Wiki Ortho Op Report-Quadriceps tendon repair/lateral release


Perryville, MO
Best answers
I'm a little confused by this report and exactly what to bill. The physician states in the body of the note arthrotomy performed along with lateral release and tear to Quadriceps tendon. Any suggestions on appropriate coding?

Procedure Performed: left knee quadriceps tendon repair & Lateral release

His leg was exsanguinated and tourniquet tourniquet inflated to 300 mm of Mercury. A standard midline approach was taken over the prior scar. Careful dissection continued down toward the arthrotomy was made. Just proximal to the patella there was a 1-1.5 inch tear of his quadriceps tendon. At this point in time it was determined to complete the arthrotomy in order to perform a lateral release. The arthrotomy was performed in the prior area. A lateral release with a Bovey cautery was then performed. With the towel clip holding the arthrotomy closed, the knee had full extension and flexion past 120 degrees with good patella tracking and no subluxation. The knee was then irrigated out under pulsatile lavage. A Hemovac drain was placed. With #2 forced fiber the quadriceps tendon was closed in full thicknesses as well as the retinaculum. The patient again had flexion extension touching it. He had good range of motion in form and normal patella tracking.
At this point in time the quadriceps tendon repair was augmented with a graft jacked which was sutured into place over the tendon. At this point in time the knee was irrigated again. #2-0 Vicryl sutures were used to close the subcutaneous tissue. Staples were used to close the skin. The knee was injected with 50 cc's 0.25% Marcaine with Epinephrine. Sterile soft dressing with Xeroform, 4X4's, ABD and ACE bandage was placed. The patient went to recovery in stable condition.
just a suggestion......27385 for the quadriceps repair, 27425 for the lateral release, and 27331 for the arthrotomy.... but you would need to check for bundling issues. Hope this helps.