Need assistance on CPT

Jsillaway

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I was wondering if anyone had an opinion on coding this. I'm thinking either an unlisted CPT 27299, or 27033 with a 52 modifier, since the description of 27033 is "The physician performs an arthrotomy of the hip that includes exploration or removal of any loose or foreign body. An incision is made over the hip, the soft tissues are dissected away, and the joint capsule is exposed & incised. The joint space is explored and any necrotic tissue is removed. If a loose or foreign body is present it is exposed and removed...."

Op report below:

POSTOPERATIVE DIAGNOSIS: Healing avulsion of the hamstring muscles, left
hip.

OPERATION PERFORMED: Exploration for repair of the avulsed _____ tendon of
the hamstring muscles, left hip.

ANESTHESIA: General.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room
and was given general anesthesia. After intubation, the patient was turned
on face down position. The left hip was already marked and later on
prepped and draped. The left lower extremity was draped free. The
incision was made over the posterior aspect of the hip and the upper thighs
starting at the level of the greater tuberosity coming down distally for
about 3 inches, the incision was deepened. We were very careful going down
and making sure that we protect the posterior cutaneous femoral nerve.
This was well protected. As we went down towards the lower border of the
gluteus maximus, we found that there was lot of scarring and as we tried to
go down, there was no clear delineation of the muscle planes. We then very
slowly carefully with the guided blunt dissection and dissection with
scissors, we reached to the ischial tuberosity. This was covered with
scarred down remnants of the tendon without any sign of the hamstring
tendon. The hamstring itself had retracted down into the back of thigh and
the tendon tissue which I could feel in the office was no more there and it
seemed to have amalgamated with the back of the thigh. I could see the
muscle and these were all scarred down and I could not find the upper end
of the hamstring muscles where the tendon should be. I tried to feel and
also very gingerly looked for the tendon. The sciatic nerve was always
kept in line. We did not dry to dissect the sciatic never either because
there was lot of scarring around that area of the muscle and I did not want
to do any harm to the sciatic nerve. We basically left everything alone
since there was no tissue there which we could identify as the tendon and
to detach it. I feel this patient's injury may have resolved at a much
faster pace or is possible that it is more than 6 weeks old. I felt that
the best thing would be to accept what it is and not try to do anything
else. The patient will be treated conservatively with physical therapy.
At that point, the irrigation was done. Subcutaneous tissue was
approximated with 2-0 Vicryl in interrupted manner. Skin was closed with
Quill suture and Steri-Strips. Sterile dressing was applied in the form
Aquacel dressing. Postop condition was satisfactory. Blood loss was about
30 milliliters.
 
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