Wiki Can 27427 and 27447 be billed together with a -59 modifier?

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LCCoder

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Surgeon self-coded the following with 27447 and 27429.

surgery report: "After asepsis and antisepsis, an anterior approach to the knee is performed, an incision is made in layers, a retinaculotomy is performed, a synovectomy is performed, a femoral graft is performed with a 3-mm femur, stability tests are performed, a tibial graft is performed with a 3-mm tibia, stability tests are performed with a 10-mm insert, a patellar g raft is performed, a definitive 3-mm cemented femur prosthesis is placed, a 29-mm anatomical patella is placed, stability is verified, a 10-mm insert is placed, a partial tear of the lateral collateral ligament is assessed and located, and a lateral collateral graft is performed until stability and balance of the knee is achieved. A retinaculoplasty is performed, the remainder is repaired in layers, the skin is repaired with staples, a sterile medicated dressing and anti-edema bandage are applied, and the patient is discharged into stable recovery."
Operation performed: Lateral Collateral Ligament Repair (27429) + Total Knee Arthroplasty (27447)
Surgical Findings: Significant Hemarthrosis + Total ACL Tear + Parsial LCL Injury

I don't specialize in Ortho coding and the surgery was performed outside the US so the surgery report is not as detailed as most US surgeons would provide, but my thoughts are 27427 may be justified instead of his 27429 as there is mention of grafting the LCL. Since no other tendon repair is documented I don't think I can code 27249 as surgeon suggested. And unfortunately source of the LCL graft is not mentioned so not sure if I can even use 27427. I believe for this surgery, I can code 27447 and am wondering if there is an appropriate code for the LCL work like 27427-59 or possibly 27405-59?

Lastly, are any of the bone grafts billable? no additional incision sites are mentioned which seems necessary to code for 20900. But wondering if based on the bone graft sources, is an additional incision assumed and so codable?

Would love to hear from a pro! Thanks in advance.
 
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I would consider the lateral collateral ligament tear an iatrogenic complication and, as such, it would not be billable as a separate procedure.

This is the most embarrassingly bad op note I've seen in a long time, btw. Where was the surgery performed?
 
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NRaizman said:
I would consider the lateral collateral ligament tear an iatrogenic complication and, as such, it would not be billable as a separate procedure.

This is the most embarrassingly bad op note I've seen in a long time, btw. Where was the surgery performed?
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South of the border. Thank you for your quick reply. I'm not sure we can chalk the lcl tear to a procedure complication, patient was in surgery due to a traumatic fall. But @NRaizman In your experience, are ligament repairs ever billed and paid in addition to total knee replacement? Thank you!
 
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LCCoder said:
South of the border. Thank you for your quick reply. I'm not sure we can chalk the lcl tear to a procedure complication, patient was in surgery due to a traumatic fall. But @NRaizman In your experience, are ligament repairs ever billed and paid in addition to total knee replacement? Thank you!
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If performed for fracture, that is not well described. If performed for instability, that's not really a thing, so I remain a bit skeptical. Not even sure what is meant by "graft" for femur and tibia here. And certainly not clear on why a partial LCL would need to be fixed, let alone grafted.

If you had a separate preoperative diagnosis of collateral ligament instability, you MIGHT, with a -59 modifier and a third party payor, be able to make a case, but generally 27427-9 ALL bundle into 27447, and the GSD clear says that repair, release and reconstruction of the collateral ligaments are integral to the knee replacement. To balance the knee, you need to address the collaterals.
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