Wiki Need help coding this surgery - the CPT codes

jdibble

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Can someone please help with the CPT codes on this one! I have read this over and over and I am really not sure what I am looking at! I am not sure what I can or cannot code - can I code the bone grafts and if so, what codes? So far have 27236 and 27507, but I am not sure if those are correct and if I need to add more codes for the bone graft.

PREOPERATIVE DIAGNOSES:
1. Left displaced femoral neck fracture.
2. Retained IM rod left femur fracture.
3. Femoral shaft fracture proximal.

POSTOPERATIVE DIAGNOSES:
1. Left displaced femoral neck fracture.
2. Retained IM rod left femur fracture.
3. Femoral shaft fracture proximal.

OPERATION:
1. Removal of intramedullary rod.
2. Repair of proximal femoral shaft fracture.
3. Bipolar hemiarthroplasty for displaced femoral neck fracture.
4. Autologous bone graft with augmentation.
5. Impact bone graft of the femoral stem prosthesis.

PROSTHESIS: The left hip hemiarthroplasty prosthesis was an ExacTech CFS Press-Fit femoral stem collared size 12 with a 49 mm bipolar component, -3.5 cobalt chrome neck with a 28 mm head.

SURGEON:

ANESTHESIA: General endotracheal.

DESCRIPTION OF PROCEDURE: The patient was brought to the operative theater and while supine upon the operating table. After satisfactory general endotracheal anesthesia was administered, the patient was brought into the right lateral decubitus position with an axillary roll in place and held the Montreal frame. A time-out was carried out confirming the operative site with the operative consent and the patient was given antibiotic medication. Meticulous sterile prepping and draping of the left lower extremity was carried out from the iliac crest to the ankle. After meticulous sterile prepping and draping, an incision was made in a Kocher-Langenbeck manner. The distal leg of the incision was made through a previous scar from a previous intramedullary rod fixation of a proximal femoral fracture. This was taken through subcutaneous tissue sharply and the tensor fascia lata was incised in line with the skin incision.
Dissection of the tensor fascia lata from the vastus lateralis was carried out as some fibrous adhesion had occurred from previous surgery. The femoral rod was identified as it was prominent from the tip of the greater trochanter. This aspect was identified and was removed with the rod extraction device. This allowed for visualization and evaluation of the fractures. The short external rotators were tagged and released with the pyriformis tendon identified, tagged and released for repair at the end. A T-incision was then made through the posterior capsule and along the femoral neck. This allowed for evaluation of the status of the femoral head which revealed a displaced femoral neck fracture which is subcapital. It appeared that this fracture was not acute. There were some chronic changes noted in the bone. Similarly, an evaluation of the proximal femur revealed a fracture of the proximal femoral shaft which involved the calcar region as a large medial fragment extending from a defect that extended from a defect that existed in the proximal femur from the area of the previous fracture site. On evaluation of this, it was determined that the femoral stem could not be cemented in place. At this point, it was evaluated further and determined that impact grafting would be carried out and augment grafting would be carried out and augmented with bone croutons and calcified cancellous bone chips. The bone graft was obtained from the femoral head which was easily removed with the hip dislocated. It was sized to 49 mm outer diameter. At this point, it was elected to pass a Dall-Miles cable to augment and maintain the calcar fragment in place. This was performed with a 12 mm broach having been brought into the wound and into position to allow for estimation of the position of the prosthesis. The broach was put in place. A femoral neck cut was then made and the proximal femoral shaft fracture was stabilized with 2 additional Dall-Miles cables. At this point, the bone graft was added to this femoral shaft defect area as well. The femoral stem prosthesis was then utilized to impact graft the proximal femur. The slurry of autologous and homologous bone graft was then placed into the proximal femoral canal with the size 12 femoral stem being impacted and brought to an area where the lipped and collared stem remained 5 mm proximal. At this point, the proximal calcar region and metaphyseal region was filled with cortical cancellous slurry graft and liquid calcium phosphate bone graft was then squirted into the femoral canal to act as a cementing graft. This having been injected, the collar was then impacted down into the proximal femur with the cables, maintaining the integrity of the fragments. Once this was in place, another Dall-Miles cable was then cerclaged and passed beneath the vastus lateralis muscle and tightened to maintain the integrity of the proximal construct. The calcium phosphate cement bone graft was then allowed to harden and the hip was reduced with a -3.5 mm neck and 49 mm bipolar outer diameter cup. The hip had been trialed with these trial components and brought through a range of motion and found to be stable in flexion to 90 degrees and internal rotation to 50 degrees, full extension without shucking and without significant over-tightness or lengthening. This being satisfactory, with reduction of the prosthesis construct, x-rays were obtained intraoperatively to verify the stability of the construct as well. The tibiofemoral stem was noted to be 1-1/2 cortical diameters of the femoral canal distal to the femoral defect and fracture. At this point, the wound was irrigated and short external rotators were repaired to the posterior trochanter. Additionally, the tip of the trochanter was bone grafted as well where the defect of the IM rod was. A deep Hemovac drain was placed. The tensor fascia lata was repaired with #1 Vicryl in a figure-of-eight fashion, the subcu closed with 0 Vicryl and skin reapproximated with skin staples. The patient was returned to recovery, having tolerated the procedure well without complications.

Thank you to all who can help with this surgery! :)
 
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