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The procedure described by CPT® Code 25415 pertains to the surgical repair of a nonunion or malunion of both the radius and ulna bones, specifically performed without the use of a bone graft. A nonunion occurs when the fracture fragments fail to heal together after an adequate period, while a malunion refers to a situation where the fragments heal but in an incorrect alignment, leading to potential complications. These complications can include osseous abnormalities, incongruity of articular surfaces, soft tissue contracture, and nerve impingement, which may result in pain and functional impairment. During the procedure, the surgeon exposes the original fracture sites of the radius and ulna to assess the condition of the nonunion or malunion. The evaluation determines the necessary repair technique, which may involve the application of internal fixation methods. In cases where a compression technique is utilized, a compression plate is affixed over the fracture site and secured with lag screws to promote stability. If malunion is present, the surgeon may need to refracture the bones to realign them properly before applying internal fixation to maintain anatomical alignment. The procedure emphasizes the importance of ensuring the stability and correct alignment of the fracture, which is verified through radiographic imaging following the placement of the fixation device.
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The procedure is indicated for the following conditions:
The surgical procedure for the repair of nonunion or malunion of the radius and ulna without a graft involves several critical steps:
Post-procedure care involves monitoring the surgical site for signs of infection and ensuring that the fixation remains stable. Patients may require follow-up imaging to assess the healing process of the radius and ulna. Rehabilitation may be necessary to restore function and strength to the affected limb, and the healthcare team will provide guidance on activity restrictions and physical therapy as needed to facilitate recovery.
| Short Descr | REPAIR RADIUS & ULNA | Medium Descr | RPR NONUNION/MALUNION RADIUS&ULNA W/O AUTOGRAF | Long Descr | Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 145 - Treatment, fracture or dislocation of radius and ulna |
This is a primary code that can be used with these additional add-on codes.
| 20703 | Add-on Code MPFS Status: Active Code APC N Removal of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure) |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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