andreat.williams
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Pre/Post Op Dx: Right hip posterior superior labral tear.
Primary Surgeon billed: 27033
Assistant Surgeon insists we also bill an unlisted 27299 for the labral repair
Report is as follows:
At this juncture, a direct lateral incision made centered over the tip of the greater trochanter was outlined in the skin. Skin was incised sharply and deeper dissection was carried out with Bovie cautery down to the IT band which was incised in line with the fascia. A Gibson modification of the approach to the hip was performed and the gluteus maximus was reflected posteriorly.
The extensive bursectomy was performed. The piriformis tendon was identified and the interval developed between the piriformis tendon and the gluteus minimus up to the stable portion of the troch, posterior margin of vastus lateralis and dissected free, and the planned trochanteric osteotomy outlined with the Bovie cautery. The trochanteric osteotomy was then performed with a sagittal saw. The bleeding cancellous base was packed with wax. {27033}
Continued exposure was then performed of the hip capsule superior to the pyriformis underlying the gluteus minimus anteriorly beneath the rectus. Once appropriate exposure was achieved, a Z-capsulotomy was performed of the hip capsule. The hip was then subluxated and ligamentum teres was taut. This was then cut, which allowed a complete dislocation. {I thought he should code a 27036}
Overall, the chondral surface of the femoral head was intact, as was within the labrum.
Two tears of the labrum were noted, both posterior and superior; one at the 11 o'clock position, and one at the 10 o'clock position. These were both repaired with Mitek sutures. Knots made extracapsular. The hip was then reinspected and no additional labral pathology identified. {AS wants to use Unlisted 27299}
No osteochondral issues were concerned. The head was relocated and irrigated. Capsule repaired with #1 Vicryl suture. After repair of the capsule, the trochanter was repaired to its origin with two 3.5 mm fully threaded screws, one 55 mm and one 50 mm in length. Wound was then again irrigated and 0 Vicryl suture used for the IT band. Deeper tissues were closed with 2-0 Vicryl, 2-0 V-Loc, and then the skin closed with 3-0 Vicryl in a subcuticular Monocryl stitch, dressed with Steri-Strips, Xeroform, 4 x 4, Tegaderm dressings. The patient was then awakened from anesthesia in stable condition.
(I added the italics)
**Here's my argument against using the unlisted code: if they had started the arthrotomy and found the tear that needed to be repaired, the unlisted procedure is warranted. But since they knew going in to the arthrotomy they were going to repair the joint along w/ the tear, I don't see how we can justify the unlisted code.
Any other thoughts?
Primary Surgeon billed: 27033
Assistant Surgeon insists we also bill an unlisted 27299 for the labral repair
Report is as follows:
At this juncture, a direct lateral incision made centered over the tip of the greater trochanter was outlined in the skin. Skin was incised sharply and deeper dissection was carried out with Bovie cautery down to the IT band which was incised in line with the fascia. A Gibson modification of the approach to the hip was performed and the gluteus maximus was reflected posteriorly.
The extensive bursectomy was performed. The piriformis tendon was identified and the interval developed between the piriformis tendon and the gluteus minimus up to the stable portion of the troch, posterior margin of vastus lateralis and dissected free, and the planned trochanteric osteotomy outlined with the Bovie cautery. The trochanteric osteotomy was then performed with a sagittal saw. The bleeding cancellous base was packed with wax. {27033}
Continued exposure was then performed of the hip capsule superior to the pyriformis underlying the gluteus minimus anteriorly beneath the rectus. Once appropriate exposure was achieved, a Z-capsulotomy was performed of the hip capsule. The hip was then subluxated and ligamentum teres was taut. This was then cut, which allowed a complete dislocation. {I thought he should code a 27036}
Overall, the chondral surface of the femoral head was intact, as was within the labrum.
Two tears of the labrum were noted, both posterior and superior; one at the 11 o'clock position, and one at the 10 o'clock position. These were both repaired with Mitek sutures. Knots made extracapsular. The hip was then reinspected and no additional labral pathology identified. {AS wants to use Unlisted 27299}
No osteochondral issues were concerned. The head was relocated and irrigated. Capsule repaired with #1 Vicryl suture. After repair of the capsule, the trochanter was repaired to its origin with two 3.5 mm fully threaded screws, one 55 mm and one 50 mm in length. Wound was then again irrigated and 0 Vicryl suture used for the IT band. Deeper tissues were closed with 2-0 Vicryl, 2-0 V-Loc, and then the skin closed with 3-0 Vicryl in a subcuticular Monocryl stitch, dressed with Steri-Strips, Xeroform, 4 x 4, Tegaderm dressings. The patient was then awakened from anesthesia in stable condition.
(I added the italics)
**Here's my argument against using the unlisted code: if they had started the arthrotomy and found the tear that needed to be repaired, the unlisted procedure is warranted. But since they knew going in to the arthrotomy they were going to repair the joint along w/ the tear, I don't see how we can justify the unlisted code.
Any other thoughts?