Question

A 49 year-old female presented with chronic deQuervain's disease and has been unresponsive to physical therapy, bracing or cortisone injection. She has opted for more definitive treatment. After induction of anesthesia, the patient's left arm was prepared and draped in the normal sterile fashion. Local anesthetic was injected using a combination 2% lidocaine and 0.25% Marcaine. A transverse incision was made over the central area of the first dorsal compartment. The subcutaneous tissues were gently spread to protect the neural and venous structures. The retractors were placed. The fascial sheath of the first dorsal compartment was then incised and opened carefully. The underlying thumb abductor and extensor tendons were identified. The tissues were dissected and the extensor retinaculum of the first extensor compartment was incised. The fibrotic tissue was incised and the tendons gently released. The tendons were freely moving. Subcutaneous tissues were closed with a 3-0 Vicryl and the skin with 3-0 Prolene subcuticular closure. Steri-strips, Xeroform and dry sterile dressings were applied. What CPT® code is reported?

Answer 1

The CPT code for the surgical procedure for a 49-year-old female with chronic deQuervain's disease, as described, is most likely 25000, which covers the incision and release of deQuervain's disease of the wrist.

Step-by-step explanation:

The clinical scenario provided describes a surgical procedure for a patient with chronic deQuervain's disease who has not responded to conservative treatment measures. To report the correct CPT (Current Procedural Terminology) code, we need to identify the procedure's key elements, identify the surgical steps undertaken, and apply the specific coding rules as laid out by the American Medical Association (AMA). In this case, the surgical steps include the administration of a local anesthetic, making a transverse incision over the first dorsal compartment, identification and dissection of the abductor pollicis longus and extensor pollicis brevis tendons, release of the fibrotic tissue, and then closure of the surgical site.

Considering the details of the procedure described, the CPT code that would most likely be reported in this scenario is 25000, which corresponds to the incision and release of deQuervain's disease of the wrist (extensor tendons).