Hi list I have only been coding Ortho for a little over a year and can't recall if I have ever seen this being done. Could use some guidance here 
27416? 29877 would be included from what I am reading since it is same compartment.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Osteochondral injury, left lateral femoral condyle with loose
osteochondral fragment.
POSTOPERATIVE DIAGNOSIS:
Osteochondral injury, left lateral femoral condyle with loose
osteochondral fragment.
PROCEDURES:
1. Open osteochondral allograft transplantation/fixation
(27416).
2. Arthroscopic shaving chondroplasty, left patellofemoral
joint (29877). Please put a modifier 22 on this case due to
the extended surgical time of over 2 hours. The arthrotomy,
the size of the fragment that required 9 absorbable screws and
considerable time for debridement and fixation of the fragment
itself.
SURGEON:
ASSISTANT:
procedure. There was no qualified resident available.
ANESTHESIA:
General with a block.
ESTIMATED BLOOD LOSS:
Less 100 mL.
INTRAVENOUS FLUIDS:
1000 mL.
INDICATIONS FOR PROCEDURE:
is a 17-year-old male who goes toHigh
School who had a previous knee injury in the summer but
recovered from that without surgical intervention. On January
30th, he was doing some personal training with his ROTC
program, he twisted his knee, he had immediate pain and
swelling in his left knee, difficulty moving his knee and felt
a pop. He reports swelling, stiffness, pain and instability
in the left knee. He was seen by Dr. on February
3, 2015. Dr. asked me to see him, evaluate his MRI
and clinical findings. He had an injury consistent with an
osteochondral lesion over his lateral femoral condyle with a
large osteochondral fragment. He and his parents were advised
the risks and benefits of operative versus nonoperative
intervention and agrees to proceed with surgery today.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine
on the OR table, underwent general anesthesia without
difficulty. Preop time-out was done, identifying his left
knee as the operative knee. His exam under anesthesia
revealed a stable Lachman, stable to varus and valgus stress,
stable anterior and posterior drawer. He had a negative pivot
shift evaluation. His patella mobility was symmetric
bilaterally. He was then placed in nonsterile tourniquet and
a leg holder with all bony prominences padded. He was prepped
and draped in sterile fashion using ChloraPrep. His limb was
elevated, exsanguinated and tourniquet was raised. We first
began the diagnostic arthroscopy through an anteromedial and
anterolateral portal with the following findings. He had some
grade II chondromalacia both on his medial aspect of his
patella as well as the lateral aspect of his trochlea. This
was debrided back to stable rim using oscillating shaver, was
a partial full-thickness defect. He had a large osteochondral
fragment that measured 4 x 3 cm and essentially was the entire
weightbearing portion of his lateral femoral condyle. We
expanded our lateral portal and removed this arthroscopically
for later transfer and fixation into the defect. This was a
large osteochondral fragment upon inspection, did have viable
bone and cartilage. We then completed the remaining portions
of the diagnostic arthroscopy with the following findings.
His medial joint had no chondromalacia and an intact meniscus.
Intercondylar notch had an intact ACL and PCL. His lateral
joint had an intact meniscus. No chondromalacia on the tibia.
He had a large osteochondral defect along his weightbearing
portion of his lateral femoral condyle measuring 3 x 3 cm in
length and 2.5 cm in diameter. The bone was viable and with
minimal debridement bled nicely. Due to the size of the
fragment, the osteochondral fragment/fixation was necessitated
and arthrotomy. We extended our anterolateral portal both
proximally and distally, being careful to not injure the
lateral meniscus. This gave us good access to the
osteochondral injury. The fragment was then reduced until the
defect was slightly proud. We therefore used a bur to contour
the osteochondral injury to accept the fragment. The fragment
was then provisionally reduced into the defect using K-wires.
We subsequently drilled, tapped, and placed 9 Arthrex
Bioabsorbable screws along the defect in order to hold it
securely. The reduction on the weightbearing portion of the
fragment was excellent with a small step-off, both proximally
and laterally approximately 1 mm that was not a weightbearing
portion and not an articular portion of the defect. Once this
was accomplished, we ranged the knee through flexion and
extension and the fragment was stable and fixed nicely.
We then copiously irrigated the wound and closed the
arthrotomy with interrupted #1 Vicryl stitches in a
figure-of-eight fashion, 2-0 Vicryls on the subcutaneous layer
and 3-0 nylons on the skin. Xeroform, dressing sponges,
Webril, Ace wrap and a hinged knee brace from 0-90 degrees was
applied. The patient tolerated the procedure well and
transferred to recovery room in stable condition.
Postoperatively, he will be placed on knee arthroscopy with
OATS protocol. Of note, he is to be TOUCHDOWN WEIGHTBEARING
for the next 6 weeks. He is also to start a continuous
passive motion machine from 30-70 degrees and advance 10
degrees for goal 0-120 degrees. He is to use for at least 2
hours a day for 200 flexion, extension cycles, whichever comes
first. We will start physical therapy in 1-3 days and follow
up in clinic in 10-14 days for repeat evaluation and suture
removal.
