Wiki Need help on these ankle procedures.

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3
Location
Alpena, MI
Best answers
0
Pre-Op Diagnosis:
1-right ankle early degenerative changes with anterolateral impingement
2-right symptomatic os trigonum
3-suspected right peroneus brevis longitudinal tendon tear

Post-Op Diagnosis:
1-right ankle early degenerative changes with anterolateral impingement
2-right symptomatic os trigonum
3-peroneal tendon stenosing tenosynovitis without evidence of tear and hypertrophic peroneal tubercle

Procedure:
1–right ankle arthroscopy with extensive debridement including the anterior ankle joint capsule anterolateral capsule and gutter, and bony resection of distal tibial osteophyte
2–right calcaneus excision of peroneal tubercle
3–excision of right talar os trigonum and associated fragments
4–right peroneal tendon tenosynovectomy

Anesthesia:
General

Staff:


Estimated Blood Loss:
No blood loss documented.

INTRAOPERATIVE FLUIDS: 700 cc crystalloid

Specimens: Os trigonum fragments, calcaneal peroneal tubercle fragments sent to pathology

COMPLICATIONS: None.

PATIENT CONDITION AT END OF CASE: Stable.

Assistant:

DESCRIPTION OF PROCEDURE:

Patient was brought to the operating room and placed in the supine position on the beanbag. A timeout was called confirming site and procedure. After adequate general anesthesia as well as preoperative antibiotics, the patient was positioned in a slight sloppy left lateral decubitus with a beanbag to help facilitate the second portion of the procedure following arthroscopy. The ankle arthroscopy thigh holder was positioned. A tourniquet was placed at the right thigh. The right lower extremity was prepped and draped in the standard surgical fashion. The external traction device was applied to the foot. Bony and tendinous landmarks were drawn on the skin. The previous ankle arthroscopy portal sites were marked. The ankle joint was insufflated with fluid through the anterior medial portal utilizing normal saline. A 3 mm skin incision was made followed by a blunt dissection to the capsule. The blunt trocar and cannula were inserted followed by the arthroscope. The joint was insufflated with fluid and inspection was begun. A moderate amount of anterior synovial hypertrophy was noted. There was very mild grade I chondromalacia involving the talar dome without predisposition to a certain location and was generally diffuse. A fairly sizable distal tibial osteophyte was noted primarily laterally based. At this point the anterolateral portal was established through the previous portal incisional scar after transilluminating the area to ensure there was no evidence of neurologic structures passing through this area. A 3 mm incision was made through the previous scar, followed by blunt dissection intra-articularly under direct visualization with a small snap. The probe was inserted and the talar dome inspected, the cartilage appeared firm overall. The shaver was introduced and debridement from the medial to the lateral aspect of the joint was performed removing all hypertrophic and some pedunculated tissue that had potential for impingement. The posterior aspect of the joint was fully visible and no obvious pathology was noted. The bur was introduced through the anterolateral portal and the distal tibial bone spur resected. Care was taken to remove all bony debris. Instrumentation was switched in the respective portals to facilitate final synovial debridement of the anterior medial aspect of the joint. The joint was inspected prior to suctioning free of fluid and removal of instrumentation. The right leg was removed from the thigh holder. The right lower extremity was elevated and exsanguinated, the tourniquet inflated to 300 mmHg.

Using the previous lateral ankle incision, sharp dissection was carried through skin. This extended longitudinally along the posterior aspect of the fibula and curved gently towards the sinus Tarsi. The peroneal retinaculum was located and incised proximal and distal to the tip of the fibula so as to preserve the previous peroneal retinacular reconstruction. Mild to moderate synovitis was present without significant scarring or adherence of the peroneal tendons to surrounding structures. A synovectomy was performed. Based on this patient's symptoms, stenosing tenosynovitis was likely and so the fibro-osseous tunnels of the peroneal tendons were released resecting a relatively large peroneal tubercle utilizing rongeurs. There was no evidence of longitudinal split tear within the peroneal tendons and so tenosynovectomy only was performed. Using self-retaining retractors, the peroneal tendons were displaced anteriorly and blunt dissection was carried to the posterior aspect of the talar dome where the os trigonum bony fragments were encountered. Utilizing soft tissue protection as well as flexion and extension of the great toe, the FHL tendon was located and protected. Each of the osseous fragments were carefully removed using a pituitary rongeur and tissue dissection from the bony margins. Complete removal of all posterior bony fragments was confirmed with the mini C arm. The incision sites were irrigated and closed. The anterior portal sites were closed with simple 4-0 nylon suture. The peroneal fascia and retinaculum was repaired with multiple figure-of-eight 2-0 Vicryl sutures. Subcutaneous closure was performed with 3-0 Vicryl simple suture and final skin closure was performed with running 3-0 Quill suture. Incision sites were washed and dried and a sterile dressing applied. A bulky cotton roll was applied followed by a short leg posterior mold sugar tong 4 inch Ortho-Glass splint. The tourniquet was let down, the toes demonstrated normal perfusion. The patient was awoke from anesthesia and transferred to the recovery room.
 
Did you try it at all? What did you come up with? Use key words and outline the op report into sections to break out each procedure and then have a "scratch sheet" of what you think the codes are. Once you do that you can research for bundling and to make sure you are using the correct code. Start with the anatomic area, approach (closed, open, scope, etc.), and then move to what was performed in that area. Having an understanding of foot and ankle anatomy is needed. Do you have an anatomy book to reference?

