Wiki 25447 VS 25448?

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dsibley67

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Below is my physician's op note for CMC. I need some coding direction if this should be coded as 25447 or 25448 and why? Any help will be greatly appreciated. Thanks!
PROCEDURES PERFORMED:
1. Left thumb CMC arthroplasty with internal brace.
2. Left wrist FCR weave
PROCEDURE:
The patient was seen preoperatively, site was marked and
verified. Preoperative antibiotics were given. She was taken back to the OR. Time-out was taken at the
beginning of the procedure. The arm was exsanguinated. The tourniquet was inflated. A transverse
incision was made in the mid forearm. We carefully dissected down and transected the FCR tendon. A
separate incision was made along the radial aspect of the wrist, carefully dissected down protecting the
cutaneous nerve branches. First dorsal compartment was released. We then placed a retractor between
the tendons and identified the radial artery. This was protected through the remainder of the procedure.
The trapezium was then exposed and removed with osteotome, rongeur and curette. The joint between
the scaphoid and trapezoid was examined and appeared to be healthy. The FCR tendon was then
withdrawn from the base of the wound. We placed a Arthrex FiberTak anchor across the base of the
index metacarpal. Once this was secured, the FiberTape was then secured to the base of the thumb
metacarpal. She did have osteoporotic bone. In the process of securing the FiberTape, the screw itself
would not see appropriately, but the foretip became large and actually secured the FiberTape quite nicely.
The thumb appeared stable and at this point, the FiberTape was cut. The FCR tendon was secured to the
base of the thumb metacarpal as well using 2-0 PDS. Remainder of the FCR tendon was sutured together
with 3-0 Vicryl, placed into the space left by the trapeziectomy. The capsule was then closed with Vicryl,
skin was closed with Monocryl. She was placed in a thumb spica splint and tolerated the procedure well.
 
This is a suspension arthroplasty and is coded 25448.

25447 is -only- for interposition, which is almost never done. It was typical to code 25447/26480 to encompass the work done for an FCR weave, but because that code pair (and 25447/25310) were coded together 80% of the time, CMS mandated the creation of a new code to encompass any suspension or tendon transfer-type procedures about the thumb.
 
NRaizman said:
This is a suspension arthroplasty and is coded 25448.

25447 is -only- for interposition, which is almost never done. It was typical to code 25447/26480 to encompass the work done for an FCR weave, but because that code pair (and 25447/25310) were coded together 80% of the time, CMS mandated the creation of a new code to encompass any suspension or tendon transfer-type procedures about the thumb.
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Thanks so much for answering. I have it coded as 25448, but I just wanted to make sure that I was coding it correctly.
 
Would it be okay if I build upon your question? We have a physician that is asking about using CPT 25312 with 25448 I am thinking this may be a stretch, while he reports the operations performed as 1.Right thumb carpometacarpal joint interposition arthroplasty. 2. Harvest of right flexor carpi radialis tendon from separate incision. I am thinking this may be all inclusive to 25448. I found the following article from aaos https://www.aaos.org/aaosnow/2025/jan/managing/managing01/ and am having a hard time justifying the use of both 25448 & 25312.

an example would be "The branches of the radial sensory nerve were identified and protected. The branches of the radial artery were identified and protected. The capsule overlying the CMC joint was opened, and the trapezium was visualized. It was cut into four and removed in its entirety. The FCR was visualized at the base of the arthroplasty space. A hole was made at the base of the first metacarpal. Two separate incisions were made in the volar forearm. The half of the FCR tendon was harvested and pulled into the distal wound. It was pulled through the hole at the base of the first metacarpal and tied to itself at the base of the arthroplasty space. The remainder of the tendon was rolled up as an arthroplasty spacer and placed within the joint. The joint was closed firmly with 3-0 Ethibond.

I appreciate your thoughts and guidance. Thank you.
 
