Wiki Help coding this op note please

[dsibley67]

This is a new physician to our facility, and new procedures I am not used to coding. I want to make sure I am coding this op note correctly. I have so far 29888, 29889, 27427. Any help will be greatly appreciated.
POSTOPERATIVE DIAGNOSIS: Multiligament knee injury.
PROCEDURES PERFORMED:
1. ACL reconstruction with quad allograft plus InternalBrace.
2. Popliteal fibular reconstruction with allograft.
3. LCL reconstruction with allograft.
4. Posterior cruciate ligament repair.
5. Closed treatment of MCL tear.
6. Peroneal nerve neurolysis
DESCRIPTION OF PROCEDURE
The right leg was sterilely prepped and draped in standard orthopedic
fashion. A time-out was called confirming patient laterality and plan for administration of antibiotics and
every one in the room agreed to proceed. The leg was exsanguinated with an Esmarch tourniquet, it was
a venous tourniquet, so I elected to dropped the tourniquet after 11 minutes. I placed the trocar. I went
into the suprapatellar pouch. There were no loose bodies in the medial and lateral gutters difficult but did
not see any free loose bodies. I went into the varus and valgus stress. There is no meniscus tear medially
or laterally. There was abundant amount of hematoma. This was debrided sharply away. There were no
full-thickness cartilage defects. At that point, the PCL had adequate tissue quality, so I was able to free
up the scarring of the PCL and then mobilized. I attempted to the shape of the ACL, but overall the ACL
tissue quality was poor, so I elected to proceed with an ACL reconstruction then do a repair of the PCL.
I placed two fiber ring stitches through the PCL. I shuttled them into a suspensory fixation. I then made a
provisional another portal more lateral to get better trajectory. I placed then a 4 mm spade tip out the
medial side in relative hyperflexion. Following this, I brought a passing stitch through to the medial side. I
then passed the stitches. I tightened provisionally down to 90 degrees of flexion and at the same time did
an anterior to posterior translation of the tibia. Following this, I then proceeded with the ACL
reconstruction. I used 65 mm x 10 mm QuadLink allograft. This was prepared in standard suspensory
fixation on the back table by physician assistant. Then, I used a FlipCutter to both my tunnels after
prepping at 10.5 mm each way, so I shuttled and this was done from the lateral portal visualized from the
medial portal for the femur and then made the tunnel approximately 25 mm. Then, I flipped the tunnels. I
then removed the debride with a shaver. I then passed the suture. I then viewed laterally used my tibial
guide and made a tunnel of 25 mm. I then proceeded with passing the graft with an internal brace. I dunk
the graft on both sides. I tensioned this in extension. I did great tension. I then did 20 flexion and
extension to get clip part of the system and then went into extension. I tightened both on the tibia and
femur. I used the tibial button. I placed the InternalBrace through a hole into the tibial button. I then
proceeded with open posterolateral corner as described by RCRO. I identified the peroneal nerve. I
released both proximally and distally around the fibula, so I protected this throughout duration of the case.
I identified the fibular head. I exposed anteriorly. There was no attachment to the LCL and all scar
tissue. So I did not attempt to tease out the LCL. Following this, I performed anterolateral to
posteromedial with a pin. I then over rimmed by 6 mm because the graft was prepared on the back table
and had easily gone through the 6. Following this, I made the window through the IT band. I excised the
IT band bursa laterally. My ACL fixation was at the level of my LCL, so I went ahead to make a
popliteal fixation point. I used 20 mm from center to center. I inserted the knee FiberTak in slightly
proximally and anterior to make sure I did not have any tunnel convergence with my ACL. Following this,
I then brought out the allograft. I brought it through my fibular head and then deep I brought from within
the popliteal hiatus from posterior to anterior. Then, I took my anterior limb and went underneath the IT
band and bicipital femoral attachment back to my LCL. I tied LCL and made a staple configurations. I
then did a knotless mechanism of the FiberTak and then I tied it back onto itself with a #2 FiberWire. This
was done in 30 degrees of internal flexion, slight internal rotation of valgus force. Following this, I then
retensioned, made sure I was down completely on my PCL repair. I did have to retension. I tensioned
and then I also did my InternalBrace in extension. This was drilled and then used a tap as well and then
placed the SwiveLock. The knee had a 1A Lachman, 2A PCL and 1A lateral LCL. We then closed with
0-Vicryl within my layers of the RCRO technique followed by 2-0 Vicryl, followed by horizontal mattress
nylon stitches. The portal sites were all closed with nylon. The medial side was closed with 2-0 Vicryl
followed by nylon and then the anteromedial tibial wound was closed with a 2-0 Vicryl followed by nylon.
The wounds were dressed with Xeroform, 4x4s, ABD, MediPort, sterile Webril followed by Ace wrap
and then patient was placed in a T-scope hinged knee brace. The patient was successfully awoken up
from anesthesia and taken to PACU in stable condition. The BK was injected postop immediately
following surgery prior to her waking up for added postoperative pain control. Overall, total tourniquet
time was 11 minutes. Modifier 22 given the patient's BMI of 43. Increased duration of surgical time and
planning as well as graft preparation. The patient will be foot flat weightbearing with the knee locked in
extension. She can work on flexion and extension from 0 to 90 degrees and then progress. She will come
back at a two week check for skin check and then we will see back at six week mark as well

