How To Use CPT Code 25545

CPT 25545 describes the open treatment of an ulnar shaft fracture, including internal fixation, when performed. 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 25545?

CPT 25545 can be used to describe the open treatment of an ulnar shaft fracture, which involves the use of internal fixation to stabilize the fracture. This code is used when a provider performs an incision to realign the bones and applies hardware, such as plates, screws, nails, or wires, if necessary.

2. Official Description

The official description of CPT code 25545 is: ‘Open treatment of ulnar shaft fracture, includes internal fixation, when performed.’

3. Procedure

1. The provider prepares the patient for the procedure and administers anesthesia.
2. An incision is made over the area of the ulnar shaft fracture.
3. The provider reduces, or realigns, the fracture and applies internal fixation, such as plates, screws, nails, or wires, if necessary.
4. Imaging is used to confirm the reduction of the fracture.
5. The area is irrigated, checked for bleeding, and any instruments are removed.
6. The incision is closed, and a splint or cast material is applied to prevent movement of the fracture during the healing process.

4. Qualifying circumstances

CPT 25545 is used for patients with an ulnar shaft fracture that requires open treatment and internal fixation. The provider must make an incision and use hardware to stabilize the fracture. This code is specific to the ulnar shaft fracture and does not apply to fractures of other bones in the forearm or wrist.

5. When to use CPT code 25545

CPT code 25545 should be used when a provider performs open treatment of an ulnar shaft fracture and includes internal fixation. This code is appropriate when the provider makes an incision, realigns the fracture, and applies hardware to stabilize it. It should not be used for closed treatment or fractures of other bones in the forearm or wrist.

6. Documentation requirements

To support a claim for CPT 25545, the provider must document the following information:

• Patient’s diagnosis of an ulnar shaft fracture
• Details of the procedure, including the incision, reduction of the fracture, and application of internal fixation
• Confirmation of the reduction through imaging
• Documentation of any additional procedures performed, such as irrigation or removal of instruments
• Description of the post-procedure care, including the application of a splint or cast
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 25545, ensure that the procedure performed meets the criteria for open treatment of an ulnar shaft fracture with internal fixation. Use additional codes as necessary to report any additional procedures or services provided during the same encounter. It is important to follow the specific guidelines and requirements of the payer when submitting claims for CPT 25545.

8. Historical information

CPT 25545 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 provider performs an open treatment of an ulnar shaft fracture in a patient involved in a car accident.
2. A patient sustains an ulnar shaft fracture while playing sports, and the provider performs open treatment with internal fixation.
3. A provider treats an ulnar shaft fracture in a patient who fell from a ladder, performing open treatment and using plates and screws for internal fixation.
4. An individual fractures their ulnar shaft in a workplace accident, and the provider performs open treatment with internal fixation using wires.
5. A patient presents with an ulnar shaft fracture due to a fall, and the provider performs open treatment with internal fixation using nails.
6. A provider performs open treatment with internal fixation for an ulnar shaft fracture in a patient involved in a motorcycle accident.
7. An individual sustains an ulnar shaft fracture while playing a contact sport, and the provider performs open treatment with internal fixation using screws.
8. A patient fractures their ulnar shaft in a fall from a bicycle, and the provider performs open treatment with internal fixation using plates.
9. A provider treats an ulnar shaft fracture in a patient involved in a sports-related injury, performing open treatment with internal fixation using wires.
10. An individual sustains an ulnar shaft fracture in a fall at home, and the provider performs open treatment with internal fixation using nails.