CPT -capsular repair - left ankle dislocation

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I need help with the attached op note. I'm just not sure what CPT for the capsular repair. I've got 97605 for the wound vac; maybe 11011 for the debridement which I am thinking might be bundled with whatever code for the capsular repair. Any help is much appreciated. thank you,
 

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Orthocoderpgu

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Code 11011 is for excisional debridement down to muscle tissue. There was no debridement performed down to the muscle tissue. Sterile saline was used to wash out the surgical area, but that is just part of the procedure, not debridement.
 
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Overland Park, KS
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Code 11011 is for excisional debridement down to muscle tissue. There was no debridement performed down to the muscle tissue. Sterile saline was used to wash out the surgical area, but that is just part of the procedure, not debridement.
Okay, I understand. Now, can you help me with the capsulare repair code? Thanks,
 

Orthocoderpgu

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This really is not a normal foot & ankle surgery that you see. I would say trimming the skin is incidental. Notice that your physician cut the capsule open. I'm thinking that this was performed mostly to rule out infection. Anything that your doctor cuts you can't bill for repairing it. If they cut it, they have to repair it. But due to instability your doctor is performing a procedure where the joint capsule is put back together "tighter" than it would normally be. Your doctor may have performed an imbrication type of procedure for this, but they really don't say. Making the capsule tighter is the restorative procedure in this case. That would be unlisted 27899. I would also say that modifier -58 would be used since your doctor knew that they would be returning to perform a procedure. With a severe dislocation it's probable that the collateral ligament/s where probably stretched out. Was a collateral ligament or two repaired? Possibly but if so it's really not clear in the documentation. After the swelling goes down the patient will return for closure. I hope this helps.
 
Messages
126
Location
Overland Park, KS
Best answers
0
This really is not a normal foot & ankle surgery that you see. I would say trimming the skin is incidental. Notice that your physician cut the capsule open. I'm thinking that this was performed mostly to rule out infection. Anything that your doctor cuts you can't bill for repairing it. If they cut it, they have to repair it. But due to instability your doctor is performing a procedure where the joint capsule is put back together "tighter" than it would normally be. Your doctor may have performed an imbrication type of procedure for this, but they really don't say. Making the capsule tighter is the restorative procedure in this case. That would be unlisted 27899. I would also say that modifier -58 would be used since your doctor knew that they would be returning to perform a procedure. With a severe dislocation it's probable that the collateral ligament/s where probably stretched out. Was a collateral ligament or two repaired? Possibly but if so it's really not clear in the documentation. After the swelling goes down the patient will return for closure. I hope this helps.
Good explanation. I'll have to query the physician on this one. Thank you,
 
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