Orthopedic Coding Alert

"Question: How do I code an open medial plication for dislocation of patella? Also done during the same operative session was a scope with loose body removal, debridement of patella and arthroscopic lateral retinacular release. The operative report reads: Sharp dissection was carried down to the edial retinaculum with no attempt to dissect any of the vastus medialis. The retinaculum was opened and then imbricated approximately 1.5 cm in the repair zone. Vest-over-pants repair was done utilizing #2 Ethibond. The knee was put through a range of motion and found to be very stable with good repair. There was some lateral translation of the patella so it did not overtighten.

Georgia Subscriber

Answer: When it seems as if multiple procedures have been performed, it is best to take a step back and ask, What was the main procedure done?, says C.J. Wolf, MD, CPC, senior coding consultant with Intermountain Health Care in Salt Lake City. In the above question, the phrase for dislocation of the patella sticks out. The musculoskeletal system in the surgery section of CPT is a good place to start. Because this operation was performed on the knee, using a code from the femur (thigh region) and knee joint section (27301-27599) is one option.

But because arthroscopy is also mentioned in the operative report, choosing an arthroscopic code (29800-29909) is also a choice.

Any time multiple codes are chosen, coders should check the Correct Coding Initiative (CCI) edits to see if any are considered bundled. Although the CCI is the Health Care Financing Administrations (HCFAs) editing system, most other payers follow its lead. In other words, payment may vary depending on the payers policy. Looking in the repair, revision, and/or reconstruction section we find codes 27420 -27424 for reconstruction of a dislocating patella. One of these codes will be the primary procedure. Without having the entire operative report, it would be impossible to give the exact code. But, from the brief description given, 27424 (reconstruction of dislocating patella; with patellectomy) sounds like the best choice. Coders should recheck the operative report with the surgeon and check the CCI edits because 27425 (lateral retinacular release) is considered included in 27424 and is not reportable unless it is done at a separate incision, site or session. In other words, 27424 is the more extensive procedure and should be reported instead.

Code 29874 (arthroscopy, knee, surgical; for removal of loose body or foreign body [e.g., osteochondritis dissecans fragmentation, chondral fragmentation]) should be reported with modifier -51 to show it was a multiple procedure done at the same session. The -51 modifier is appended to the lesser of the procedures. This is determined by looking up the relative value unit for each procedure in the Federal Register. Whichever has the greatest value is considered the primary procedure. All other procedures performed would have the -51 modifier appended.
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