Need help please! Physician harvested bone marrow from the tibia to make a putty to fill the subtalar joint. I am not sure what code to use for the harvesting (38220 or 20902). I have coded the rest as 28725 & 20680. I have no idea how to proceed with the bone marrow coding. Below is the op note. Any help will be greatly appreciated. Thanks!
PREOPERATIVE DIAGNOSES: 1. Painful retained hardware.
2. Subtalar joint nonunion, right.
POSTOPERATIVE DIAGNOSES: 1. Painful retained hardware.
2. Subtalar joint nonunion, right.
PROCEDURES PERFORMED: 1. Harvest of bone marrow right tibia.
2. Removal of hardware of the right subtalar
joint.
3. Revision subtalar joint arthrodesis with bone
marrow aspirate addition and bone graft with
two screw fixation
The patient was identified and placed on the treatment table in the supine
position. Following general endotracheal intubation, the patient was repositioned right lateral decubitus
left-sided down and bean bag secured with well padded prominence throughout. The right thigh tourniquet
was inflated after the right lower extremity was scrubbed, prepped and draped in usual aseptic manner.
_____ (01:55) to the tibia of the right leg. A small portal made at the tibial plateau, transitioned into the
geographical region of the tibia, trocar inserted, manual pressure rotation was inserted into the medullary
canal. 50 cc of the MAC were extracted, sent to the back table for centrifuge. Incision was closed, we
kept under compression following completion. The right thigh tourniquet was inflated. At this time, we
broached anterior prior incision where a blunt dissection was carried down to the screw head of the talar
neck. Screw was removed without complication. That incision was closed with 4-0 nylon. Attention was
directed to the sinus tarsi where curvilinear incision was made over that area. Blunt dissection carried
down to the EDB. It was reflected anterior of the anterior process exposing the subtalar into the
operative field. Talar joint was heavily scarred with no bony union. Resection of all the soft tissue within
the joint was resected. No bone elements were identified. Fenestration was completed. We fish scaled
with osteotome and mallet. Good emulsification of the dorsal calcaneus and plantar talus were completed
with good bleeding surfaces. The putty then was created with BMAC, inserted into the site for
arthrodesis. Two screws were inserted from posterior to anterior across the calcaneus with excellent
alignment noted and two cannulated bone screws were inserted from posterior to anterior dorsal with very
good compression noted. Following completion of procedure, additional bone putty was inserted to the
lateral sinus tarsi. The EDB was then sutured back in place to lateral joint capsule, subcu closed with 3-0
Vicryl and skin closed with 4-0 nylon. Remaining BMAC on the table was injected back into the sinus
tarsi into the fusion site without complications. The posterior incision was closed with 2-0 Vicryl and 4-0
nylon. Following completion of procedure, 50 cc of Bupivacaine/Ketorolac were infiltrated in an ankle
block. Adaptic, 4x4s, Kling, Ace bandages and a posterior splint secured with an Ace bandage to the right
lower extremity. The patient tolerated the procedure and was transferred out of the treatment room with
vital signs stable with vascular status intact.
PREOPERATIVE DIAGNOSES: 1. Painful retained hardware.
2. Subtalar joint nonunion, right.
POSTOPERATIVE DIAGNOSES: 1. Painful retained hardware.
2. Subtalar joint nonunion, right.
PROCEDURES PERFORMED: 1. Harvest of bone marrow right tibia.
2. Removal of hardware of the right subtalar
joint.
3. Revision subtalar joint arthrodesis with bone
marrow aspirate addition and bone graft with
two screw fixation
The patient was identified and placed on the treatment table in the supine
position. Following general endotracheal intubation, the patient was repositioned right lateral decubitus
left-sided down and bean bag secured with well padded prominence throughout. The right thigh tourniquet
was inflated after the right lower extremity was scrubbed, prepped and draped in usual aseptic manner.
_____ (01:55) to the tibia of the right leg. A small portal made at the tibial plateau, transitioned into the
geographical region of the tibia, trocar inserted, manual pressure rotation was inserted into the medullary
canal. 50 cc of the MAC were extracted, sent to the back table for centrifuge. Incision was closed, we
kept under compression following completion. The right thigh tourniquet was inflated. At this time, we
broached anterior prior incision where a blunt dissection was carried down to the screw head of the talar
neck. Screw was removed without complication. That incision was closed with 4-0 nylon. Attention was
directed to the sinus tarsi where curvilinear incision was made over that area. Blunt dissection carried
down to the EDB. It was reflected anterior of the anterior process exposing the subtalar into the
operative field. Talar joint was heavily scarred with no bony union. Resection of all the soft tissue within
the joint was resected. No bone elements were identified. Fenestration was completed. We fish scaled
with osteotome and mallet. Good emulsification of the dorsal calcaneus and plantar talus were completed
with good bleeding surfaces. The putty then was created with BMAC, inserted into the site for
arthrodesis. Two screws were inserted from posterior to anterior across the calcaneus with excellent
alignment noted and two cannulated bone screws were inserted from posterior to anterior dorsal with very
good compression noted. Following completion of procedure, additional bone putty was inserted to the
lateral sinus tarsi. The EDB was then sutured back in place to lateral joint capsule, subcu closed with 3-0
Vicryl and skin closed with 4-0 nylon. Remaining BMAC on the table was injected back into the sinus
tarsi into the fusion site without complications. The posterior incision was closed with 2-0 Vicryl and 4-0
nylon. Following completion of procedure, 50 cc of Bupivacaine/Ketorolac were infiltrated in an ankle
block. Adaptic, 4x4s, Kling, Ace bandages and a posterior splint secured with an Ace bandage to the right
lower extremity. The patient tolerated the procedure and was transferred out of the treatment room with
vital signs stable with vascular status intact.