Wiki Arthroscopic-Assisted vs. Conversion to Open (BEAR ACL)

kle0204

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NCCI edits mentions that if a provider starts with a scope but it is then converted to an open procedure, then it would be coded as open. I have seen examples where the plan was to scope but due to complications or complexity, the scope had to be discontinued and an open procedure was performed, therefore, it is billed as open.

My provider is doing a BEAR procedure where he starts with a scope, preps the area via scope, and then makes an arthrotomy to place the implant in and finish the ACL repair. He states that because he's made an arthrotomy, it is an open procedure. The arthrotomy is part of the procedure so it's not a complication/complexity that requires a conversion from scope to open, so in my opinion, it should still be billed as arthroscopic.

Is my understanding correct or will this be considered open because he ended up making an arthrotomy? Does "conversion to" not require a discontinuation due to complication/complexity and it is still billed as open if the provider starts with the scope and ends up making an open incision?

Thank you!
 
Setting aside the discussion on conversion, I think we would have to see the op report to be sure. Did he make an open incision and do the arthrotomy and complete the ACL repair in an open fashion. Was the implant placement and work done through one of the stab/portal holes? Was there anything else done like the meniscus? Doesn't ACL repair always require an arthrotomy since it's intr-articular?
I would probably code 29888 in this case.
 
Setting aside the discussion on conversion, I think we would have to see the op report to be sure. Did he make an open incision and do the arthrotomy and complete the ACL repair in an open fashion. Was the implant placement and work done through one of the stab/portal holes? Was there anything else done like the meniscus? Doesn't ACL repair always require an arthrotomy since it's intr-articular?
I would probably code 29888 in this case.
Here is a copy of the procedure. I really appreciate your inputs!

DESCRIPTION OF PROCEDURE: After informed consent was obtained, he was taken to the operating room and general anesthetic and adductor canal block administered. Left leg was examined under anesthesia, positive pivot shift, positive anterior drawer and Lachman's. Leg was prepped and draped in normal sterile fashion. Leg was exsanguinated, tourniquet inflated to 300 mmHg. Anterolateral and anteromedial arthroscopic portals were established. Systematic arthroscopic examination of the knee was carried out. Inspection of the notch revealed a complete tear of the ACL with a stump remaining on the tibial portion. The PCL was intact. The anterior compartment revealed no pathology. The medial compartment revealed a meniscal capsular separation at the junction of posterior horn and middle portion of the medial meniscus. The lateral compartment demonstrated that he had a tear of the white to the white-red zone far posterior to the popliteal hiatus.

At this point, meticulous care was taken to clean up the lateral meniscal tear. Initially, it was attempted to do a suture through this to see if it was repairable, but the suture pulled through because the tissue was really too thin on the meniscal portion that was torn, and the Mitek anchor was removed, and the partial lateral meniscectomy was carried out, smoothing this back to a stable articular rim. Inspection of the medial compartment revealed the meniscocapsular junction had been disrupted. A rasp was used to clean this up to create a bleeding surface and then, once this was done, 2 horizontal mattress sutures with Mitek TrueSpan meniscal repair kit were done, placed them on the inferior portion of the meniscus working posteriorly and then medially, obtaining anatomic fixation of the medial meniscal tear. Next, a very small notchplasty was carried out in the notch, and then, utilizing a PassPort cannula in the medial portal, a FiberLink was used to pass alternating sutures, medial to lateral to medial and the medial to lateral through the stump of the tissue and then the knee was flexed and just anterior to the footprint, a pilot hole was punched for the anchor, and the SwiveLock anchor was loaded with 2 FiberWire sutures plus the FiberLink from the stump of the ACL, and it was placed in the femoral side and seated appropriately. The sutures were then docked through an accessory portal medially and once this was done, and the drill hole through the tibia was made bringing this up just anterior to the ACL stump and then the sutures were pulled out and locked through an accessory medial portal, and an arthrotomy was then performed. Once this was done, the bare implant was opened, and it was hydrated with the patient's blood after passing the sutures from the anchor down through this in 4 different quadrants and then passing the suture tails down out through the tibial tunnel. Once it was appropriately hydrated, the BEAR implant, after doing the arthrotomy, the knee was opened, and the BEAR implant was then introduced through the open arthrotomy, and this was this was placed in line with the fibers of the ACL stump all the way up to the lateral wall. Per technique, bringing the knee out to extension. The sutures were tensioned through the tibial tunnel and repaired with a 4.75 mm SwiveLock anchor. The knee was kept in full extension the remainder of the course, and the arthrotomy was closed with 0 Ethibond in interrupted fashion, 2-0 Vicryl and staples were applied to the skin. Sterile dressing was applied. He was taken to Recovery in stable condition. There were no known complications.
 
I can see this being debated for a while until this technique becomes more mainstream. Keep in mind that 29888 is not 100% arthroscopic. Most of the prep is arthroscopic and a portal is extended just enough for the graft to be placed. In the BEAR procedure again all the prep is performed arthroscopically and the incision is made to get the graft into the knee joint. The BEAR implant is wider than an ACL graft so the incision does have to be bigger. It's just wide enough that the doctor can put his index finger through the opening. The description of code 29888 is arthroscopically "aided". Since 90% of the work is performed arthroscopically and the opening is just wide enough to get the graft in, I think that code 29888 is appropriate. But I certainly do understand and respect your providers viewpoint.
 
I agree, it's too "new" of a technique. Short of a CPT assistant or other official guidance, I would also go with 29888. I see why they want to report an open cpt. It's really rare to see the 27407 or 27428 reported unless they are doing a multiligamentous case and posterolateral corner reconstruction for a major knee blowout type injury which then usually turns into 27429 with other codes.
 
I agree, it's too "new" of a technique. Short of a CPT assistant or other official guidance, I would also go with 29888. I see why they want to report an open cpt. It's really rare to see the 27407 or 27428 reported unless they are doing a multiligamentous case and posterolateral corner reconstruction for a major knee blowout type injury which then usually turns into 27429 with other codes.
At 5:30 AM I am feeding the cat and shaving. Your answering questions. I agree 100%. The AMA and AAOS really should review this and update their guidelines so we can be coding consistently. Until then...
 
Adding to keep this thread open for discussion. Even 1 yr later, providers are being told to use 27428 & are labeling this as an augmentation reconstruction. Since the ACL is not repaired nor is a ligament graft applied to consider this a reconstruction, the absorbable implant leaves nothing to remove in the future. So I'm curious as to how this could be considered augmenting and/or repairing. As well as FDA clearance states this implant is for a repair, while other FDA approved implants are approved as ACL reconstruction implant (ie: Arthrex Tightrope). To note, I did send a general request to AMA CPT assist for guidance but response may be delayed & would like other coders' input. Am I overthinking this procedure?
 
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