cclarson
Guru
Hello everyone! I'm not sure if I'm coding this correctly, so I could really use some advice. So this patient is having an arthroscopic ACL, open MCL, and open POL (Posterior Oblique Ligament) reconstructions done. I know to code the ACL as 29888, the MCL as 27427 since it's an extraarticular ligament, but I'm not sure how to code the POL ligament reconstruction? Would it be 27428? and if so, does that mean I code both 27427 and 27428, or just 27429? I've never come across this situation before so every bit of help would be greatly appreciated! 
Here is the report:
POSTOPERATIVE DIAGNOSES:
Left knee dislocation with anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament disruptions.
OPERATIONS PERFORMED:
Left knee anterior cruciate ligament and posterior cruciate ligament reconstruction with medial collateral ligament repair and augmentation with allograft and internal brace.
DESCRIPTION OF PROCEDURE:
He was taken to the OR and placed in the supine position on the operating room table. After the administration of anesthesia, he was positioned, prepped, and draped in the usual fashion.
After a surgical-out, a long medial incision was made centered over the medial epicondyle proximally and extending proximally beyond that and then distally along the mid tibia. I dissected deeply using sharp dissection and Bovie. I opened the sartorius fascia and then identified the MCL distally. The distal insertion attachments were intact as showed by the MRI. I followed it proximally, and he was proximally avulsed off the medial epicondyle region of the distal femur. His femur was also avulsed at some area. I had cleaned up the scar, and I decided that this is what actually I could most likely repair. I placed my first anchor just posterior and proximal to the medial epicondyle for the superficial MCL. I then identified the gastrocnemius tubercle and placed my attachment for the posterior oblique ligament based upon that and the adductor tubercle.
I now turned our attention to the intraarticular portion of the scope. I made a routine lateral portal and placed the scope into the knee over a blunt trocar. I made a medial portal through the open incision.
Routine arthroscopy was performed. The suprapatellar pouch was benign. The patellofemoral joint looked to be in good condition and tracking well. The notch showed obvious ACL and PCL disruptions. The medial compartment gapped wide open and was clearly visualized. The articular surface was in good condition, and the medial meniscus was stable. The lateral compartment showed similar normal articular cartilage and meniscus.
I then began my reconstruction. I debrided the stumps. I performed a notchplasty to identify the over-the-top position for the ACL. I then introduced the curved curette and got down to the PCL insertion. I placed a guidepin up at the tibia at a 55-degree angle. I brushed the posterior cortex of the tibial flare. I protected the neurovascular structures with the pin catcher. I liked the position and overreamed with a 12-mm reamer. I had previously made a 12-mm Achilles allograft on the back table. I passed the suture. I placed a guidepin in the medial condyle through the open incision as well for the femoral attachment. With the numerous tunnels already in the femoral condyle, I felt a two-bundle reconstruction would be this too much.
I then began my ACL preparation. I placed a stab incision laterally and placed the guidepin down into the 2 o'clock position on the wall. I advanced with the TRUNAV, 8-mm graft, so I used an 8-mm TRUNAV and made a nice 25-mm socket with a 1-mm posterior wall. I pulled the suture down into the knee. I made the tibial tunnel through the open incision as well. It was proximal to the PCL tunnel. I rasped the edges and pulled the sutures out through the tunnel. I then made the femoral tunnel for the PCL as well from outside-in.
I was then ready for the final graft placement. I first passed a PCL up to the tibial tunnel and then out through the femoral tunnel. I placed a 30-mm interference screw up the tibial tunnel with good purchase. I tensioned the PCL graft on the knee on anterior drawer in 90 degrees of flexion and placed a femoral screw. I pulled the ACL through the tibia up into the femoral socket and deployed the ULTRABUTTON XL. It was then used to pull the graft up in the femoral socket. I tensioned that and placed a 9- x 25-mm PEEK interference screw. The knee was near full extension when I placed that.