Last edited:
Any and all work associated with tendon transfer or suspension of the CMC joint is included in 25448.
Using a different code to describe identical work to plainly attempt to unbundle an included service is fraud.
The procedure described above is a standard LRTI and EXACTLY the same as that which was previously coded 25447/25310 or 25447/26480 and which was considered bundled by CMS and which led to the demand that we create 25448 to reflect the bundled work of those two codes in the first place.
The answer is a clear and unequivocal no.
N.
 
NRaizman said:
Any and all work associated with tendon transfer or suspension of the CMC joint is included in 25448.
Using a different code to describe identical work to plainly attempt to unbundle an included service is fraud.
The procedure described above is a standard LRTI and EXACTLY the same as that which was previously coded 25447/25310 or 25447/26480 and which was considered bundled by CMS and which led to the demand that we create 25448 to reflect the bundled work of those two codes in the first place.
The answer is a clear and unequivocal no.
N.
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Dr. Raizman, thank you for such a quick response. Your insight is always valued and much appreciated!
 
No worries.

If you need context for how this code came to be, it is all published in last year's CMS Physician Fee Schedule Final Rule.
CMS rejected the RUC valuation on very shaky ground despite vociferous objections by both the RUC and the various specialty societies. And just dropped the reimbursement by around 30%. It is not surprising that surgeons are trying to recoup that lost value, but it is not appropriate to add in other codes to try to buff reimbursement. STT arthritis surgery here is separately reimbursable, as are some associated procedures, but you can't add in extra codes for the exact same work, and your surgeons need to be told that in no uncertain terms. If they have any questions or objections, you can feel free to refer them to me. If they are ASSH or AAOS members, they should have no trouble finding me.
 
NRaizman said:
This is a suspension arthroplasty and is coded 25448.

25447 is -only- for interposition, which is almost never done. It was typical to code 25447/26480 to encompass the work done for an FCR weave, but because that code pair (and 25447/25310) were coded together 80% of the time, CMS mandated the creation of a new code to encompass any suspension or tendon transfer-type procedures about the thumb.
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Dr. Raizman, I appreciate your response to the above question. I just have a question if you don't mind. Can you tell me what verbiage in the above note supports the suspension arthroplasty?

The doctor I am coding for did a CMC arthroplasty with tendon transfer procedure and wants to bill 25447 & 26480 as before. I tried explaining that those codes can no longer be billed together and the new code 25448 would be the code now for tendon transfer, but he states he did not do a suspensionplasty because "that would imply where a suture is passed between the APL and FCR tendon and in that surgery (27448), the APL tendon is not transected and transferred. In the surgery performed, the APL tendon is transected proximally and then transferred to the FCR tendon". In his note he describes a FiberTak fixation.

My question would be if he is saying he did not do a suspension, but did a tendon transfer and 25447 and 26480 no longer covers a tendon transfer, how would this be coded? Would 25448 be used if no suspension was done?

Thanks for your help!
 
This is the suspension.

"The FCR tendon was then withdrawn from the base of the wound. We placed a Arthrex FiberTak anchor across the base of the index metacarpal. Once this was secured, the FiberTape was then secured to the base of the thumb metacarpal. "

This describes an anchor-based suspension between the first and second metacarpal. The code is agnostic to method of suspension (eg tightrope/suture button, suture only, anchor, or tendon weave)

Your surgeon is dead wrong. If he has an issue, he can contact me directly or submit a query through either ASSH or AAOS. Along with my team which leads the ASSH coding committee, we quite literally wrote the code, shepherded it through CPT, and valued it at the RUC. It is not a matter of discussion or negotiation - this is exactly what 25448 is meant to encompass.
 
NRaizman said:
This is the suspension.

