Hi everyone.
Provider billed 27535-LT, 27332-LT, 76000, and 27599 -LT. Is the unlisted code supported by the following ?
PREOPERATIVE DIAGNOSIS:
1. Left tibial plateau fracture
2. Left lateral meniscus tear
POSTOPERATIVE DIAGNOSIS:
1. Left tibial plateau fracture
2. Left lateral meniscus tear
PROCEDURE INFORMATION:
1. Left tibial plateau open reduction and internal fixation
2. Left knee, lateral partial meniscectomy, open
3. Supervision of fluoroscopy
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 10 cc.
IMPLANTS: DePuy Synthes tibial plateau plate and screws
COMPLICATIONS: None
DISPOSITION: Stable to PACU
INDICATIONS: The patient is a 48 year old male with a severely displaced and depressed left lateral tibial plateau fracture characterized by significant articular surface depression and
malalignment, consistent with an unstable intra-articular injury. There is a large depressed and tilted chondral/articular fragment, and the patient is unable to bear weight. He also demonstrates a mechanical block to knee range of motion, raising concern for an associated meniscal tear or intra-articular fragment interposition. Given the degree of displacement, articular involvement, and mechanical block, this injury is not amenable to nonoperative management. Operative intervention was medically necessary to restore joint congruity, alignment, and function, and to address likely associated intra-articular pathology. The recommended procedure was open reduction and internal fixation (ORIF) of the tibial plateau fracture, including elevation of thedepressed articular surface, bone grafting and/or bone void filler as needed, and plate and screwfixation, with concomitant evaluation and treatment of intra-articular pathology including possible meniscal repair or debridement as indicated intraoperatively. Surgical management was
recommended on an urgent basis as delay in treatment increases the risk of permanent articular incongruity, persistent mechanical symptoms, post-traumatic osteoarthritis, malunion, chronic pain, and functional limitation. The recommended operative procedure was discussed with patient in detail. Indications and procedural description provided in depth. All questions answered. Risks of the surgery were discussed which included but were not limited to neurovascular injury,
chronic knee pain and stiffness, malunion, nonunion, symptomatic hardware, implant failure, infection, incomplete resolution of symptoms, the possible need for additional operations, and the risks associated with anesthesia including deep venous thrombosis, pulmonary embolism, stroke, heart attack, and potentially death. Patient verbalized an understanding of these risks and signed consent can be found in the chart.
OPERATIVE PROCEDURE: Patient was seen preoperatively. All questions were answered. He was taken by Anesthesia to the operating room and general anesthesia was induced. Pt was
transferred to the OR table, bump was placed under the operative side hip. Preoperative IV antibiotics were given within an hour of incision. A Foley was placed. Touniquet was placed
around proximal operative side thigh. SCDs were placed on the contralateral lower extremity. All bony prominences padded. He was then pre-prepped and sterilely prepped and draped in the usual standard fashion.
A time-out was called and all were in agreement. Esmarch was used to exanguinate the operative extremity. Tourniquet was inflated to 250 mmHg. Triangle was placed under the knee. Incision was marked out longitudinally 2cm lateral to the crest then curving over Gerdy's tubercle and then posteriorly at the joint line towards the fibula. Incision was made sharpy through skin and subcutaneous tissue down to tibialis anterior fascia distally and IT band proximally. Tibialis anterior fascia was incised with a small cuff to be used for repair. The IT band was released off Gerdy's tubercle and posteriorly. A periosteal elevator was used to release the tibialis anterior muscle off the tibia. The submeniscal arthrotomy was performed just above the lateral plateau. Joint hematoma was expelled from the joint. The meniscus was identified as well as a small tear in
the white zone of the lateral meniscus that was not amendable to repair so we performed a open partial meniscectomy. The fracture and large depressed fragment was then identified and booked open. Fracture hematoma and small loose cartilage fragments was removed. The site was irrigated. The meniscus was identified in the joint and pulled out of the fracture site. A 2-0 fiberwire suture was used to tag the lateral meniscus anteriorly and posteriorly.
The fracture site was booked open with a lamina spreader and the depressed fragment was identified. This was loosened up with a freer and then a curved tamp was used to elevate the fragment to its proper position via direct visualization and fluoroscopy. We used a freer to also assess the joint line and confirmed appropriate position. A k-wire was then introduced from lateral to medial to hold the fragment and then brought out medially to allow for reduction of the lateral fragment. We then placed cancellous bone chips into the void beneath the depressed fragment and tamped them in. Cerament was then used to fill in the crevices of the void. The plate was then placed with fracture reduced manually, but just prior to placement, we then placed a the fiberwire from the meniscus through the proximal anterior k-wire hole. K-wire was then placed into the proximal pin holes to hold the plate and fracture in position. A large Weber clamp was used to compress the plate and fracture site nicely. We then filled the proximal rafter holes
with locking screws, removed the k-wires and then placed the oblique kickstand screw. We then placed the distal screw. We then secured the meniscus fiberwire and tied it to the plate. This completed our fixation. We confirmed appropriate position of implant and alignment of the plateau. We then irrigated copiously, and closed in the standard fashion with #1 vicryl for the deep fascia, capsule and iliotibial band, 0 figure-of-eight Vicryl for deep layers, 2-0 Vicryl and 3-0 stratafix monocryl with prineo dermabond mesh for skin. Marcaine with epinephrine was injected. We then released tourniquet. Sterile dressing was placed. The patient was awakened in the operating room and taken to recovery in stable condition.