I then performed my MCL repair. I had placed anchors previously and I used the sutures to repair the MCL and the posterior oblique ligament. I then had a single SutureTape that I used to reinforce the MCL, which I placed distally about 6 cm distal to the joint line in the mid footprint of the MCL. Along with that SutureTape, I also placed a single suture on that anchor. It was a Multifix anchor. I used that SutureTape and used to tie down the excess Achilles tendon graft from the MCL overlying the MCL.
Here is the report:
POSTOPERATIVE DIAGNOSES:
Left knee dislocation with anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament disruptions.
OPERATIONS PERFORMED:
Left knee anterior cruciate ligament and posterior cruciate ligament reconstruction with medial collateral ligament repair and augmentation with allograft and internal brace.
DESCRIPTION OF PROCEDURE:
He was taken to the OR and placed in the supine position on the operating room table. After the administration of anesthesia, he was positioned, prepped, and draped in the usual fashion.
After a surgical-out, a long medial incision was made centered over the medial epicondyle proximally and extending proximally beyond that and then distally along the mid tibia. I dissected deeply using sharp dissection and Bovie. I opened the sartorius fascia and then identified the MCL distally. The distal insertion attachments were intact as showed by the MRI. I followed it proximally, and he was proximally avulsed off the medial epicondyle region of the distal femur. His femur was also avulsed at some area. I had cleaned up the scar, and I decided that this is what actually I could most likely repair. I placed my first anchor just posterior and proximal to the medial epicondyle for the superficial MCL. I then identified the gastrocnemius tubercle and placed my attachment for the posterior oblique ligament based upon that and the adductor tubercle.
I now turned our attention to the intraarticular portion of the scope. I made a routine lateral portal and placed the scope into the knee over a blunt trocar. I made a medial portal through the open incision.
Routine arthroscopy was performed. The suprapatellar pouch was benign. The patellofemoral joint looked to be in good condition and tracking well. The notch showed obvious ACL and PCL disruptions. The medial compartment gapped wide open and was clearly visualized. The articular surface was in good condition, and the medial meniscus was stable. The lateral compartment showed similar normal articular cartilage and meniscus.
I then began my reconstruction. I debrided the stumps. I performed a notchplasty to identify the over-the-top position for the ACL. I then introduced the curved curette and got down to the PCL insertion. I placed a guidepin up at the tibia at a 55-degree angle. I brushed the posterior cortex of the tibial flare. I protected the neurovascular structures with the pin catcher. I liked the position and overreamed with a 12-mm reamer. I had previously made a 12-mm Achilles allograft on the back table. I passed the suture. I placed a guidepin in the medial condyle through the open incision as well for the femoral attachment. With the numerous tunnels already in the femoral condyle, I felt a two-bundle reconstruction would be this too much.
I then began my ACL preparation. I placed a stab incision laterally and placed the guidepin down into the 2 o'clock position on the wall. I advanced with the TRUNAV, 8-mm graft, so I used an 8-mm TRUNAV and made a nice 25-mm socket with a 1-mm posterior wall. I pulled the suture down into the knee. I made the tibial tunnel through the open incision as well. It was proximal to the PCL tunnel. I rasped the edges and pulled the sutures out through the tunnel. I then made the femoral tunnel for the PCL as well from outside-in.
I was then ready for the final graft placement. I first passed a PCL up to the tibial tunnel and then out through the femoral tunnel. I placed a 30-mm interference screw up the tibial tunnel with good purchase. I tensioned the PCL graft on the knee on anterior drawer in 90 degrees of flexion and placed a femoral screw. I pulled the ACL through the tibia up into the femoral socket and deployed the ULTRABUTTON XL. It was then used to pull the graft up in the femoral socket. I tensioned that and placed a 9- x 25-mm PEEK interference screw. The knee was near full extension when I placed that.
I then performed my MCL repair. I had placed anchors previously and I used the sutures to repair the MCL and the posterior oblique ligament. I then had a single SutureTape that I used to reinforce the MCL, which I placed distally about 6 cm distal to the joint line in the mid footprint of the MCL. Along with that SutureTape, I also placed a single suture on that anchor. It was a Multifix anchor. I used that SutureTape and used to tie down the excess Achilles tendon graft from the MCL overlying the MCL.