"The FCR tendon was then withdrawn from the base of the wound. We placed a Arthrex FiberTak anchor across the base of the index metacarpal. Once this was secured, the FiberTape was then secured to the base of the thumb metacarpal. "

This describes an anchor-based suspension between the first and second metacarpal. The code is agnostic to method of suspension (eg tightrope/suture button, suture only, anchor, or tendon weave)

Your surgeon is dead wrong. If he has an issue, he can contact me directly or submit a query through either ASSH or AAOS. Along with my team which leads the ASSH coding committee, we quite literally wrote the code, shepherded it through CPT, and valued it at the RUC. It is not a matter of discussion or negotiation - this is exactly what 25448 is meant to encompass.
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Thank you for the quick response! I just want to clarify that I am not the original poster and this is a different surgeon. Not to beat a dead horse but this is an excerpt from his note where he describes the tendon transfer:

Next, preparations were made for FiberTak fixation. The radial corner of the index finger metacarpal was identified. Under fluoroscopic guidance, a guide K-wire was inserted for a 1.6 FiberTak suture anchor. Cannulated drill sleeve was placed over top of the K-wire and the K-wire was removed. Drill was next inserted. 1.6 FiberTak suture anchor was then placed within the index finger metacarpal and brought through the ulnar cortex. There was excellent purchase. 1.3 FiberTape was then brought to the radial base of the thumb metacarpal. Thumb was brought to appropriate positioning and point of suture anchor was marked. Drill was next inserted for a 3.5 mm Arthrex suture anchor. The thumb was brought to appropriate position and FiberTape was secured with the suture anchor. Fluoroscopic imaging was obtained confirming maintenance of metacarpal height.
Tenotomies were next used to further dissect along the APL tendon. There was noted to be 2 slips of the APL tendon. More ulnar slip was dissected away and then transected proximally maintaining its distal insertion. APL tendon was next secured to the FCR tendon with 2-0 FiberWire, completing tendon transfer.

This is where I am asking is this a 25448.

Thank you again!
 
NRaizman said:
No worries.

If you need context for how this code came to be, it is all published in last year's CMS Physician Fee Schedule Final Rule.
CMS rejected the RUC valuation on very shaky ground despite vociferous objections by both the RUC and the various specialty societies. And just dropped the reimbursement by around 30%. It is not surprising that surgeons are trying to recoup that lost value, but it is not appropriate to add in other codes to try to buff reimbursement. STT arthritis surgery here is separately reimbursable, as are some associated procedures, but you can't add in extra codes for the exact same work, and your surgeons need to be told that in no uncertain terms. If they have any questions or objections, you can feel free to refer them to me. If they are ASSH or AAOS members, they should have no trouble finding me.
Click to expand...
Hello Dr. Raizman,

I have a provider wanting 25447 x2 for the CMC and for the STT. Since there is a tendon transfer being done for the CMC arthroplasty the first CPT would be 25448. However, my question is for the STT joint. I would normally bill this as 25210,XS/59 but the provider continues to state "STT interposition arthroplasty" and it is throwing me off. Documentation states: "There were significant degenerative changes between the trapezoid and the scaphoid, thus the proximal aspect of the trapezoid was excised, used a rongeur and osteotome and Gelfoam filled the void from that excision for the second interposition arthroplasty and the STT interposition arthroplasty." Wouldn't this be 25210 or would this be allowed as 25447?

Thank you for your time.
 
I would code the CMC as 25448 and the STT as 25447. I would recommend to your surgeon to separate these out into two distinct paragraphs in the op report and be seriously and overly explicit about it, but I would think this entirely allowable and have recommended it to others. AAOS and ASSH have maintained that the CMC and STT joints are separate structures and have reflected that in the GSD.
 
Hi, Dr. Raizman. My surgeon did a suspension arthroplasty. There was fusion of the trapezoid to the trapezium, hence part of it had to be removed as well. Is the partial removal of the trapezoid included in code 25448? Thank you in advance for your help.
 
25210 for partial excision of the trapezium.

For the record regarding the above - the CPT book says not to code 25447 with 25448, which creates a bit of a dilemma, as there is no code to otherwise cover the work of a suspension arthroplasty in the setting of an interposition arthroplasty of -another- joint. We are currently working through our options here. I have coded 25447 and 25448 together and some payors have reimbursed. But that is not a great strategy and goes against the published guidance in CPT
 
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