How To Use CPT Code 25375

CPT 25375 describes the procedure of multiple osteotomies with realignment on intramedullary rod for both the radius and ulna. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 25375?

CPT 25375 is used to describe a surgical procedure in which the provider performs multiple osteotomies on both the radius and ulna bones. These osteotomies involve cutting the improperly developed bone shafts in multiple sections and realigning them using intramedullary rods. This procedure is known as the Sofield type procedure.

2. Official Description

The official description of CPT code 25375 is: ‘Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna.’

3. Procedure

1. After appropriate patient preparation and anesthesia, the provider makes a long incision to access the radial and ulnar shafts.
2. The provider exposes the bones by retracting the adjacent muscles and carefully retracting the nerves and blood vessels to prevent any damage.
3. Both ends of the radius and ulna are cut through the necks to allow for the insertion of an intramedullary rod later in the middle of each shaft.
4. If necessary, the provider cuts each shaft in multiple sections to correct the alignment.
5. Deformed bony areas are chipped out, and intramedullary rods are inserted into the center of each bone to provide support.
6. The provider fixes back the initially cut epiphyses and confirms proper alignment and rotation.
7. The bone sections are then fixed in place using screws or nails over the rods.
8. The operative site is closed in layers, and the arm is immobilized with a splint.

4. Qualifying circumstances

CPT 25375 is performed on patients who require correction of improperly developed radius and ulna bone shafts. This procedure is typically indicated for patients with specific conditions or deformities that affect the alignment of these bones. The provider must assess the patient’s condition and determine the need for multiple osteotomies with realignment on intramedullary rod.

5. When to use CPT code 25375

CPT code 25375 should be used when the provider performs multiple osteotomies with realignment on intramedullary rod for both the radius and ulna. This code is appropriate when the procedure is performed on the same patient during a single session. If the provider treats either the radius or ulna, but not both, use the appropriate code for that specific bone (e.g., CPT code 25370 for radius or ulna).

6. Documentation requirements

To support a claim for CPT code 25375, the provider must document the following information:

• Patient’s diagnosis and the need for multiple osteotomies with realignment on intramedullary rod
• Details of the procedure, including the specific osteotomies performed and the use of intramedullary rods
• Date of the procedure
• Any additional procedures or interventions performed during the same session
• Confirmation of proper alignment and rotation
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 25375, ensure that the procedure involves multiple osteotomies with realignment on intramedullary rod for both the radius and ulna. It is important to accurately document the details of the procedure and any additional interventions performed. There are no specific guidelines regarding reporting CPT code 25375 with other codes. However, it is essential to follow any applicable bundling or unbundling rules and guidelines provided by payers.

8. Historical information

CPT code 25375 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a congenital deformity of both the radius and ulna undergoes a surgical procedure in which the provider performs multiple osteotomies with realignment on intramedullary rod for both bones.
2. A patient with a traumatic injury to both the radius and ulna requires correction of the improperly developed bone shafts through multiple osteotomies with realignment on intramedullary rod.
3. A patient with a developmental disorder affecting the alignment of both the radius and ulna undergoes a surgical procedure in which the provider performs multiple osteotomies with realignment on intramedullary rod for both bones.
4. A patient with a chronic condition causing deformities in both the radius and ulna requires correction through multiple osteotomies with realignment on intramedullary rod.
5. A patient with a previous failed surgery on both the radius and ulna undergoes a revision procedure involving multiple osteotomies with realignment on intramedullary rod for both bones.
6. Provide four more examples of cases in which CPT code 25375 should be billed. Only explain the examples and make them all original. Do not include ‘CPT 25375” or ‘CPT code 25375” in the text of an example.