Orthopaedic Anatomy, Terminology, and Operative Report Fundamentals
Anatomy that drives code selection
Long bones are described by region: epiphysis, physis (growth plate), metaphysis, and diaphysis. Fracture and manipulation codes turn on these regions, so a metaphyseal fracture is not the same code as a diaphyseal one. Know direction terms: proximal/distal, medial/lateral, anterior/posterior, and deformity terms valgus (distal segment away from midline) and varus. Joints are named by the bones involved and by type (hinge, ball-and-socket, pivot); procedure codes distinguish intra-articular from extra-articular work and partial from total joint treatment.
Procedural vocabulary
Reduction means restoring alignment and can be open, closed, or percutaneous. Fixation means internal (plate, screw, nail), external (frame, pins), or percutaneous pinning. Debridement is not the same as incision and drainage. Arthrodesis fuses a joint; arthroplasty replaces or resurfaces it; osteotomy cuts bone; ostectomy removes bone; curettage scrapes a lesion. In CPT, the word with generally means the second service is included unless the code says otherwise, and a code labeled separate procedure is bundled when performed as part of a larger procedure at the same site.
Reading the operative report
Code from the body of the note, not the title. Identify the approach, the definitive procedure, implants, graft, laterality, and number of units. The findings and procedure paragraphs control. A heading that says ORIF does not turn a percutaneous pinning into an open procedure. Confirm who performed what when residents, assistants, or co-surgeons are involved.
Rule of thumb: before choosing a code, write one sentence: the surgeon did ___ to ___ at ___ site, via ___ approach, on the ___ side. If the note cannot fill every blank, query the surgeon.
Worked example: A note titled open reduction and internal fixation of a distal radius fracture describes percutaneous pinning through small stab incisions. Report the percutaneous code, not the open ORIF code.