27416? 29877 would be included from what I am reading since it is same compartment.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Osteochondral injury, left lateral femoral condyle with loose
osteochondral fragment.
POSTOPERATIVE DIAGNOSIS:
Osteochondral injury, left lateral femoral condyle with loose
osteochondral fragment.
PROCEDURES:
1. Open osteochondral allograft transplantation/fixation
(27416).
2. Arthroscopic shaving chondroplasty, left patellofemoral
joint (29877). Please put a modifier 22 on this case due to
the extended surgical time of over 2 hours. The arthrotomy,
the size of the fragment that required 9 absorbable screws and
considerable time for debridement and fixation of the fragment
itself.
SURGEON:
ASSISTANT:
procedure. There was no qualified resident available.
ANESTHESIA:
General with a block.
ESTIMATED BLOOD LOSS:
Less 100 mL.
INTRAVENOUS FLUIDS:
1000 mL.
INDICATIONS FOR PROCEDURE:
is a 17-year-old male who goes toHigh
School who had a previous knee injury in the summer but
recovered from that without surgical intervention. On January
30th, he was doing some personal training with his ROTC
program, he twisted his knee, he had immediate pain and
swelling in his left knee, difficulty moving his knee and felt
a pop. He reports swelling, stiffness, pain and instability
in the left knee. He was seen by Dr. on February
3, 2015. Dr. asked me to see him, evaluate his MRI
and clinical findings. He had an injury consistent with an
osteochondral lesion over his lateral femoral condyle with a
large osteochondral fragment. He and his parents were advised
the risks and benefits of operative versus nonoperative
intervention and agrees to proceed with surgery today.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine
on the OR table, underwent general anesthesia without
difficulty. Preop time-out was done, identifying his left
knee as the operative knee. His exam under anesthesia
revealed a stable Lachman, stable to varus and valgus stress,
stable anterior and posterior drawer. He had a negative pivot
shift evaluation. His patella mobility was symmetric
bilaterally. He was then placed in nonsterile tourniquet and
a leg holder with all bony prominences padded. He was prepped
and draped in sterile fashion using ChloraPrep. His limb was
elevated, exsanguinated and tourniquet was raised. We first
began the diagnostic arthroscopy through an anteromedial and
anterolateral portal with the following findings. He had some
grade II chondromalacia both on his medial aspect of his
patella as well as the lateral aspect of his trochlea. This
was debrided back to stable rim using oscillating shaver, was
a partial full-thickness defect. He had a large osteochondral
fragment that measured 4 x 3 cm and essentially was the entire
weightbearing portion of his lateral femoral condyle. We
expanded our lateral portal and removed this arthroscopically
for later transfer and fixation into the defect. This was a
large osteochondral fragment upon inspection, did have viable
bone and cartilage. We then completed the remaining portions
of the diagnostic arthroscopy with the following findings.
His medial joint had no chondromalacia and an intact meniscus.
Intercondylar notch had an intact ACL and PCL. His lateral
joint had an intact meniscus. No chondromalacia on the tibia.
He had a large osteochondral defect along his weightbearing
portion of his lateral femoral condyle measuring 3 x 3 cm in
length and 2.5 cm in diameter. The bone was viable and with
minimal debridement bled nicely. Due to the size of the
fragment, the osteochondral fragment/fixation was necessitated
and arthrotomy. We extended our anterolateral portal both
proximally and distally, being careful to not injure the
lateral meniscus. This gave us good access to the
osteochondral injury. The fragment was then reduced until the
defect was slightly proud. We therefore used a bur to contour
the osteochondral injury to accept the fragment. The fragment
was then provisionally reduced into the defect using K-wires.
We subsequently drilled, tapped, and placed 9 Arthrex
Bioabsorbable screws along the defect in order to hold it
securely. The reduction on the weightbearing portion of the
fragment was excellent with a small step-off, both proximally
and laterally approximately 1 mm that was not a weightbearing
portion and not an articular portion of the defect. Once this
was accomplished, we ranged the knee through flexion and
extension and the fragment was stable and fixed nicely.
We then copiously irrigated the wound and closed the
arthrotomy with interrupted #1 Vicryl stitches in a
figure-of-eight fashion, 2-0 Vicryls on the subcutaneous layer
and 3-0 nylons on the skin. Xeroform, dressing sponges,
Webril, Ace wrap and a hinged knee brace from 0-90 degrees was
applied. The patient tolerated the procedure well and
transferred to recovery room in stable condition.
Postoperatively, he will be placed on knee arthroscopy with
OATS protocol. Of note, he is to be TOUCHDOWN WEIGHTBEARING
for the next 6 weeks. He is also to start a continuous
passive motion machine from 30-70 degrees and advance 10
degrees for goal 0-120 degrees. He is to use for at least 2
hours a day for 200 flexion, extension cycles, whichever comes
first. We will start physical therapy in 1-3 days and follow
up in clinic in 10-14 days for repeat evaluation and suture
removal.