Question 27620 & 27695

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Is it possible to bill 27695 & 27620 together? Below is the op report. To my knowledge as there wasn't any separate incisions or diagnoses you wouldn't be able to. I have already accounted for the OCD repair with 29892.

Pre-Operative Diagnosis: 1. Ankle arthritis with OCD, left ankle
2. Loose body, left ankle
3. Deltoid ligament tear, left ankle

Post-Operative Diagnosis: Same

Procedure: 1. Ankle arthroscopy with complex synovectomy and OCD repair, left ankle
2. Loose body removal, left ankle
3. Primary repair deltoid ligament tear, left ankle

Anesthesia: General with Pop/saph

Hemostasis: Ankle at 250 mmHg

EBL: Minimal

The patient was brought to the operating room and placed supine on the operating room table. After adequate general sedation, the left foot was then prepped and draped in the usual aseptic fashion. Upon exsanguination of the left foot and ankle with an esmark bandage and placement of padding at the ankle, the pneumatic ankle tourniquet was inflated to 250 mmHG.

Surgery began in the following manner:
Attention was directed to the anterior medial aspect of the left ankle just medial to the tibialis anterior tendon where a 20-gauge needle was inserted into the joint and 20cc’s of Lactated ringers' solution was injected into the ankle joint. A skin incision was made at the insertion site of the 20-gauge needle.

A 30-degree Dionic 2.9-millimeter endoscope was inserted and a complete diagnostic arthroscopy was performed with the following findings being noted. There was extensive thickening of the synovial lining of the ankle. No purulent drainage is noted within the ankle joint. Diffuse synovitis, of chronic and acute nature, with multiple adhesions, are noted on the lateral and medial shoulder of the talar dome. All ligaments appear intact medially.

Attention was then directed to the lateral aspect of the ankle where a skin incision was made at the level of the ankle joint just lateral to the extensor digitorum longus tendons. The incision was then deepened and a 3.5-millimeter razor cutter shaver was inserted, and areas of hypertrophied synovium were surgically lavaged and excised. The OCD, approx. 1.0 cm x 0.6 cm was encountered on the medial talar dome, with other smaller lesions noted on lateral talar dome, and the wafer of attached cartilage was removed with grasper. Utilizing curved small ankle pick, microfracture surgery was performed to the defects to promote bloody infiltrate. 3000 cc of lactated ringers were used to continually lavage the ankle joint.

All instrumentation was then removed, and the ankle was put through range of motion.

The site was then copiously flushed and irrigated with normal saline solution. The skin was closed using 3-0 Prolene in an interrupted fashion.

Next, attention was directed to the medial left ankle at the location of the medial malleolus. Dense scar tissue is encountered making skin layers and identification more difficult. Blunt and sharp dissection was performed with care taken to identify and retract all vital neuro and vascular structures. The medial malleolus and the loose body are identified. The loose body was primarily removed, with small fragments within the deep deltoid ligament left, as in to not further compromise them. The tearing in the rest of the superficial deltoid ligament is encountered and a Smith and Nephew anchor is placed within the medial malleolus, at this level, and the talus, and each anchor was tied in a box stitch fashion with the ankle DF utilizing the suture strands attached to the anchors. The ankle is now noted to supportive and without laxity.