khatcher
New
I need some help with this please. My provider did a hip arthroscopy and is asking me to bill the scope and the open procedures. He sent me the following codes to bill and I attached the OP report. If anyone can tell me if this can be billed together or not that would be fantastic.
CPT codes 29916-RT, 29914-51 RT, 27062-51 RT, 27305-51 RT
INDICATIONS: The patient is a 70-year-old female who presented to my office with severe right hip pain. She had previously been seen by another physician. Her pain was primarily over her groin as well as her lateral hip. She had been treated with at least 5 cortisone injections to her greater trochanter without improvement as well as physical therapy and was very frustrated with her symptoms. She did have groin pain on exam as well with positive Stinchfield. Her x-rays; however, reveal very minimal arthritis and an MRI showed a large flap tear of her labrum as well as hip bursitis.
DESCRIPTION OF PROCEDURE: The patient was identified in preop holding area. Her right lower extremity was marked. She was brought to the operating room where she was positioned in supine position and her right lower extremity was prepped and draped in standard fashion. She was placed into traction boots and we applied gentle traction onto her right hip until there is some gradual distraction. A needle was advanced over an anterolateral portal into the hip joint to allow us to release suction seal and increased traction. We had a total of approximately 2-3 cm of distraction, a cannula and camera brought in through an anterolateral portal. We then brought a needle in from an anterior portal under direct visualization and placed the cannula there. We then performed a capsulotomy connecting 2 anterior portals. She had a large flap tear of her labrum which was folded into her joint, used a 3.5 shaver to debride it. We did not detach the base of labrum. There was residual labrum remaining.
We used a radiofrequency wand to clear soft tissue attachments on the anterior and superior acetabular rim. There was an osteophyte here and we used a burr to resect approximately 2 mm osteophyte along the anterior and superior acetabular rim from approximately 12 o'clock to 3:30 on her acetabulum. Diagnostic exam of the cartilage itself showed healthy cartilage of the femoral head. She had grade I to II chondrosis of her acetabular cartilage mild.
We then released traction and identified her femoral neck, she did have a Cam deformity anterolaterally. We used a burr to create a concavity resembling a more anatomic neck. With this was done on the anterior superior neck, taking care not to damage the zona orbicularis anteriorly, or the vessels laterally. Once this was complete, we removed our instruments from the hip joint. We then placed a needle through the anterolateral portal to the greater trochanter space. We then made a distal peritrochanteric portal approximately 5 cm. This was then brought in needle and cannula under direct visualization to the greater trochanteric space. She had an extensive amount of bursitis and inflammation. This was ablated using radiofrequency. We ablated anterior to the femur and posterior to the femur, taking care not to advance towards the sciatic nerve posteriorly. Patient's gluteal attachment appeared grossly intact.
Once this was complete, we removed our instruments and fluid from the patient's hip. Her incisions were closed. She was allowed to wake up in the operating room and taken to the PACU for recovery. She tolerated this procedure without any complications.
Thank you in advance!
CPT codes 29916-RT, 29914-51 RT, 27062-51 RT, 27305-51 RT
INDICATIONS: The patient is a 70-year-old female who presented to my office with severe right hip pain. She had previously been seen by another physician. Her pain was primarily over her groin as well as her lateral hip. She had been treated with at least 5 cortisone injections to her greater trochanter without improvement as well as physical therapy and was very frustrated with her symptoms. She did have groin pain on exam as well with positive Stinchfield. Her x-rays; however, reveal very minimal arthritis and an MRI showed a large flap tear of her labrum as well as hip bursitis.
DESCRIPTION OF PROCEDURE: The patient was identified in preop holding area. Her right lower extremity was marked. She was brought to the operating room where she was positioned in supine position and her right lower extremity was prepped and draped in standard fashion. She was placed into traction boots and we applied gentle traction onto her right hip until there is some gradual distraction. A needle was advanced over an anterolateral portal into the hip joint to allow us to release suction seal and increased traction. We had a total of approximately 2-3 cm of distraction, a cannula and camera brought in through an anterolateral portal. We then brought a needle in from an anterior portal under direct visualization and placed the cannula there. We then performed a capsulotomy connecting 2 anterior portals. She had a large flap tear of her labrum which was folded into her joint, used a 3.5 shaver to debride it. We did not detach the base of labrum. There was residual labrum remaining.
We used a radiofrequency wand to clear soft tissue attachments on the anterior and superior acetabular rim. There was an osteophyte here and we used a burr to resect approximately 2 mm osteophyte along the anterior and superior acetabular rim from approximately 12 o'clock to 3:30 on her acetabulum. Diagnostic exam of the cartilage itself showed healthy cartilage of the femoral head. She had grade I to II chondrosis of her acetabular cartilage mild.
We then released traction and identified her femoral neck, she did have a Cam deformity anterolaterally. We used a burr to create a concavity resembling a more anatomic neck. With this was done on the anterior superior neck, taking care not to damage the zona orbicularis anteriorly, or the vessels laterally. Once this was complete, we removed our instruments from the hip joint. We then placed a needle through the anterolateral portal to the greater trochanter space. We then made a distal peritrochanteric portal approximately 5 cm. This was then brought in needle and cannula under direct visualization to the greater trochanteric space. She had an extensive amount of bursitis and inflammation. This was ablated using radiofrequency. We ablated anterior to the femur and posterior to the femur, taking care not to advance towards the sciatic nerve posteriorly. Patient's gluteal attachment appeared grossly intact.
Once this was complete, we removed our instruments and fluid from the patient's hip. Her incisions were closed. She was allowed to wake up in the operating room and taken to the PACU for recovery. She tolerated this procedure without any complications.
Thank you in advance!