SirCodesAlot07
Networker
Are you allowed to use modifier 62 in an ASC? I don't see it on the approved ASC modifier list. Also I am confused as to how exactly to code this procedure. One surgeon did the elbow collateral ligament repair and arthrotomy and the other surgeon prepared the graft. I am not sure if I use both codes on both surgeons or just the codes each surgeon performed. We have never had a surgery here with co-surgeons so this is very new to me. The way I think it should be coded is
Dr. #1 24344 62,RT
Dr. #2 24344 62,RT 20900
Thank you for any input you may have!
Doctor #1 Dictation:
Dr. #2 will dictate the hamstring and bone graft. The right upper extremity had a tourniquet high on the arm over Webril and was prepped and draped in the sterile fashion. The left leg was done as well. We began by marking out the incision. Local anesthetic was infiltrated in the incision at the elbow and the joint. The arm was elevated and exsanguinated. The previous scar was excised. The skin flaps were elevated. Electrocautery was used for hemostasis. We dissected down from the interval between the anconeus and the wrist extensors. We opened that interval up. We came across our previous sutures, which were completely removed. As we carefully dissected down and opened up the capsule, we found the loose body was scarred to the anterolateral capsule. We excised it. The articular surface was in good shape. The posterolateral complex was loose. Posterolateral subluxation was occuring. We saw remnants of the allograft. We debrided that and the cyst or lucency around the docking site was carefully debrided with curettes. The posterior wall was somewhat deficient. After we thoroughly debrided that, we decided to go with an autograft considering the fact that she had had an allograft and had this reaction in the docking site. We felt that the best chance that she had of having no recurrence would be her own tendon. We also left the harvest bone graft to fill in the defects around the bone tunnels. Next, we made a drill hole in the ulna near the pronator tuberosity. Two drill holes were made. We tunneled between them. We made two drill holes to communicate with the proximal docking site with 2 mm drill bit. We were able to place sutures through that to allow for pulling sutures through later. Once we had the drill holes made, we enhanced, enlarged, and fit with hand instruments. We irrigated extensively the joint and the bone tunnels. Dr. #2 harvested the gracillis tendon. We placed 4-0 ethibond in the end and we were able to pass it through the two bone tunnels in the ulna. We then measured the docking length. We cut the tendons to the length we wanted and placed #2-0 MaxBraid sutures into both tendons. Each set of sutures were then passed through into one of the bone tunnels, one was anterior and one was posterior so we hung over the lateral columns, so we had very sturdy bone. Next, we then placed the sutures through and made sure the bone docks beautifully. We then tensioned it in 30 to 40 degrees throughout in full extension and neutral. We then pronated the arm, tensioned it, and tied it over the bone tunnel. We had an excellent fill. We took bone graft that Dr. #2 had harvested from the tibia and impacted it into the tunnels. After completing this, we then turned our attention to repairing capsule. We repaired it with #2 MaxBraid sutures repairing the interval back to the bone and to the above and below the epicondyle. The fascia of the forearm was repaired as well. Copious irrigation was performed. Tourniquet was released. Wounds were closed with 3-0 Monocryl and 3-0 Prolene. Steri-Strips were applied. Adaptic gauze, Webril, posterior splint with the arm at 90 and the wrist in pronation were applied with Ace wraps. The patient tolerated the procedure well and went to the recovery room in stable condition.
Doctor #2 dictation:
The left leg was prepped and draped in a regular sterile fashion after placement of a non-sterile tourniquet. The leg was exsanguinated and the tourniquet was inflated to 275 mmHg. Incision was made over the left hamstring. Dissection was carried down to the gracilis tendon. The gracilis tendon was identified at its insertion separated from the surrounding soft tissues and then harvested with the tendon strip repair. It was then taken back to the back table for preparation.
The second procedure was autologous bone graft from the tibia. At the side of the hamstring harvest, a small cortical window was made. I used a curette to obtain autologous cancellous bone from the site. This bone was then placed on the back table as well for bone grafting around the tip of the tunnels and the humerus and in the ulna on the right elbow. I then replaced the cortical window, I washed out the incision. I dropped the tourniquet after 21 minutes, achieved hemostasis, and I closed the incision with 3-0 Monocryl and then running 3-0 nylon on the skin. Blood loss was minimal. No complications. No drains. I dressed with Xeroform, 4x4s, cast padding, and an Ace wrap.