 

[NRaizman]

He should be proofreading his operative reports. It's Arciero, not RCRO.

Your initial codes are correct.
You cannot code for peroneal nerve neurolysis when it was performed incidentally to the extra-articular ligament reconstruction.
The extra-articular ligament recon code includes both LCL and posterolateral corner.
There is no code for closed treatment of the MCL. There is a code for closed treatment of knee dislocation, but since he's already treated it operatively, there's no additional coding for the MCL.

 

[amyjph]

@dsibley67 Are you a newer coder to orthopedics? This is not meant to be disrespectful, however, I notice you post a lot of full op reports for coding help. Do you have a senior coder, supervisor or a coding educator in your group you can collaborate with? If you are coding mostly orthopedics, do you have training and education available to you? It seems you are coming to the forums frequently for full coding of operative reports. While it is great that you are listing the CPTs you have chosen, it is helpful for your learning if you explain to us WHY you chose them. You could also outline the op report to show where you think the code occurs. Otherwise it just feels like we are coding these for you. I would also suggest using an NCCI editor, other product like an encoder pro type, or AAOS Code-X and/or AAOS Complete Global Service Data for Orthopaedic Surgery (this is inside codex or available separately) if you have access to any of these. I also suggest watching procedures and googling them to see how they are performed. Example: https://www.orthobullets.com/knee-and-sports/3012/posterolateral-corner-injury https://jassm.org/the-posterolateral-corner-explanations-and-outcomes/

This is another resource I have used for learning: https://www.kzanow.com/specialties
This is my feedback from years of training, specifically, orthopedic coders. It helps you learn and grow if you have to explain the reasoning behind the codes chosen. Not just listing them next to the procedure header. My suggestion would be to list the CPTs next to the header list, then go into the body and underling or highlight where each one occurred in the body of the report. I have seen so many times where the provider forgot to describe something in the body, or the body is too vague and the report has to be sent back to them for review/clarification (proofreading ). I know this can be difficult when we are working under time and production constraints, but it's the only way to learn.

Something to point out in this op note: Modifier 22 given the patient's BMI of 43. Increased duration of surgical time and planning as well as graft preparation.

As always, agree with Dr. Raizman, we're lucky he helps us out on these forums! If you have access, you can also reach out to your providers for education. Many times they love to do lunch and learns and/or work with coders to help them learn about procedures. This is especially true for new providers to your practice. Take the time to fully review their notes and look for any improvement opportunities and clarification if you are not used to seeing what they do.

