2010 Procedures Adult Criteria , Diagnostic, +/- Synovial Biopsy, Wrist

2010 Procedures Adult Criteria Arthroscopy, Diagnostic, +/- Synovial Biopsy, Wrist(1*RIN)

CLIENT: Name D.O.B. ID# GROUP# CPT/ICD9: Code Facility Service Date PROVIDER: Name ID# Phone# Signature Date

ICD-9-CM: 80.23

INDICATIONS (choose one and see below)

100 Suspected ligamentous/TFCC injury 200 Chronic monarticular pain 300 Suspected joint infection Indication Not Listed (Provide clinical justification below)

(2) 100 Suspected ligamentous/TFCC injury [All] 110 Wrist injury by Hx 120 Wrist pain 130 Findings at wrist [Both] (3) 131 Pain with provocative wrist maneuvers/ (4) 132 Weakness (5, 6) 140 Wrist x-ray nondiagnostic for etiology of pain (7) 150 MRI/ nondiagnostic for etiology of pain (8, 9) 160 Continued Sx/findings after Rx [Both] (10) 161 NSAID [One] -1 Rx ≥ 4 wks (11) -2 Contraindicated/not tolerated 162 Splint/cast ≥ 4 wks

(12) 200 Chronic monarticular joint pain [All] 210 Symptoms at wrist [One] 211 Joint pain 212 Locking 220 Findings at wrist [Two] 221 Pain with passive ROM 222 Limited ROM 223 Tenderness

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(13) 224 Crepitus 225 Joint effusion/swelling (5) 230 Wrist x-ray nondiagnostic for etiology of pain 240 MRI/arthrogram nondiagnostic for etiology of pain (8, 9) 250 Continued Sx/findings after Rx [Both] (10) 251 NSAID [One] -1 Rx ≥ 4 wks (11) -2 Contraindicated/not tolerated 252 Splint/cast ≥ 6 wks

(14) 300 Suspected joint infection [All] 310 Joint tenderness 320 Pain with passive ROM 330 Findings [Two] 331 Erythema/warmth overlying joint 332 Temperature > 100.4 F(38.0 C) 333 WBC > 10,000/cu.mm(10x109/L) 334 ESR > 30 mm/hr 335 C-reactive protein > 10 mg/L (15) 340 Joint aspiration nondiagnostic for infection

Notes

(1)-RIN: If a surgically remediable lesion is found during diagnostic arthroscopy, an intraoperative conversion to a surgical arthroscopy will occur, and does not need additional authorization. (2) Wrist stability is provided by a number of ligamentous and fibrocartilage structures that are susceptible to injury. These include the scapholunate and lunotriquetral interosseous ligaments, volar radiocarpal and ulnocarpal ligaments, and the triangular fibrocartilage complex (TFCC). Depending upon the location and grade of the injury as well as the integrity of the tissue open repair or reconstruction may be necessary and is a matter of clinical judgment. (3) Systematic palpation of all of the wrist is done to localize tenderness and pathology (Young et al., Orthop Clin North Am 2007; 38(2): 149-165, v; Eathorne, Prim Care 2005; 32(1): 17-33). A variety of provocative maneuvers (e.g., scaphoid shift test, ballottement tests) are used to assess wrist stability or kinematics (i.e., mechanics of motion) (Young et al., Orthop Clin North Am 2007; 38(2): 149-165, v; Eathorne, Prim Care 2005; 32(1): 17-33). The examination should include the carpus (i.e., carpal and articulations) as well as the distal radioulnar joint. (4) Weakness may present as decreased grip strength, or as weakness and pain with "loading activities," (e.g., push-ups) (Walsh et al., J Am Acad Orthop Surg 2002; 10(1): 32-42.; Nagle, J Am Acad Orthop Surg 2000; 8(1): 45-55). (5) X-ray should be performed to exclude fracture, dislocation, or tumor as possible causes of the patient's symptoms. (6)

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The pain of severe arthritis of the wrist can mimic that of a ligamentous injury. Although not an absolute contraindication to arthroscopy, arthritis should be excluded as the sole cause of the patient's pain before surgery is performed. (7) An MRI or an MR arthrogram may be performed more often than a conventional arthrogram. (8) The listed treatment(s) may have occurred at any time in the course of the illness. (9) In addition to NSAIDs, corticosteroid injection may also be helpful. (10)-POL: It is a matter of local medical policy whether to accept acetaminophen or analgesics as substitutes for NSAIDs. (11) Contraindications to NSAIDs may be absolute (e.g., pregnancy, history of allergic reaction) or relative (e.g., anticoagulant use, history of PUD). (12) Chronic monarticular pain, with or without prior trauma, may be caused by intra-articular loose bodies, chondromalacia, or chondral defects. Chronic pain in more than one joint may represent a systemic rheumatic disorder which may be diagnosed by clinical evaluation and blood tests. (13)-DEF: Crepitus is a sometimes audible, or sometimes palpable, grating sensation caused by two irregular surfaces moving relative to each other. It can be appreciated when the joint is extended or flexed. (14) Diagnostic arthroscopy is rarely needed in this situation; it is done only when the diagnosis is in question. (15) If the joint fluid has an elevated WBC but a negative Gram stain or culture and the clinical suspicion for joint infection is high, arthroscopy is indicated for diagnosis to obtain tissue for culture.

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