How To Use CPT Code 25515

CPT 25515 describes the open treatment of a fracture in the shaft of the radius, one of the bones in the forearm. 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 25515?

CPT 25515 is used to describe the open treatment of a fracture in the shaft of the radius. This procedure involves accessing the fracture through an incision in the forearm and applying internal fixation, such as plates, screws, nails, or wires, if necessary, to stabilize the fracture while it heals.

2. Official Description

The official description of CPT code 25515 is: ‘Open treatment of radial shaft fracture, includes internal fixation, when performed.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision over the fracture in the forearm.
3. The provider reduces the fracture and, if necessary, inserts pins or wires to stabilize it.
4. A radiographic image is obtained to confirm adequate reduction of the fracture.
5. The provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision.
6. A splint or cast material is applied to prevent movement of the fracture until healing takes place.

4. Qualifying circumstances

CPT 25515 is used for the open treatment of a fracture in the shaft of the radius. This procedure is performed when internal fixation, such as plates, screws, nails, or wires, is necessary to stabilize the fracture. The patient must have a fracture in the shaft of the radius that requires surgical intervention.

5. When to use CPT code 25515

CPT code 25515 should be used when the provider performs an open treatment of a fracture in the shaft of the radius and includes internal fixation, such as plates, screws, nails, or wires, if necessary. This code should not be used for closed treatment of fractures or for fractures in other locations.

6. Documentation requirements

To support a claim for CPT 25515, the provider must document the following information:

• Patient’s diagnosis of a fracture in the shaft of the radius
• Description of the procedure performed, including the use of internal fixation
• Date of the procedure
• Details of the reduction and stabilization of the fracture
• Confirmation of adequate reduction through radiographic imaging
• Documentation of any additional procedures performed, such as irrigation or closure of the incision
• Application of a splint or cast material

7. Billing guidelines

When billing for CPT 25515, ensure that the procedure performed is an open treatment of a fracture in the shaft of the radius and includes internal fixation, if necessary. This code should not be reported for closed treatment of fractures or for fractures in other locations. It is important to follow the specific guidelines provided by the payer for accurate billing and reimbursement.

8. Historical information

CPT 25515 was added to the Current Procedural Terminology system on January 1, 1990. On January 1, 2008, the code description was updated to include the option of performing the procedure with or without internal or external fixation.

9. Examples

1. A patient undergoes open treatment of a fracture in the shaft of the radius with internal fixation using plates and screws.
2. A provider performs open treatment of a fracture in the shaft of the radius with internal fixation using nails.
3. A patient requires open treatment of a fracture in the shaft of the radius with internal fixation using wires.
4. A provider performs open treatment of a fracture in the shaft of the radius with internal fixation using a combination of plates and screws.
5. A patient undergoes open treatment of a fracture in the shaft of the radius with internal fixation using a combination of nails and wires.
6. A provider performs open treatment of a fracture in the shaft of the radius with internal fixation using a combination of plates, screws, and nails.
7. A patient requires open treatment of a fracture in the shaft of the radius with internal fixation using a combination of plates, screws, and wires.
8. A provider performs open treatment of a fracture in the shaft of the radius with internal fixation using a combination of plates, screws, nails, and wires.
9. A patient undergoes open treatment of a fracture in the shaft of the radius with internal fixation using external fixation as an adjunct.
10. A provider performs open treatment of a fracture in the shaft of the radius with internal fixation using bone grafting.