 

[dsibley67]

@dsibley67 Are you a newer coder to orthopedics? This is not meant to be disrespectful, however, I notice you post a lot of full op reports for coding help. Do you have a senior coder, supervisor or a coding educator in your group you can collaborate with? If you are coding mostly orthopedics, do you have training and education available to you? It seems you are coming to the forums frequently for full coding of operative reports. While it is great that you are listing the CPTs you have chosen, it is helpful for your learning if you explain to us WHY you chose them. You could also outline the op report to show where you think the code occurs. Otherwise it just feels like we are coding these for you. I would also suggest using an NCCI editor, other product like an encoder pro type, or AAOS Code-X and/or AAOS Complete Global Service Data for Orthopaedic Surgery (this is inside codex or available separately) if you have access to any of these. I also suggest watching procedures and googling them to see how they are performed. Example: https://www.orthobullets.com/knee-and-sports/3012/posterolateral-corner-injury https://jassm.org/the-posterolateral-corner-explanations-and-outcomes/

This is another resource I have used for learning: https://www.kzanow.com/specialties
This is my feedback from years of training, specifically, orthopedic coders. It helps you learn and grow if you have to explain the reasoning behind the codes chosen. Not just listing them next to the procedure header. My suggestion would be to list the CPTs next to the header list, then go into the body and underling or highlight where each one occurred in the body of the report. I have seen so many times where the provider forgot to describe something in the body, or the body is too vague and the report has to be sent back to them for review/clarification (proofreading ). I know this can be difficult when we are working under time and production constraints, but it's the only way to learn.

Something to point out in this op note: Modifier 22 given the patient's BMI of 43. Increased duration of surgical time and planning as well as graft preparation.

As always, agree with Dr. Raizman, we're lucky he helps us out on these forums! If you have access, you can also reach out to your providers for education. Many times they love to do lunch and learns and/or work with coders to help them learn about procedures. This is especially true for new providers to your practice. Take the time to fully review their notes and look for any improvement opportunities and clarification if you are not used to seeing what they do.

Thank you for your suggestions. This is a new physician performing surgeries at our facility. So these procedures that he is doing, I am not used to coding. So, when I post for help, I mostly want confirmation that I have coded it correctly. I am the only coder at our facility, and no, I don't have a senior coder, supervisor, or coding educator that I can go to for help with coding questions. In the future, I will list the CPT codes and explain why I chose the codes. I try to take as many training webinars as I can, as my budget allows, since my employer does not pay for training. I do have Codify. Once I have my codes, I input them into Codify NCCI edits to make sure there are no edits for them. Thank you again for your suggestions.

 

[dsibley67]

He should be proofreading his operative reports. It's Arciero, not RCRO.

Your initial codes are correct.
You cannot code for peroneal nerve neurolysis when it was performed incidentally to the extra-articular ligament reconstruction.
The extra-articular ligament recon code includes both LCL and posterolateral corner.
There is no code for closed treatment of the MCL. There is a code for closed treatment of knee dislocation, but since he's already treated it operatively, there's no additional coding for the MCL.

Thank you so much for your help! It is much appreciated!

 

[amyjph]

Thank you for your suggestions. This is a new physician performing surgeries at our facility. So these procedures that he is doing, I am not used to coding. So, when I post for help, I mostly want confirmation that I have coded it correctly. I am the only coder at our facility, and no, I don't have a senior coder, supervisor, or coding educator that I can go to for help with coding questions. In the future, I will list the CPT codes and explain why I chose the codes. I try to take as many training webinars as I can, as my budget allows, since my employer does not pay for training. I do have Codify. Once I have my codes, I input them into Codify NCCI edits to make sure there are no edits for them. Thank you again for your suggestions.

Darn, that sounds tough and like you are mostly going it alone. Sorry to hear that. Sounds like a difficult place to work. No paid training, no help
Great that you are using Codify at least. Are you coding for the facility charges or pro-fee? Sometimes that makes a difference.