• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • Important Note: We will be performing important server maintenance on 15 July 2020 , during which time this site will be unavailable for approximately 2 hours. If you are in the middle of something critical , please save your work. We apologize for any inconvenience this may cause.

Question Revision total knee replacement using tibial polyethylene, extensive debridement and quadricepsplasty

Kestrelwa

Contributor
Messages
19
Best answers
0
Hello,

How would you all code the following op report? This was has been coded a couple different ways and the payor has denied charges as not supported.

This was coded as 27486-52-RT, 27430-51-RT and denied. A corrected claim was submitted with 27430-RT, 27310-51-RT. Still denied.

Would appreciate any help you could offer in getting this surgery paid.

DESCRIPTION OF PROCEDURE:
His old total knee incision was used and dissection carried out down to and through the soft tissues to the quadriceps mechanism. The old medial parapatellar arthrotomy was entered and knee fluid was sent for cell count, differential, Gram stain, culture and intra-articular synovial for frozen section. We noted the extremely dense scarring about the knee. We began performing a complete meticulous synovectomy including removing as much of the scar tissue as possible throughout the knee. We performed a formal quadricepsplasty freeing up the quad mechanism where it was densely scarred down to the femur. We then circumferentially exposed the patellar component. It appeared to be well aligned and fixed. In my judgment, it was best served by being left in place. Again, he had extremely dense scarring about the knee, and we spent a very significant amount of time attempting to remove as much of the scar as possible. We were eventually able to flex the knee further and eventually were able to remove the tibial polyethylene. We then completed our synovectomy and continued debriding all of the heterotopic ossification and bone as much as possible about the entire knee. After we had done this, we then placed trial polys, beginning with a 12.5 mm poly and eventually felt with a 17.5 mm poly we had full complete extension, excellent flexion and stability. With this in place, we were able to flex his knee easily to 120 degrees. At this point, in my judgment, he is best served by going with this construct. Please note, we had circumferentially exposed as much of the femoral and tibial components as possible, and again they appear to be well aligned and fixed, and in my judgment, will be best served by being left in place. We irrigated. We then seated the final DePuy PFC Sigma mobile bearing TC3 polyethylene 17.5 mm thick for the size 4 component. We injected about the knee with 60 mL of 0.25 percent Marcaine with epinephrine. The tourniquet was released and hemostasis was obtained with electrocautery. A single 1/8 inch drain was placed in lateral gutter. Quadriceps mechanism was approximated using interrupted #2 Ethibond and #1 Vicryl sutures. Deep and superficial subcutaneous tissues were approximated using a 0 Quill suture and the skin was closed with running subcuticular 3-0 Stratafix suture. Dermabond was placed on the incision, followed by sterile dressing and cold therapy pad. He was taken to the recovery room in stable condition.

Thank you!!
 

AReilly

Contributor
Messages
10
Best answers
0
Hello,

How would you all code the following op report? This was has been coded a couple different ways and the payor has denied charges as not supported.

This was coded as 27486-52-RT, 27430-51-RT and denied. A corrected claim was submitted with 27430-RT, 27310-51-RT. Still denied.

Would appreciate any help you could offer in getting this surgery paid.

DESCRIPTION OF PROCEDURE:
His old total knee incision was used and dissection carried out down to and through the soft tissues to the quadriceps mechanism. The old medial parapatellar arthrotomy was entered and knee fluid was sent for cell count, differential, Gram stain, culture and intra-articular synovial for frozen section. We noted the extremely dense scarring about the knee. We began performing a complete meticulous synovectomy including removing as much of the scar tissue as possible throughout the knee. We performed a formal quadricepsplasty freeing up the quad mechanism where it was densely scarred down to the femur. We then circumferentially exposed the patellar component. It appeared to be well aligned and fixed. In my judgment, it was best served by being left in place. Again, he had extremely dense scarring about the knee, and we spent a very significant amount of time attempting to remove as much of the scar as possible. We were eventually able to flex the knee further and eventually were able to remove the tibial polyethylene. We then completed our synovectomy and continued debriding all of the heterotopic ossification and bone as much as possible about the entire knee. After we had done this, we then placed trial polys, beginning with a 12.5 mm poly and eventually felt with a 17.5 mm poly we had full complete extension, excellent flexion and stability. With this in place, we were able to flex his knee easily to 120 degrees. At this point, in my judgment, he is best served by going with this construct. Please note, we had circumferentially exposed as much of the femoral and tibial components as possible, and again they appear to be well aligned and fixed, and in my judgment, will be best served by being left in place. We irrigated. We then seated the final DePuy PFC Sigma mobile bearing TC3 polyethylene 17.5 mm thick for the size 4 component. We injected about the knee with 60 mL of 0.25 percent Marcaine with epinephrine. The tourniquet was released and hemostasis was obtained with electrocautery. A single 1/8 inch drain was placed in lateral gutter. Quadriceps mechanism was approximated using interrupted #2 Ethibond and #1 Vicryl sutures. Deep and superficial subcutaneous tissues were approximated using a 0 Quill suture and the skin was closed with running subcuticular 3-0 Stratafix suture. Dermabond was placed on the incision, followed by sterile dressing and cold therapy pad. He was taken to the recovery room in stable condition.

