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2025 CPT code 25365

Osteotomy of the radius and ulna.

The application and removal of the first cast, splint, or traction device are included in the code. Separate reporting for external fixation is only necessary if it's not inherent to the procedure. Modifier 76 should be appended for repeat procedures on the same bone by the same surgeon. Modifier 54 is used if the surgeon performs the osteotomy but not the subsequent care.

Modifiers such as 22 (increased procedural services), 50 (bilateral procedure), 59 (distinct procedural service), 76 (repeat procedure by the same physician), 77 (repeat procedure by another physician), 78, and 79 (unrelated procedure by same or another physician during postoperative period), might be applicable. Use modifier 54 for surgical care only when appropriate.

Medical necessity must be established by documenting the functional limitations, pain, or instability resulting from the underlying condition affecting the radius and ulna. Conservative treatments should be attempted before surgery unless contraindicated.

In simple words: This procedure corrects problems with the two bones in your forearm (radius and ulna). The surgeon makes cuts in the bones and reshapes them to improve alignment and function. Metal plates and screws may be used to hold the bones in place while they heal.

This code represents a surgical procedure where the surgeon cuts and reshapes both the radius and ulna bones in the forearm. This is often done to correct deformities, malunions (fractures that healed incorrectly), or other conditions affecting the forearm bones. The procedure may involve internal fixation with plates and screws to stabilize the bones after reshaping.

Example 1: A patient with a malunited distal radius fracture resulting from a fall experiences pain and limited wrist movement. The surgeon performs an osteotomy of both the radius and ulna to restore proper alignment and joint function., A child with a congenital forearm deformity has a shortened and bowed radius and ulna. An osteotomy is performed on both bones to straighten and lengthen them, improving the appearance and function of the arm., An adult patient with a nonunion of the radius and ulna following a previous fracture experiences persistent pain and instability. The surgeon performs an osteotomy along with bone grafting to promote healing and restore stability to the forearm.

Operative report detailing the surgical technique, including the location of osteotomies, method of fixation (if used), and any associated procedures like bone grafting. Preoperative imaging studies (X-rays, CT scans) showing the deformity or malunion. Postoperative care plan.

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