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Official Description

Open treatment of radial shaft fracture, includes internal fixation, when performed

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Open treatment of a radial shaft fracture involves a surgical procedure where the fractured radius, which is the lateral bone of the forearm, is directly accessed and repaired. The term "shaft" refers to the central portion of the radius. This type of fracture is characterized by a break in the radial shaft, and while it is uncommon for such a fracture to occur in isolation—without any accompanying fracture of the ulna or joint dislocation—it typically necessitates an open reduction approach. During the procedure, a surgical incision is made directly over the fracture site to allow for clear visibility and access to the bone. The area is meticulously cleaned to remove any debris that may interfere with the healing process. Once the fracture is properly aligned, the bone fragments are stabilized using internal fixation methods, which often involve the application of a plate and screw device to maintain anatomical alignment. After securing the fracture, the incision is closed, and a suitable immobilization device, such as a sling, splint, or cast, may be applied to support the healing process and prevent movement of the affected area.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The open treatment of a radial shaft fracture is indicated in specific circumstances where surgical intervention is necessary to ensure proper healing and alignment of the bone. The following conditions typically warrant this procedure:

  • Radial Shaft Fracture An isolated fracture of the radial shaft that requires surgical intervention for proper alignment and stabilization.
  • Fracture Displacement Significant displacement of the fracture fragments that cannot be adequately managed through non-surgical methods.
  • Inability to Maintain Reduction Cases where closed reduction techniques have failed to maintain proper alignment of the fracture.

2. Procedure

The procedure for the open treatment of a radial shaft fracture involves several critical steps to ensure successful repair and stabilization of the fracture. Each step is essential for achieving optimal outcomes.

  • Step 1: Incision A surgical incision is made directly over the fracture site on the radial shaft. This incision allows the surgeon to access the fractured bone and surrounding tissues effectively.
  • Step 2: Debridement The area around the fracture is carefully cleared of any debris, including blood clots and damaged tissue, to create a clean surgical field. This step is crucial for reducing the risk of infection and promoting healing.
  • Step 3: Fracture Reduction The fractured bone fragments are manipulated back into their proper anatomical alignment. This process, known as reduction, is vital for restoring the normal function and appearance of the forearm.
  • Step 4: Internal Fixation Once the fracture is aligned, internal fixation is performed using a plate and screw device. This hardware stabilizes the bone fragments and maintains their position during the healing process.
  • Step 5: Wound Closure After ensuring that the fracture is securely fixed, the surgical incision is closed using sutures or staples. Proper closure is important for minimizing scarring and promoting healing.
  • Step 6: Application of Immobilization Device Following the closure of the incision, an immobilization device such as a sling, splint, or cast may be applied to support the forearm and restrict movement, facilitating the healing of the fracture.

3. Post-Procedure

After the open treatment of a radial shaft fracture, patients can expect specific post-procedure care and considerations. It is essential to monitor the surgical site for any signs of infection or complications. Patients are typically advised to keep the immobilization device in place for a prescribed duration to ensure proper healing. Follow-up appointments are necessary to assess the healing progress through physical examinations and imaging studies, if required. Rehabilitation exercises may be introduced gradually to restore strength and range of motion once the fracture has sufficiently healed. Pain management strategies will also be discussed to ensure patient comfort during the recovery period.

Short Descr OPTX RADIAL SHAFT FRACTURE
Medium Descr OPEN TREATMENT RADIAL SHAFT FRACTURE W/INT FIXJ
Long Descr Open treatment of radial shaft fracture, includes internal fixation, when performed
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) P5B - Ambulatory procedures - musculoskeletal
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.

20702 Add-on Code MPFS Status: Active Code APC N Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure)
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)
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
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).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
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
GW Service not related to the hospice patient's terminal condition
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)
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2025-01-01 Changed Short and Medium Descriptions changed.
2008-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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