Thank you!!
First thing you want to ask yourself is, why were the prosthesis(es) removed. If there is no indication of failed hardware to justify removing and replacing the prosthesis(es), then this work is included in the other reported CPT code. From reading the op note, it sounds like the tibial poly was removed to complete the synovectomy. The op note states multiple times that the prostheses were well aligned and fixed.

AAOS Now Feb 2013
"An infection may be treated in a single surgical session or it may be treated in two or more stages depending on the organism and its virulence. If the infection is treated in two sessions (staged management), during the first operation the prior prosthesis(es) are removed, with or without insertion of an antibiotic spacer or removal and reinsertion of a spacer.
For example, the surgeon performs a total knee arthroplasty on a 78-year-old male patient. During the global period, the surgeon returns the patient to the surgical suite for an arthrotomy, irrigation, and débridement. The surgeon removes the polyliner to access the posterior knee and replaces it with a new polyliner at the end of the surgery.
The surgeon reports CPT code 27310-78 (arthrotomy, knee, with exploration, drainage, or removal of foreign body [eg, infection]). This is not a revision case or a staged procedure, even though the surgeon exchanged the polyliner. The polyliner was removed to allow access to the posterior knee."

I would look at CPT code 27335.

I would not code CPT 27430 because in the op note it states the quad mechanism was freed up from the densely scarred tissue. When I look at the surgical techniques of a quadricepsplasty they all reference muscle lengthening and/or muscle excision to correct the quadriceps contracture.
I would not code 27310 due to exploration is for diagnostic purposes and the provider performed a surgical procedure. There is no documentation of infection that was drained or removal of foreign body(ies).

Hope this helps!
 

Kestrelwa

Contributor
Messages
19
Best answers
0
First thing you want to ask yourself is, why were the prosthesis(es) removed. If there is no indication of failed hardware to justify removing and replacing the prosthesis(es), then this work is included in the other reported CPT code. From reading the op note, it sounds like the tibial poly was removed to complete the synovectomy. The op note states multiple times that the prostheses were well aligned and fixed.

AAOS Now Feb 2013
"An infection may be treated in a single surgical session or it may be treated in two or more stages depending on the organism and its virulence. If the infection is treated in two sessions (staged management), during the first operation the prior prosthesis(es) are removed, with or without insertion of an antibiotic spacer or removal and reinsertion of a spacer.
For example, the surgeon performs a total knee arthroplasty on a 78-year-old male patient. During the global period, the surgeon returns the patient to the surgical suite for an arthrotomy, irrigation, and débridement. The surgeon removes the polyliner to access the posterior knee and replaces it with a new polyliner at the end of the surgery.
The surgeon reports CPT code 27310-78 (arthrotomy, knee, with exploration, drainage, or removal of foreign body [eg, infection]). This is not a revision case or a staged procedure, even though the surgeon exchanged the polyliner. The polyliner was removed to allow access to the posterior knee."

I would look at CPT code 27335.

I would not code CPT 27430 because in the op note it states the quad mechanism was freed up from the densely scarred tissue. When I look at the surgical techniques of a quadricepsplasty they all reference muscle lengthening and/or muscle excision to correct the quadriceps contracture.
I would not code 27310 due to exploration is for diagnostic purposes and the provider performed a surgical procedure. There is no documentation of infection that was drained or removal of foreign body(ies).

Hope this helps!
Thank you for your response!
 
Top