kathydaniel
Networker
You're probably starting to get used to seeing my name in here 
I've just stated coding with a Ortho/Neuro group and am trying to keep my head above water. Can anyone review this op report and tell me if I'm missing anything?
DX: Left ankle instability & left ankle impingement syndrome with exostosis of the patient's tibia
Procedure:
...The scope was inserted into the ankle joint itself and dx arthroscopy was begun. Anterolateral and posterolateral portals are established under direct visualization and scopes switched to each of the accessory portals for completion of the 21 point stage examination. There was impingement lesion identified in the anterolateral, anterior, anteromedial aspect of the ankle joint itself. There is significant exostosis identified in the patient's anterior aspect of his tibia causing bony impingement. No osteochondral lesions, no loose bodies identified throughout the ankle joint itself. There is synovitis present in the posterior aspect of the ankle joint itself, as well as the syndesmosis. Once the dx arthroscopy was completed, shaver was introduced into the ankle joint itself and extensive debridement and synovectomy was carried out to the ankle joint, removing the impingement lesion identified in the anterolateral, anterior, antermedial aspect of the ankle joint itself. Synovectomy performed to the syndesmosis as well. Once found to be stable, a motorized bur was placed within the joint space itself. This exostosis of the patient's anterolateral tibia was removed without complication, was found be stable, the scope was then retrieved. The portals were closed with 4-0 nylon suture. The patient then removed from the furcal leg holder remained in supine position.
A lateral incision was placed over the ankle joint itself. Sharp dissection was carred down through the skin. All bleeding was controlled with Bovie cautery. Blunt dissection carried down. The extensor retinaculum itself was identified, dissected clean and retracted. Periosteal flaps then created to the distal to the patient's fibula bone. The collateral ligaments themselves are identified. The peroneal tendons are identified. A significan amount of muscle encroachment was found throughout the tract in the patient's peroneal tendons beyond the patient's fibular groove. This was then stripped brought up proximally at this point in time. This decompresses the peroneal tendons themselves. Debridement synovectomy was carried out as well. Once found to be stable, the collateral themselves were then identified. The bone was then repaired to a good bleeding base utilizing curettes as well as a rongeur until a stable border has been identified. The collateral ligaments themselves were then repaired utilizing 0 Ethibond suture. The anklw is then everted and a slight posterior drawer applied. The sutures were then hand tied...
The doctor is trying to code:
27698
29898
29895
28086
29999
I'm thinking it should be:
29898
27698
28086
Any suggestions? Am I missing something? I can't tell you how much I appreciate all of your help while I'm getting my ortho coding legs under me!!!!
I've just stated coding with a Ortho/Neuro group and am trying to keep my head above water. Can anyone review this op report and tell me if I'm missing anything?DX: Left ankle instability & left ankle impingement syndrome with exostosis of the patient's tibia
Procedure:
...The scope was inserted into the ankle joint itself and dx arthroscopy was begun. Anterolateral and posterolateral portals are established under direct visualization and scopes switched to each of the accessory portals for completion of the 21 point stage examination. There was impingement lesion identified in the anterolateral, anterior, anteromedial aspect of the ankle joint itself. There is significant exostosis identified in the patient's anterior aspect of his tibia causing bony impingement. No osteochondral lesions, no loose bodies identified throughout the ankle joint itself. There is synovitis present in the posterior aspect of the ankle joint itself, as well as the syndesmosis. Once the dx arthroscopy was completed, shaver was introduced into the ankle joint itself and extensive debridement and synovectomy was carried out to the ankle joint, removing the impingement lesion identified in the anterolateral, anterior, antermedial aspect of the ankle joint itself. Synovectomy performed to the syndesmosis as well. Once found to be stable, a motorized bur was placed within the joint space itself. This exostosis of the patient's anterolateral tibia was removed without complication, was found be stable, the scope was then retrieved. The portals were closed with 4-0 nylon suture. The patient then removed from the furcal leg holder remained in supine position.
A lateral incision was placed over the ankle joint itself. Sharp dissection was carred down through the skin. All bleeding was controlled with Bovie cautery. Blunt dissection carried down. The extensor retinaculum itself was identified, dissected clean and retracted. Periosteal flaps then created to the distal to the patient's fibula bone. The collateral ligaments themselves are identified. The peroneal tendons are identified. A significan amount of muscle encroachment was found throughout the tract in the patient's peroneal tendons beyond the patient's fibular groove. This was then stripped brought up proximally at this point in time. This decompresses the peroneal tendons themselves. Debridement synovectomy was carried out as well. Once found to be stable, the collateral themselves were then identified. The bone was then repaired to a good bleeding base utilizing curettes as well as a rongeur until a stable border has been identified. The collateral ligaments themselves were then repaired utilizing 0 Ethibond suture. The anklw is then everted and a slight posterior drawer applied. The sutures were then hand tied...
The doctor is trying to code:
27698
29898
29895
28086
29999
I'm thinking it should be:
29898
27698
28086
Any suggestions? Am I missing something? I can't tell you how much I appreciate all of your help while I'm getting my ortho coding legs under me!!!!