CHASITYWATSON
New
I’m reviewing an operative report that was dictated as a “Revision repair of left quadriceps tendon,” but the documentation doesn’t actually describe a quadriceps tendon rupture or a true quadriceps tendon repair.
I queried the surgeon for clarification, and he stated that the structure repaired was the vastus medialis/medial retinaculum, not the quadriceps tendon itself.
Based on the documentation and the clarification, would you code this case as 27425 (open lateral retinacular release) and 27599 (unlisted knee procedure) for the medial retinacular/vastus medialis advancement?
Below is the operative report for reference:
PREOPERATIVE DIAGNOSES: Left patellofemoral resurfacing, deep fascial dehiscence/quadriceps dehiscence.
POSTOPERATIVE DIAGNOSES: Left patellofemoral resurfacing, deep fascial dehiscence/quadriceps dehiscence.
OPERATION PERFORMED: Revision repair of left quadriceps tendon.
INDICATIONS: A 55-year-old diabetic smoker who underwent patellofemoral resurfacing for a work-related injury. He later developed increasing lateral patellar tilt and pain. Exam and MRI showed a palpable defect and medial retinacular disruption. He is brought back for revision.
DESCRIPTION OF PROCEDURE: He was taken to the OR and placed in the supine position on the operating room table. After the administration of anesthesia, he was positioned, prepped, and draped in the usual fashion.After a surgical time-out, the old scar was incised but carried proximal slightly with the entire distal incision, but her scar was not opened. I dissected down through the subcutaneous tissues. I bluntly dissected around the anterior patella and the quadriceps tendon. He had an obvious defect of his medial retinaculum at the superior pole of the patella. I did not violate the joint capsule. He had some scar, deep. I mobilized the vastus medialis. I started to repair the vastus medialis to the patella, and I felt it was just tight laterally. The lateral retinaculum contracted from the chronic subluxation. I dissected laterally and performed a lateral release not entering the capsule once again. The patella was much more mobile at this point. I then placed a combination of #2 Vicryl and #2 Ethibond sutures across the tear in a figure-of-eight fashion for the Ethibond and simple fashion for the Vicryl. I had a nice watertight repair, and I advanced the tissue slightly and certainly brought the vastus medialis tendon back to the patella appropriately. It was irrigated and injected the joint cocktail. He was closed with 2-0 Monocryl suture for the subcutaneous and staples for the skin. He was dressed with Mepilex dressing and a compression wrap. He was placed in a range of motion brace locked at 0. He was awakened and taken from the OR in stable condition.
I queried the surgeon for clarification, and he stated that the structure repaired was the vastus medialis/medial retinaculum, not the quadriceps tendon itself.
Based on the documentation and the clarification, would you code this case as 27425 (open lateral retinacular release) and 27599 (unlisted knee procedure) for the medial retinacular/vastus medialis advancement?
Below is the operative report for reference:
PREOPERATIVE DIAGNOSES: Left patellofemoral resurfacing, deep fascial dehiscence/quadriceps dehiscence.
POSTOPERATIVE DIAGNOSES: Left patellofemoral resurfacing, deep fascial dehiscence/quadriceps dehiscence.
OPERATION PERFORMED: Revision repair of left quadriceps tendon.
INDICATIONS: A 55-year-old diabetic smoker who underwent patellofemoral resurfacing for a work-related injury. He later developed increasing lateral patellar tilt and pain. Exam and MRI showed a palpable defect and medial retinacular disruption. He is brought back for revision.
DESCRIPTION OF PROCEDURE: He was taken to the OR and placed in the supine position on the operating room table. After the administration of anesthesia, he was positioned, prepped, and draped in the usual fashion.After a surgical time-out, the old scar was incised but carried proximal slightly with the entire distal incision, but her scar was not opened. I dissected down through the subcutaneous tissues. I bluntly dissected around the anterior patella and the quadriceps tendon. He had an obvious defect of his medial retinaculum at the superior pole of the patella. I did not violate the joint capsule. He had some scar, deep. I mobilized the vastus medialis. I started to repair the vastus medialis to the patella, and I felt it was just tight laterally. The lateral retinaculum contracted from the chronic subluxation. I dissected laterally and performed a lateral release not entering the capsule once again. The patella was much more mobile at this point. I then placed a combination of #2 Vicryl and #2 Ethibond sutures across the tear in a figure-of-eight fashion for the Ethibond and simple fashion for the Vicryl. I had a nice watertight repair, and I advanced the tissue slightly and certainly brought the vastus medialis tendon back to the patella appropriately. It was irrigated and injected the joint cocktail. He was closed with 2-0 Monocryl suture for the subcutaneous and staples for the skin. He was dressed with Mepilex dressing and a compression wrap. He was placed in a range of motion brace locked at 0. He was awakened and taken from the OR in stable condition.