Still Confused
I don't know why I am having such a problem with this. My Dr. coded this with 27090 w/a modifier 22. Do you think CPT 27091 would be appropriate? Thank you for your help. I REALLY appreciate it.
"We started by excising the old incision at the proximal end. It curved posterolaterally over her buttock. This was where the sinus tract had developed and it was excised. Full thickness slices were developed.
Distally the fascia was separated from the vastus lateralis proximally. It was very difficult and was one mass and so it was taken through a longitudinal incision and elevated it up off the femur distally and the
ileum proximally, as well as, construct. Having dissection planes created, dissection was then carried out. The anterior brim of the pelvis was identified and a cobra retractor was placed and then later a Homan
retractor was placed into the superior ileum to gain exposure. The cup itself was loose. There was radiolucency around it on the x-ray. It had gross mobility but was mechanically locked within a few millimeters of its position with an osteotome and a large amount of the cement around it was removed and with Moreland cup remover, the remainder was removed. The stem itself appeared to be Striker design so the proximal body was removed from the stem. We then turned our attention back to the acetabulum. Several pendulum wedges were identified. Most were covered in cement and difficult to access. Some were removed en bloc with the cement they were attached to. As best I could tell, only two maybe three were attached to bone but did not have any type of fixation other than the screw. We were able to use the drills and drill the cement out of the screw hole and then use the standard 3.5 drill bit to remove the screw and the blocks themselves were removed. After removing all excess cement, thorough debridement with a
Midas Rex was carried out and we identified the areas of living bone. It was overall very sclerotic and hard, but there were areas of punctate bleeding. Having done a thorough debridement, the pubis and ischium were palpated. There was a large gap that was potentially amenable to gap reconstruction in the future with possibly a seven graft type as described by Paprosky. Once this was done, the stem was fully porous coated and had excellent radiographic end growth. There was some cement from about 1 to 2 centimeters around the proximal ring. It was unclear the purpose of this cement. It was removed with an osteotome and access to the bony surface was identified and excellent on growth and end growth was confirmed. As
this was fully porous coated, it was about 120 to 125 in length. Given that, the only way to use the proximal end to remove the device would be to split the femur. This would require additional hardware placement which may preclude clearing of her infection; therefore, the end of the device was removed with a Midas Rex wheel taking care to protect the soft tissues from metal debris with lap sponges. Once this was done, the immediate interface between the porous coated stem and the bone was disrupted with a
Midas Rex side cutting bit circumferentially for as best we could for the depth of the bit. We then passed what appeared to be a 13 mm stem so we initially passed a 13 mm trephine over it, but expected that it would eventually bind up and then we went to the 14 mm trephine and with quite a bit of effort, we were able to get down to the tip and remove it without splitting the femur and preserving a majority of the bone. The tip of the device had very solid attachment to the anterior cortex and removed with the device was a small piece of cortical bone with muscle attached to it that was from this location but no disruption of the continuity of the femoral shaft occurred. We then irrigated with 6 liters of antibiotic solution followed by Betadine and Peroxide followed by irrigation with an additional 6 liters."