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26990 or 26991

cmacpc

Networker
Messages
80
Location
Oakbrook, IL
Best answers
0
Need help Please:
excisional debridement of skin, subcutaneous tissue, fascia, muscle, and bone left hip
Primary Surgeon:

Anesthesia:
general
Estimated Blood Loss: 75
Drains:
small hemovac
Complications:
none
Indications:
50 yo female presented with 4 month history of progressively worsening left hip pain. Hip aspiration revealed staph aureus growing from synovial fluid culture. I recommended irrigation and debridement of the hip in the OR. I explained the risk of the procedure to the patient, and she agreed to proceed. Informed consent was obtained.
Description of Procedure
Patient was brought back to the OR and placed supine on the table. After general anesthesia, the left LE and hip were prepped and draped. A 10cm incision was made anteriorly. The tensor fascia was incised. An anterior capsulotomy was made. A small amount of cloudy fluid was encountered. Cultures were obtained. The wound was irrigated with 3L of saline using pulse lavage. A drain was placed next to the joint. The fascia was closed using #1 vicryl, the subcutaneous tissues were closed using 2-0 vicryl, and the skin was closed using staples. The patient was awakened from anesthesia and tranferred to the recovery room in stable condition having tolerated the procedure well.

The only codes I can up with are 26990 or 26991 any help or suggestion are appreciated,

TIA
 

cgaston

Expert
Messages
420
Best answers
0
IMHO, I would choose 26990 because there is no mention of the bursa in the op note
 

Jpad

Networker
Messages
27
Best answers
0
I would actually choose neither codes and would recommend CPT code 27030 in their stead.
Capsulotomy was performed, which meant that the joint was entered and arthrotomy was performed.
 
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