Need help please! Patient presented with both bone shaft fracture radius and ulna. The doctor states in his note:
"I placed a small flexible intramedullary nail in her radius. I did not have to open this."
He also states in procedure description:
"I initially made a small incision just proximal to the growth plate of the distal radius. I used a drill and a small awl to make a starting point was able to advance a small Synthes flexible rod down the shaft, across the fracture into the proximal radius. This provided excellent stability to the forearm."
There was nothing done to the ulna.
So, there’s no IM nailing or percutaneous code for the shaft of the radius. Would you use an ORIF code with 52 modifier?
"I placed a small flexible intramedullary nail in her radius. I did not have to open this."
He also states in procedure description:
"I initially made a small incision just proximal to the growth plate of the distal radius. I used a drill and a small awl to make a starting point was able to advance a small Synthes flexible rod down the shaft, across the fracture into the proximal radius. This provided excellent stability to the forearm."
There was nothing done to the ulna.
So, there’s no IM nailing or percutaneous code for the shaft of the radius. Would you use an ORIF code with 52 modifier?
Thank you!!
Tobi C.