Start with the procedure header and assign the codes you think, then move to the body of the op report and see if it actually matches. Using a coding tool with lay descriptions and descriptions of procedures can help. When coding foot & ankle having the AAOS Global Surgery Data Guide books is invaluable for help understanding what is considered inclusive. In foot and ankle you will find many times the "cleanup" debridement and tenolysis may be included in "greater" procedures in the same area. For example, the extensive debridement may include bony work (osteophytectomy) in the same anatomic area depending on size.

Here are some key words to get started and in this case you would need to confirm in the body of the report if the whole case was via scope or if some of it was open.
Procedure:
1–right ankle arthroscopy with extensive debridement including the anterior ankle joint capsule anterolateral capsule and gutter, and bony resection of distal tibial osteophyte
2–right calcaneus excision of peroneal tubercle
3–excision of right talar os trigonum and associated fragments
4–right peroneal tendon tenosynovectomy

Patient was brought to the operating room and placed in the supine position on the beanbag. A timeout was called confirming site and procedure. After adequate general anesthesia as well as preoperative antibiotics, the patient was positioned in a slight sloppy left lateral decubitus with a beanbag to help facilitate the second portion of the procedure following arthroscopy. The ankle arthroscopy thigh holder was positioned. A tourniquet was placed at the right thigh. The right lower extremity was prepped and draped in the standard surgical fashion. The external traction device was applied to the foot. Bony and tendinous landmarks were drawn on the skin. The previous ankle arthroscopy portal sites were marked. The ankle joint was insufflated with fluid through the anterior medial portal utilizing normal saline. A 3 mm skin incision was made followed by a blunt dissection to the capsule. The blunt trocar and cannula were inserted followed by the arthroscope. The joint was insufflated with fluid and inspection was begun. A moderate amount of anterior synovial hypertrophy was noted. There was very mild grade I chondromalacia involving the talar dome without predisposition to a certain location and was generally diffuse. A fairly sizable distal tibial osteophyte was noted primarily laterally based. At this point the anterolateral portal was established through the previous portal incisional scar after transilluminating the area to ensure there was no evidence of neurologic structures passing through this area. A 3 mm incision was made through the previous scar, followed by blunt dissection intra-articularly under direct visualization with a small snap. The probe was inserted and the talar dome inspected, the cartilage appeared firm overall. The shaver was introduced and debridement from the medial to the lateral aspect of the joint was performed removing all hypertrophic and some pedunculated tissue that had potential for impingement. The posterior aspect of the joint was fully visible and no obvious pathology was noted. The bur was introduced through the anterolateral portal and the distal tibial bone spur resected. Care was taken to remove all bony debris. Instrumentation was switched in the respective portals to facilitate final synovial debridement of the anterior medial aspect of the joint. The joint was inspected prior to suctioning free of fluid and removal of instrumentation. The right leg was removed from the thigh holder. The right lower extremity was elevated and exsanguinated, the tourniquet inflated to 300 mmHg.

Using the previous lateral ankle incision, sharp dissection was carried through skin. This extended longitudinally along the posterior aspect of the fibula and curved gently towards the sinus Tarsi. The peroneal retinaculum was located and incised proximal and distal to the tip of the fibula so as to preserve the previous peroneal retinacular reconstruction. Mild to moderate synovitis was present without significant scarring or adherence of the peroneal tendons to surrounding structures. A synovectomy was performed. Based on this patient's symptoms, stenosing tenosynovitis was likely and so the fibro-osseous tunnels of the peroneal tendons were released resecting a relatively large peroneal tubercle utilizing rongeurs. There was no evidence of longitudinal split tear within the peroneal tendons and so tenosynovectomy only was performed. Using self-retaining retractors, the peroneal tendons were displaced anteriorly and blunt dissection was carried to the posterior aspect of the talar dome where the os trigonum bony fragments were encountered. Utilizing soft tissue protection as well as flexion and extension of the great toe, the FHL tendon was located and protected. Each of the osseous fragments were carefully removed using a pituitary rongeur and tissue dissection from the bony margins. Complete removal of all posterior bony fragments was confirmed with the mini C arm. The incision sites were irrigated and closed. The anterior portal sites were closed with simple 4-0 nylon suture. The peroneal fascia and retinaculum was repaired with multiple figure-of-eight 2-0 Vicryl sutures. Subcutaneous closure was performed with 3-0 Vicryl simple suture and final skin closure was performed with running 3-0 Quill suture. Incision sites were washed and dried and a sterile dressing applied. A bulky cotton roll was applied followed by a short leg posterior mold sugar tong 4 inch Ortho-Glass splint. The tourniquet was let down, the toes demonstrated normal perfusion. The patient was awoke from anesthesia and transferred to the recovery room.
 
Agree with 29898
It's a debate between 28120 or 28100 or both. I think both. There's a CPT Assistant about this where 28120 is used more for infection (osteomyelitis) and when I've see this it's usually a big chunk (excavation) leaving a divot that has to have bone wax or sometimes graft put in place. I would go with 28100 for the calcaneus. I think you could do 28120 for the OS trigonum because it's a malformation and it states osseous fragments removed. (Check bundling edits, may need 59)
It's not 27626 because no arthrotomy (opening the ankle joint) was done on the open part. Arthrotomy was done as part of the scope 29898. The peroneals and the other structures in the open part of the case are extraarticular.
Peroneals are flexor tendons, so I would look at 27680. You could also consider 28086.
Checking CPT assistant is a good idea in this case to make sure. There could be guidance there.
 
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