Happy to review an operative note for confirmation, but, generally speaking, your surgeon is totally wrong.
This has been asked and answered in CPT-A (2025), which should give your supervisor all the information she needs:
Question:
If a surgeon makes a separate anteromedial incision to insert the harvested quadriceps tendon for grafting during an arthroscopic anterior cruciate ligament (ACL) reconstruction, would it be appropriate to report code 27428 for a mini-open procedure or code 29888 for an arthroscopically aided procedure?
Answer: It would be appropriate to report code
29888,
Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction, for an arthroscopic ACL reconstruction using quad autograft. Harvesting the graft from the ipsilateral knee through an “open incision” is included in the work of code
29888 and, therefore, would not be separately reportable. Note that code
29888 also includes harvesting and inserting the graft if it is obtained from the ipsilateral knee.
Thank you Dr. Raizman for looking at this for me. My managers basically said they want something like a side-by-side comparison of the 2 codes showing what makes this a 29888 vs a 27428. Here is one of his notes (he does this surgery often and the note is quite lengthy):
An examination under anesthesia revealed the patient had 0 to 135 degrees range of motion. 2B Lachman, 1+ pivot shift. Negative posterior drawer. Stable to varus/valgus stress test at both 0 and 30 degrees. Negative dial test. No posterolateral, no posteromedial rotatory instability.
A tourniquet was placed around the upper left thigh, and the left lower extremity was prepped and draped in the usual standard fashion. Surgical landmarks were palpated and marked out. An intraoperative time-out confirmed that the left knee was the correct operative site. An Esmarch bandage was wrapped around the left lower extremity and the knee was flexed up. The tourniquet was then inflated to 200 mmHg.
We first performed graft harvest. Made an incision over the distal quadriceps tendon approximately 2 to 3 cm. Skin was incised as well as subcutaneous tissue. Then identified the quadriceps tendon fascia, incised this. We then were able to identify the distal part of the quadriceps tendon and measured out a graft approximately 8-9 mm in diameter and 16 mm in length. We then were able to incise the graft and harvest it successfully.
Then took the graft to back table, proceeded with graft preparation. The graft measured 8.5 mm on the femoral side and 9 mm in the tibial side. The graft measured 16 mm in length. We then did a QuadLink-type construct over 2 TightRopes, FiberTak sutures. We incorporated a FiberTape InternalBrace suture within the construct. We then saved the graft on antibiotic-soaked gauze until we were ready to proceed with graft passage. Of note, we did do a vancomycin 5 mg/mL wash prior to implantation to help prevent infection.
We then proceeded with graft harvest site closure. Copiously irrigated the wound with antibiotic irrigation fluid. Closed the graft harvest site with #2 FiberWire interrupted suture. Closed the fascial layer with 0 Vicryl interrupted suture.
We then went forth with our lateral extra-articular tenodesis approach. Made a 3 to 4 cm incision near the lateral epicondyle. Skin was then incised as well as subcutaneous tissue. We then identified the IT band. We took a graft of approximately 200 mm of IT band by 1 cm in diameter and were able to incise this down and left attached to the tibia. We identified the bursa over the lateral collateral ligament and incised this and were able to identify the lateral collateral ligament. We whipstitched the 1 end of the IT band autograft and passed it under the lateral collateral ligament. We then saved the graft fixation till later when we were prepared at the end of the case.
We then created inferolateral portal to the knee joint in the usual standard fashion. We then created inferomedial portal under direct visualization. Diagnostic arthroscopy ensued.
First visualized the medial compartment. The medial femoral condyle and medial tibial condyle had intact chondral surfaces. Medial meniscus noted to be intact upon probing including the anterior and posterior roots. There were no loose bodies and no meniscocapsular junction tears in the posteromedial aspect of knee.
We then went into the notch. The ACL was noted to be completely torn with poor quality tissue. PCL was noted to be intact and stable on probing.
We went to the lateral compartment in figure-of-four position. The lateral femoral condyle and lateral tibial condyle had intact chondral surface. Lateral meniscus was noted to be intact and stable upon probing including the anterior and posterior roots. There were no loose bodies and no meniscocapsular junction tears in the posterolateral aspect of the knee.
We then went to the patellofemoral articulation. Undersurface of patella as well as trochlea had intact chondral surfaces. There were no loose bodies in the suprapatellar pouch or the medial and lateral gutters. Popliteus noted to be intact at insertion site in lateral gutter. There was excess fat pad anteriorly, which we debrided with shaver to prevent postoperative fat pad impingement.
We then went forth with notch preparation. The patient had a moderate to severe A-frame notch. We did a notchplasty anteriorly to help prevent graft impingement. We then debrided around the remnant ACL and identified the origin insertion sites of the femur and tibia, respectively.
We then went forth with our femoral socket drilling. We used outside-in technique using a FlipCutter to flip cut an 8.5 x 25 mm tunnel. We then removed the remnant bone debris and passed the suture down through our femoral socket and out through our cannulated inferomedial portal.
We then went forth with our tibial socket drilling. We used outside-in technique using a FlipCutter to flip cut a 9 x 28 mm tunnel. We then removed the remnant bone debris and passed the suture up through our tibial socket, out through our cannulated inferomedial portal.
We then went forth with graft passage. Passed the femoral side of the graft up to the knee first and flipped the button on the lateral cortex of the femur. Confirmed it was down with direct visualization. We then sutured the graft up into the femoral tunnel and repeated this procedure on the tibial side. We then cinched at least 20 mm of graft in both the femoral and tibial tunnels. We then tensioned and tied our femoral button, cycled the knee, and placed posterior drawer on the knee in full extension. We then tensioned and tied our tibial button. We then passed these sutures along with the FiberTape sutures through a 4.75 mm PEEK SwiveLock in the metaphyseal aspect of the tibia for backup tibial fixation and InternalBrace tibial fixation. We then went forth with our IT band tenodesis and lateral capsule repair and used our fixation clips to put the knee at 30 degrees and neutral rotation. We then prepared the footprint just proximal and posterior to the lateral epicondyle, creating a good bed of bleeding bone. We then placed our 2.6 mm double knotless FiberTak, which had great bite and fixation. We then passed our iliotibial band through the knotless and tied this down. We then did our capsular repair using these sutures as well to imbricate it to the attachment site for the iliotibial band.
We then went forth with testing. 1A Lachman, negative posterior drawer, negative pivot shift. No impingement on the notch or PCL in both extension and flexion, respectively. We also had full range of motion.
We then proceeded with closure. Released tourniquet. Obtained adequate hemostasis. We made sure there was no bony debris or loose bodies. We then extravasated all fluid from the knee. We then closed the IT band with 0 Vicryl interrupted suture. Closed the subcutaneous tissue with 2-0 Vicryl interrupted suture, and closed skin with 3-0 Prolene. Placed a dry sterile dressing on the patient's knee. The patient was then placed in a knee immobilizer locked in extension. Patient was then extubated with no known complications, and taken to PACU in stable condition with no known complications.
Thanks again for your guidance!
Jodi
