dsibley67
Networker
- Messages
- 61
- Location
- Southaven, MS
Good morning everyone! May someone please review this operative note for correct coding? I am leaning toward CPT code 29856 with Dx code of S82.112A. The reason for this code instead of the ACL code (29888) he doesn't mention repairing the ACL at all. Any help is greatly appreciated. Thanks in advance!
PREOPERATIVE DIAGNOSIS: Left knee ACL tibial eminence avulsion.
POSTOPERATIVE DIAGNOSIS: Left knee ACL tibial eminence avulsion.
PROCEDURE PERFORMED: Left knee arthroscopy with ACL repair via tibial eminence ORIF.
The patient is a pleasant 14-year-old male presenting to
my office after a non-contact football injury on 08/12/2026. He plays on the JV team at a local high
school. He was cutting, felt his knee gave way. He had significant swelling with loss of range of motion.
Radiographs as well as advanced imaging demonstrated a displaced tibial eminence avulsion fracture of
the ACL. Given this I discussed with him operative intervention to include arthroscopic ACL repair via
open reduction and internal fixation of a tibial eminence avulsion fracture. I discussed the risks, benefits
and alternatives of surgery with his parents as noted in the clinical note. After weighing their options, they
expressed understanding and elected to proceed with surgery.
DESCRIPTION OF THE PROCEDURE: The patient was met in the preoperative holding area, prior
to initiation of any medication, the operative extremity was marked with indelible pen. The appropriate
laterality was confirmed verbally with the patient and any remaining questions were answered in their
entirety. The patient was taken to the operative suite where general anesthesia with an LMA was
administered by the anesthesia team, placed in the supine position on the operative table with a leg roller
and a leg pose for high thigh tourniquet. The right lower extremity was prepped and draped in usual sterile
fashion. A formal time-out to include administration of antibiotics, appropriate laterality, TXA, availability
of all necessary implants and any questions or concerns by surgical team were addressed and confirmed.
Tourniquet was then inflated to 250 mmHg after exsanguination. Using an #11 blade, created an anterolateral portal, blunt scope trocar, cannula in the suprapatellar pouch,
arthroscope was introduced, diagnostic arthroscopy was completed. I would say at that point there was
significant hemarthrosis that had to be evacuated. There were no concerning findings in the
patellofemoral joint. The medial femoral condyle and medial tibial plateau cartilage was intact. Anterior
and posterior horns of the medial meniscus were intact with no tearing. No tearing in the midbody. The
lateral compartment, the lateral femoral condyle and lateral tibial plateau cartilage was intact. No
concerning findings in the posterior or anterior root attachment of the lateral meniscus. No entrapment of
the menisci. No entrapment of the intermeniscal ligament was appreciated. No tearing upon probing of
the lateral meniscus. He did have a displaced avulsion of the tibial eminence noted. After confirming this,
I then turned my attention to creating a medial portal. This was localized under direct visualization with
spinal needle. Then went through #11 blade with the skin only, then blunt scope trocar using it under the
notch from the medial side.
I then turned my attention to the ACL and the tibial eminence. I used an elevator to elevate the tibial
eminence from its subchondral bed. I used a motorized shaver to debride the avulsion site both at the
proximal tibia and off of the undersurface of tibial eminence. Then with the knee at about 90 degrees of
flexion with cycling, I was able to obtain a provisional reduction of the tibial eminence. I then used a tibial
drill guide to locate the appropriate portion for the two tibial tunnels that would be needed. I then used a
#15 blade through the skin down to the medial cortex of the proximal tibia. Periosteal elevator was used
to elevate the periosteum. Bovie electrocautery was used to maintain meticulous hemostasis. I then used
the ring guide to first drill a hole to the lateral portion of the tibial eminence and then to the medial side. I
used a cannulated drill bit past a nitinol wire and then a loop suture for later passage of the ABS
TightRope. Once this was completed medially and laterally, I then placed a Passport in the medial portal.
Using a shoulder scorpion, I placed two fiber rings, first from medial to lateral, then from lateral to medial in the ACL body. I then passed these appropriately through the attachment device of the ABS TightRope.
The medial and lateral ABS TightRopes were then passed down through the previously drilled tibial
tunnels. The ABS buttons were attached. These were sequentially tightened. This allowed for excellent
reduction of the tibial eminence. Medial chondral surface was used to assess reduction. There was a
small 1 to 2 mm anterior lip that remained from previous scar tissue. This was lightly debrided with
motorized shaver. This had excellent reduction of the tibial eminence. Upon probing of the ACL, there
was excellent stability. He had a return of a 1A Lachman’s at 30 degrees of knee flexion. Final
arthroscopic images were obtained. This completed the arthroscopic ACL repair via open reduction
internal fixation of the tibial eminence fracture.
All excess fluid was drained from the knee. Portal sites were closed with 3-0 Prolene in a portal-style
fashion. Proximal tibial incision was closed with 2-0 Monocryl and running 3-0 Monocryl with Dermabond
and Steri-Strips. All surgical counts were correct. Sterile dressings were applied. The patient was
awakened from anesthesia, transferred to PACU in stable condition in a T-scope knee brace locked in
extension.
