How To Use CPT Code 25391

CPT 25391 describes a surgical procedure known as osteoplasty, specifically the lengthening of either the radius or ulna bone using an autograft. This article will provide an overview of CPT code 25391, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 25391?

CPT 25391 is used to describe a surgical procedure in which the provider increases the length of either the radius or ulna bone by utilizing an autograft. This code is specifically used when the provider cuts the bone and affixes an additional piece of bone graft taken from the patient’s own body to extend the length of the radius or ulna.

2. Official Description

The official description of CPT code 25391 is: ‘Osteoplasty, radius OR ulna; lengthening with autograft.’

3. Procedure

1. When performing CPT 25391, the provider begins by making a long incision over the radial or ulnar shaft of the forearm.
2. They then expose the bone by retracting the adjacent muscles and carefully retract the nerves and blood vessels to prevent any damage.
3. The provider proceeds to cut the radius or ulna bone, typically from the shaft area.
4. By pulling both ends, they create a space between the bone.
5. Next, the provider fixes a piece of bone graft in the space using screws, plates, or pins to ensure proper fixation.
6. Once the fixation is confirmed, the operative site is irrigated, and the incision is closed in layers.
7. Finally, the arm is immobilized with a splint to aid in the healing process.

4. Qualifying circumstances

CPT 25391 is performed on patients who require lengthening of either the radius or ulna bone using an autograft. This procedure is typically indicated for patients with unequal limbs or other conditions that necessitate bone lengthening. The bone graft used in the procedure is taken from the patient’s own body, making it an autograft.

5. When to use CPT code 25391

CPT code 25391 should be used when a provider performs the osteoplasty procedure to lengthen either the radius or ulna bone using an autograft. It is important to note that this code is specific to the lengthening of one bone only. If both the radius and ulna are treated in the same session, CPT code 25393 should be used instead.

6. Documentation requirements

To support a claim for CPT 25391, the provider must document the following information:

• Patient’s diagnosis and the need for bone lengthening
• Specific details of the procedure, including the bone involved (radius or ulna)
• Documentation of the use of an autograft
• Date of the procedure
• Details of the incision, fixation, and closure
• Confirmation of proper fixation
• Post-operative instructions and any necessary follow-up care
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 25391, ensure that the procedure involves the lengthening of either the radius or ulna bone using an autograft. It is important to note that CPT code 25391 should not be reported if CPT codes 25366 to 25368 have already been performed in the previous seven days. Additionally, consider the location of the testing when coding for this procedure.

8. Historical information

CPT code 25391 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 provider performs osteoplasty on a patient’s radius bone, utilizing an autograft to lengthen it.
2. During a surgical procedure, the provider cuts the ulna bone and affixes an additional piece of bone graft taken from the patient’s body to increase its length.
3. A patient with unequal limbs undergoes osteoplasty on their radius bone, using an autograft to achieve bone lengthening.
4. Using an autograft, the provider performs osteoplasty on the ulna bone to increase its length in a patient with a specific medical condition.
5. During a surgical procedure, the provider utilizes an autograft to lengthen the radius bone of a patient with a congenital limb discrepancy.
6. A provider performs osteoplasty on a patient’s ulna bone, using an autograft to achieve bone lengthening.
7. Using an autograft, the provider performs osteoplasty on the radius bone of a patient with a limb length discrepancy.
8. A patient with a specific medical condition undergoes osteoplasty on their ulna bone, utilizing an autograft to increase its length.
9. During a surgical procedure, the provider cuts the radius bone and affixes an additional piece of bone graft taken from the patient’s body to achieve bone lengthening.
10. A provider performs osteoplasty on a patient’s ulna bone, utilizing an autograft to increase its length.