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Official Description

Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 25575 refers to the open treatment of fractures involving both the radial and ulnar shafts, which are the two long bones in the forearm. This surgical intervention is indicated when fractures occur in both bones, necessitating a comprehensive approach to restore their structural integrity. The term "open treatment" signifies that the procedure involves making an incision to directly access the fractured bones, allowing for precise manipulation and stabilization. During the surgery, the surgeon will make an incision over the fracture site, carefully incising the overlying fascia and dividing the muscle to expose the bones. The process includes reducing the fractures, which means aligning the broken ends of the bones to their normal position. Internal fixation, typically using a plate and screw device, is employed to maintain this alignment and promote healing. This procedure is critical for ensuring proper function and strength of the forearm post-recovery, as both the radius and ulna play essential roles in wrist and elbow movement.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The open treatment of radial and ulnar shaft fractures is indicated in the following scenarios:

  • Fractures of the Radius and Ulna: This procedure is performed when there are fractures present in both the radial and ulnar shafts, which may result from trauma or injury.
  • Displacement of Fractures: Indications include cases where the fractures are displaced, meaning the bone fragments are not aligned properly, necessitating surgical intervention for realignment.
  • Inadequate Healing: The procedure may be indicated if there is a concern for inadequate healing or non-union of the fractures that cannot be managed conservatively.

2. Procedure

The procedure for the open treatment of radial and ulnar shaft fractures involves several critical steps:

  • Step 1: An incision is made over the fracture site to access the bones directly. This incision allows the surgeon to visualize the fracture and surrounding tissues.
  • Step 2: The overlying fascia is incised, and the muscle is divided to expose the fractured radius and ulna. This step is essential for gaining access to the bones for proper treatment.
  • Step 3: The arm is first supinated to facilitate the reduction of the radial fracture. The attachment to the supinator muscle is released to allow for better access to the fracture site.
  • Step 4: The arm is then pronated, and the pronator teres muscle is identified. The insertion of the pronator teres is released to further expose the radial fracture.
  • Step 5: The radial fracture is carefully exposed, cleared of any debris, and then reduced into proper alignment. This step is crucial for ensuring that the bone heals correctly.
  • Step 6: Internal fixation is applied, typically using a plate and screw device, to stabilize the fracture and maintain alignment during the healing process.
  • Step 7: The supinator and pronator teres muscles are reattached to restore normal function and anatomy.
  • Step 8: The ulnar fracture is then treated in a similar manner, involving reduction and internal fixation as necessary.
  • Step 9: Finally, the overlying fascia is repaired, and the wound is closed to complete the procedure.

3. Post-Procedure

Post-procedure care following the open treatment of radial and ulnar shaft fractures typically involves monitoring for signs of infection, ensuring proper wound healing, and managing pain. Patients may be advised to keep the affected arm elevated to reduce swelling. Rehabilitation may be necessary to restore range of motion and strength in the forearm and wrist. Follow-up appointments will be scheduled to assess the healing process and determine when the patient can safely resume normal activities.

Short Descr OPTX RDL&ULN SHFT FX RDS&ULN
Medium Descr OPTX RADIAL&ULNAR SHFT FX W/INT FIXJ RADIUS&ULNA
Long Descr Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna
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)
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.
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
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
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)
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
SA Nurse practitioner rendering service in collaboration with a physician
SG Ambulatory surgical center (asc) facility service
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2025-01-01 Changed Short and Medium Descriptions changed.
2013-01-01 Changed Medium Descriptor changed.
2008-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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