Provider billed 27535-LT, 27332-LT, 76000, and 27599 -LT. Is the unlisted code supported by the following ?
PREOPERATIVE DIAGNOSIS:
1. Left tibial plateau fracture
2. Left lateral meniscus tear
POSTOPERATIVE DIAGNOSIS:
1. Left tibial plateau fracture
2. Left lateral meniscus tear
PROCEDURE INFORMATION:
1. Left tibial plateau open reduction and internal fixation
2. Left knee, lateral partial meniscectomy, open
3. Supervision of fluoroscopy
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 10 cc.
IMPLANTS: DePuy Synthes tibial plateau plate and screws
COMPLICATIONS: None
DISPOSITION: Stable to PACU
INDICATIONS: The patient is a 48 year old male with a severely displaced and depressed left lateral tibial plateau fracture characterized by significant articular surface depression and
malalignment, consistent with an unstable intra-articular injury. There is a large depressed and tilted chondral/articular fragment, and the patient is unable to bear weight. He also demonstrates a mechanical block to knee range of motion, raising concern for an associated meniscal tear or intra-articular fragment interposition. Given the degree of displacement, articular involvement, and mechanical block, this injury is not amenable to nonoperative management. Operative intervention was medically necessary to restore joint congruity, alignment, and function, and to address likely associated intra-articular pathology. The recommended procedure was open reduction and internal fixation (ORIF) of the tibial plateau fracture, including elevation of thedepressed articular surface, bone grafting and/or bone void filler as needed, and plate and screwfixation, with concomitant evaluation and treatment of intra-articular pathology including possible meniscal repair or debridement as indicated intraoperatively. Surgical management was
recommended on an urgent basis as delay in treatment increases the risk of permanent articular incongruity, persistent mechanical symptoms, post-traumatic osteoarthritis, malunion, chronic pain, and functional limitation. The recommended operative procedure was discussed with patient in detail. Indications and procedural description provided in depth. All questions answered. Risks of the surgery were discussed which included but were not limited to neurovascular injury,
chronic knee pain and stiffness, malunion, nonunion, symptomatic hardware, implant failure, infection, incomplete resolution of symptoms, the possible need for additional operations, and the risks associated with anesthesia including deep venous thrombosis, pulmonary embolism, stroke, heart attack, and potentially death. Patient verbalized an understanding of these risks and signed consent can be found in the chart.
OPERATIVE PROCEDURE: Patient was seen preoperatively. All questions were answered. He was taken by Anesthesia to the operating room and general anesthesia was induced. Pt was
transferred to the OR table, bump was placed under the operative side hip. Preoperative IV antibiotics were given within an hour of incision. A Foley was placed. Touniquet was placed
around proximal operative side thigh. SCDs were placed on the contralateral lower extremity. All bony prominences padded. He was then pre-prepped and sterilely prepped and draped in the usual standard fashion.
A time-out was called and all were in agreement. Esmarch was used to exanguinate the operative extremity. Tourniquet was inflated to 250 mmHg. Triangle was placed under the knee. Incision was marked out longitudinally 2cm lateral to the crest then curving over Gerdy's tubercle and then posteriorly at the joint line towards the fibula. Incision was made sharpy through skin and subcutaneous tissue down to tibialis anterior fascia distally and IT band proximally. Tibialis anterior fascia was incised with a small cuff to be used for repair. The IT band was released off Gerdy's tubercle and posteriorly. A periosteal elevator was used to release the tibialis anterior muscle off the tibia. The submeniscal arthrotomy was performed just above the lateral plateau. Joint hematoma was expelled from the joint. The meniscus was identified as well as a small tear in
the white zone of the lateral meniscus that was not amendable to repair so we performed a open partial meniscectomy. The fracture and large depressed fragment was then identified and booked open. Fracture hematoma and small loose cartilage fragments was removed. The site was irrigated. The meniscus was identified in the joint and pulled out of the fracture site. A 2-0 fiberwire suture was used to tag the lateral meniscus anteriorly and posteriorly.
The fracture site was booked open with a lamina spreader and the depressed fragment was identified. This was loosened up with a freer and then a curved tamp was used to elevate the fragment to its proper position via direct visualization and fluoroscopy. We used a freer to also assess the joint line and confirmed appropriate position. A k-wire was then introduced from lateral to medial to hold the fragment and then brought out medially to allow for reduction of the lateral fragment. We then placed cancellous bone chips into the void beneath the depressed fragment and tamped them in. Cerament was then used to fill in the crevices of the void. The plate was then placed with fracture reduced manually, but just prior to placement, we then placed a the fiberwire from the meniscus through the proximal anterior k-wire hole. K-wire was then placed into the proximal pin holes to hold the plate and fracture in position. A large Weber clamp was used to compress the plate and fracture site nicely. We then filled the proximal rafter holes
with locking screws, removed the k-wires and then placed the oblique kickstand screw. We then placed the distal screw. We then secured the meniscus fiberwire and tied it to the plate. This completed our fixation. We confirmed appropriate position of implant and alignment of the plateau. We then irrigated copiously, and closed in the standard fashion with #1 vicryl for the deep fascia, capsule and iliotibial band, 0 figure-of-eight Vicryl for deep layers, 2-0 Vicryl and 3-0 stratafix monocryl with prineo dermabond mesh for skin. Marcaine with epinephrine was injected. We then released tourniquet. Sterile dressing was placed. The patient was awakened in the operating room and taken to recovery in stable condition.