Dr. #1 24344 62,RT
Dr. #2 24344 62,RT 20900
Thank you for any input you may have!
Doctor #1 Dictation:
Dr. #2 will dictate the hamstring and bone graft. The right upper extremity had a tourniquet high on the arm over Webril and was prepped and draped in the sterile fashion. The left leg was done as well. We began by marking out the incision. Local anesthetic was infiltrated in the incision at the elbow and the joint. The arm was elevated and exsanguinated. The previous scar was excised. The skin flaps were elevated. Electrocautery was used for hemostasis. We dissected down from the interval between the anconeus and the wrist extensors. We opened that interval up. We came across our previous sutures, which were completely removed. As we carefully dissected down and opened up the capsule, we found the loose body was scarred to the anterolateral capsule. We excised it. The articular surface was in good shape. The posterolateral complex was loose. Posterolateral subluxation was occuring. We saw remnants of the allograft. We debrided that and the cyst or lucency around the docking site was carefully debrided with curettes. The posterior wall was somewhat deficient. After we thoroughly debrided that, we decided to go with an autograft considering the fact that she had had an allograft and had this reaction in the docking site. We felt that the best chance that she had of having no recurrence would be her own tendon. We also left the harvest bone graft to fill in the defects around the bone tunnels. Next, we made a drill hole in the ulna near the pronator tuberosity. Two drill holes were made. We tunneled between them. We made two drill holes to communicate with the proximal docking site with 2 mm drill bit. We were able to place sutures through that to allow for pulling sutures through later. Once we had the drill holes made, we enhanced, enlarged, and fit with hand instruments. We irrigated extensively the joint and the bone tunnels. Dr. #2 harvested the gracillis tendon. We placed 4-0 ethibond in the end and we were able to pass it through the two bone tunnels in the ulna. We then measured the docking length. We cut the tendons to the length we wanted and placed #2-0 MaxBraid sutures into both tendons. Each set of sutures were then passed through into one of the bone tunnels, one was anterior and one was posterior so we hung over the lateral columns, so we had very sturdy bone. Next, we then placed the sutures through and made sure the bone docks beautifully. We then tensioned it in 30 to 40 degrees throughout in full extension and neutral. We then pronated the arm, tensioned it, and tied it over the bone tunnel. We had an excellent fill. We took bone graft that Dr. #2 had harvested from the tibia and impacted it into the tunnels. After completing this, we then turned our attention to repairing capsule. We repaired it with #2 MaxBraid sutures repairing the interval back to the bone and to the above and below the epicondyle. The fascia of the forearm was repaired as well. Copious irrigation was performed. Tourniquet was released. Wounds were closed with 3-0 Monocryl and 3-0 Prolene. Steri-Strips were applied. Adaptic gauze, Webril, posterior splint with the arm at 90 and the wrist in pronation were applied with Ace wraps. The patient tolerated the procedure well and went to the recovery room in stable condition.
Doctor #2 dictation:
The left leg was prepped and draped in a regular sterile fashion after placement of a non-sterile tourniquet. The leg was exsanguinated and the tourniquet was inflated to 275 mmHg. Incision was made over the left hamstring. Dissection was carried down to the gracilis tendon. The gracilis tendon was identified at its insertion separated from the surrounding soft tissues and then harvested with the tendon strip repair. It was then taken back to the back table for preparation.
The second procedure was autologous bone graft from the tibia. At the side of the hamstring harvest, a small cortical window was made. I used a curette to obtain autologous cancellous bone from the site. This bone was then placed on the back table as well for bone grafting around the tip of the tunnels and the humerus and in the ulna on the right elbow. I then replaced the cortical window, I washed out the incision. I dropped the tourniquet after 21 minutes, achieved hemostasis, and I closed the incision with 3-0 Monocryl and then running 3-0 nylon on the skin. Blood loss was minimal. No complications. No drains. I dressed with Xeroform, 4x4s, cast padding, and an Ace wrap.