PREOPERATIVE DIAGNOSIS: Left knee ACL tibial eminence avulsion.
POSTOPERATIVE DIAGNOSIS: Left knee ACL tibial eminence avulsion.
PROCEDURE PERFORMED: Left knee arthroscopy with ACL repair via tibial eminence ORIF.
The patient is a pleasant 14-year-old male presenting to
my office after a non-contact football injury on 08/12/2026. He plays on the JV team at a local high
school. He was cutting, felt his knee gave way. He had significant swelling with loss of range of motion.
Radiographs as well as advanced imaging demonstrated a displaced tibial eminence avulsion fracture of
the ACL. Given this I discussed with him operative intervention to include arthroscopic ACL repair via
open reduction and internal fixation of a tibial eminence avulsion fracture. I discussed the risks, benefits
and alternatives of surgery with his parents as noted in the clinical note. After weighing their options, they
expressed understanding and elected to proceed with surgery.
DESCRIPTION OF THE PROCEDURE: The patient was met in the preoperative holding area, prior
to initiation of any medication, the operative extremity was marked with indelible pen. The appropriate
laterality was confirmed verbally with the patient and any remaining questions were answered in their
entirety. The patient was taken to the operative suite where general anesthesia with an LMA was
administered by the anesthesia team, placed in the supine position on the operative table with a leg roller
and a leg pose for high thigh tourniquet. The right lower extremity was prepped and draped in usual sterile
fashion. A formal time-out to include administration of antibiotics, appropriate laterality, TXA, availability
of all necessary implants and any questions or concerns by surgical team were addressed and confirmed.
Tourniquet was then inflated to 250 mmHg after exsanguination. Using an #11 blade, created an anterolateral portal, blunt scope trocar, cannula in the suprapatellar pouch,
arthroscope was introduced, diagnostic arthroscopy was completed. I would say at that point there was
significant hemarthrosis that had to be evacuated. There were no concerning findings in the
patellofemoral joint. The medial femoral condyle and medial tibial plateau cartilage was intact. Anterior
and posterior horns of the medial meniscus were intact with no tearing. No tearing in the midbody. The
lateral compartment, the lateral femoral condyle and lateral tibial plateau cartilage was intact. No
concerning findings in the posterior or anterior root attachment of the lateral meniscus. No entrapment of
the menisci. No entrapment of the intermeniscal ligament was appreciated. No tearing upon probing of
the lateral meniscus. He did have a displaced avulsion of the tibial eminence noted. After confirming this,
I then turned my attention to creating a medial portal. This was localized under direct visualization with
spinal needle. Then went through #11 blade with the skin only, then blunt scope trocar using it under the
notch from the medial side.
I then turned my attention to the ACL and the tibial eminence. I used an elevator to elevate the tibial
eminence from its subchondral bed. I used a motorized shaver to debride the avulsion site both at the
proximal tibia and off of the undersurface of tibial eminence. Then with the knee at about 90 degrees of
flexion with cycling, I was able to obtain a provisional reduction of the tibial eminence. I then used a tibial
drill guide to locate the appropriate portion for the two tibial tunnels that would be needed. I then used a
#15 blade through the skin down to the medial cortex of the proximal tibia. Periosteal elevator was used
to elevate the periosteum. Bovie electrocautery was used to maintain meticulous hemostasis. I then used
the ring guide to first drill a hole to the lateral portion of the tibial eminence and then to the medial side. I
used a cannulated drill bit past a nitinol wire and then a loop suture for later passage of the ABS
TightRope. Once this was completed medially and laterally, I then placed a Passport in the medial portal.
Using a shoulder scorpion, I placed two fiber rings, first from medial to lateral, then from lateral to medial in the ACL body. I then passed these appropriately through the attachment device of the ABS TightRope.
The medial and lateral ABS TightRopes were then passed down through the previously drilled tibial
tunnels. The ABS buttons were attached. These were sequentially tightened. This allowed for excellent
reduction of the tibial eminence. Medial chondral surface was used to assess reduction. There was a
small 1 to 2 mm anterior lip that remained from previous scar tissue. This was lightly debrided with
motorized shaver. This had excellent reduction of the tibial eminence. Upon probing of the ACL, there
was excellent stability. He had a return of a 1A Lachman’s at 30 degrees of knee flexion. Final
arthroscopic images were obtained. This completed the arthroscopic ACL repair via open reduction
internal fixation of the tibial eminence fracture.
All excess fluid was drained from the knee. Portal sites were closed with 3-0 Prolene in a portal-style
fashion. Proximal tibial incision was closed with 2-0 Monocryl and running 3-0 Monocryl with Dermabond
and Steri-Strips. All surgical counts were correct. Sterile dressings were applied. The patient was
awakened from anesthesia, transferred to PACU in stable condition in a T-scope knee brace locked in
extension.