign tumor of carpal bones) is a correct choice because the provider did remove a portion of bone. At the same time, you are right to question the use of 25263 (Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle) since the physician didn鈥檛 perform a repair.

Instead, you鈥檒l assign 25295 (Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon) to report that the surgeon performed tenolysis of the flexor carpi radialis tendon in the forearm and wrist.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC