Question

PREOPERATIVE DIAGNOSIS : Comminuted intraarticular distal radial Colles' fracture, left wrist.

POSTOPERATIVE DIAGNOSIS : Comminuted intraarticular distal radial Colles' fracture, left wrist.

PROCEDURE : Application of a uniplanar fixation and closed reduction of left distal radial fracture under fluoroscopy.

ANESTHESIA : General endotracheal.

DESCRIPTION OF THE PROCEDURE :

After induction of adequate general anaesthesia, the patient's left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius. We connected these two pins with clamps, and then under C-arm control, we reduced the fracture. All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible and tightened down the clamps to the bars. The pin tracks were dressed in Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

To code the surgical treatment of a comminuted intraarticular distal radial Colles' fracture, both CPT and ICD-10-CM codes must be used. The ICD-10-CM code would denote the specific type and location of the fracture, while the CPT code would describe the actual surgical procedure employed.

Step-by-step explanation:

The student is asking for the appropriate CPT and ICD-10-CM codes for a preoperative and postoperative diagnosis of a comminuted intraarticular distal radial Colles' fracture on the left wrist that was treated using a uniplanar fixation and closed reduction under fluoroscopy. For the CPT code, the procedure for the application of an external fixation system and closed reduction of a distal radial fracture is described. The precise CPT code would be dependent on the exact nature of the fixation system used and the details of the reduction process. This code can often be found in the musculoskeletal section under the subheading of fracture and/or dislocation treatment in the CPT manual.

The ICD-10-CM code for a comminuted intraarticular distal radial Colles' fracture would reflect the anatomical location, the type of fracture, and whether it is an initial or subsequent encounter for the fracture treatment. A code like S52.501A for a Colles' fracture of unspecified radius, initial encounter for closed fracture, could be used, adjusting the laterality and encounter specifics based on the exact details of the patient's case.