jdibble
True Blue
We coders are having a debate with a provider and supervisors on correct codes for this surgery. The provider is administering pain blocks during surgery and insists that he can bill for these injections based on the NOPAIN Act. Everything we find says that this is not billable during the surgery by the surgeon, however the anesthesiologist can bill for the injections if the surgeon documents that he requested it be administered. Can someone advise the correct way to bill this with supporting documentation for why it isn't billed or supporting documentation for being able to bill the injections. The provider is insisting he can bill these charges, so a valid source of the guidelines is needed! The codes he is billing for this procedure is 27447, 64447 and 64473
Pre-op Diagnosis: Right knee arthritis.
Post-op Diagnosis: SAME
PROCEDURE:
1. Right total knee arthroplasty.
2.Intra-articular I-PACK Block for non-narcotic postoperative pain management in conjunction with the NOPAIN Act
3.Intra-articular Adductor Canal block for non-narcotic postoperative pain management in conjunction with the NOPAIN Act
4.Injection of 200 mg Zynrelef for non-narcotic postoperative pain management in conjunction with the NOPAIN Act
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and positioned supine on the operating table. Excellent spinal anesthesia was obtained. Ancef and Vancomycin was administered for infection prophylaxis. The operative lower extremity was then prepped and draped in the usual sterile fashion.
The knee was exposed via a sub-vastus arthrotomy. Appropriate medial soft‑tissue release was performed. Medial and lateral meniscal remnants, as well as the anterior cruciate ligament, were excised. Extensive eburnated bone was encountered. A patellar osteotomy was performed, resecting the patella to approximately 12–14 mm, and the patella was sized to 44 mm. Three‑peg holes were drilled for placement of the polyethylene patellar button.
The distal femoral cutting guide was used to perform the distal femoral resection, establishing a neutral mechanical axis. The proximal tibial cut was then made using the extramedullary tibial cutting guide. The femur and tibia were sized, and a Conformis CR femoral component and Conformis tibial component were selected. Appropriate soft‑tissue releases were performed to achieve a balanced knee under varus‑valgus stress in full extension. A trial reduction was performed using a cruciate‑retaining femoral component, a tibial tray, and an 7‑mm medial and A‑mm lateral cruciate‑retaining polyethylene insert. With this construct in place, the knee demonstrated satisfactory range of motion, stability, and alignment along the mechanical axis. Tibial tray rotation was marked. Final preparation of the proximal tibia was completed using the central drill and broach.
In conjunction with the NOPAIN Act and the utilization of a multimodal non‑narcotic pain management protocol for postoperative pain control, an intra‑articular IPACK and adductor canal block were performed. The needle was advanced deep to the posterior capsule. Aspiration was attempted to confirm that the needle was superficial to the popliteal vessels. 10 mL of a combination of Ropivacaine, Lidocaine, Clonidine, and Depo‑Medrol was injected into this fascial plane. Next, an intra‑articular adductor canal block was performed. The adductor tubercle was identified, and a needle was directed proximally between the Adductor Magnus, Sartorius, and Vastus Medialis. 10 mL of the cocktail was injected into the adductor canal.
The posterior capsule and surrounding soft‑tissue structures were injected with the remaining 60 mL of a periarticular cocktail. The bony surfaces were irrigated with pulsed lavage, suctioned, and packed dry while two units of CMW cement were mixed and loaded into the cement gun. Final components were cemented, and the knee was held in full extension while the cement cured. The knee was then dislocated anteriorly, and excess cement was removed from all components. The knee was reduced, and patellar tracking was assessed. A lateral release was not required to obtain central tracking.
Adequate hemostasis was achieved using the Bovie coagulation system. The wound was thoroughly pulse‑irrigated, and hemostasis was rechecked. The medial capsulotomy was closed with a running #1 looped PDS suture. Just prior to completing capsular closure, 200 mg of Zynrelef was injected for non‑narcotic postoperative pain control. The subcutaneous layer was closed with a running #0 Monoderm suture, followed by skin closure with running #2‑0 Monoderm. A sterile, compressive knee dressing was applied.
The patient was transferred to the recovery room in stable condition. Estimated blood loss was 400 mL. Sponge and needle counts were correct. There were no complications.
Thanks for all the answers and help you can give me!
Jodi
Pre-op Diagnosis: Right knee arthritis.
Post-op Diagnosis: SAME
PROCEDURE:
1. Right total knee arthroplasty.
2.Intra-articular I-PACK Block for non-narcotic postoperative pain management in conjunction with the NOPAIN Act
3.Intra-articular Adductor Canal block for non-narcotic postoperative pain management in conjunction with the NOPAIN Act
4.Injection of 200 mg Zynrelef for non-narcotic postoperative pain management in conjunction with the NOPAIN Act
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and positioned supine on the operating table. Excellent spinal anesthesia was obtained. Ancef and Vancomycin was administered for infection prophylaxis. The operative lower extremity was then prepped and draped in the usual sterile fashion.
The knee was exposed via a sub-vastus arthrotomy. Appropriate medial soft‑tissue release was performed. Medial and lateral meniscal remnants, as well as the anterior cruciate ligament, were excised. Extensive eburnated bone was encountered. A patellar osteotomy was performed, resecting the patella to approximately 12–14 mm, and the patella was sized to 44 mm. Three‑peg holes were drilled for placement of the polyethylene patellar button.
The distal femoral cutting guide was used to perform the distal femoral resection, establishing a neutral mechanical axis. The proximal tibial cut was then made using the extramedullary tibial cutting guide. The femur and tibia were sized, and a Conformis CR femoral component and Conformis tibial component were selected. Appropriate soft‑tissue releases were performed to achieve a balanced knee under varus‑valgus stress in full extension. A trial reduction was performed using a cruciate‑retaining femoral component, a tibial tray, and an 7‑mm medial and A‑mm lateral cruciate‑retaining polyethylene insert. With this construct in place, the knee demonstrated satisfactory range of motion, stability, and alignment along the mechanical axis. Tibial tray rotation was marked. Final preparation of the proximal tibia was completed using the central drill and broach.
In conjunction with the NOPAIN Act and the utilization of a multimodal non‑narcotic pain management protocol for postoperative pain control, an intra‑articular IPACK and adductor canal block were performed. The needle was advanced deep to the posterior capsule. Aspiration was attempted to confirm that the needle was superficial to the popliteal vessels. 10 mL of a combination of Ropivacaine, Lidocaine, Clonidine, and Depo‑Medrol was injected into this fascial plane. Next, an intra‑articular adductor canal block was performed. The adductor tubercle was identified, and a needle was directed proximally between the Adductor Magnus, Sartorius, and Vastus Medialis. 10 mL of the cocktail was injected into the adductor canal.
The posterior capsule and surrounding soft‑tissue structures were injected with the remaining 60 mL of a periarticular cocktail. The bony surfaces were irrigated with pulsed lavage, suctioned, and packed dry while two units of CMW cement were mixed and loaded into the cement gun. Final components were cemented, and the knee was held in full extension while the cement cured. The knee was then dislocated anteriorly, and excess cement was removed from all components. The knee was reduced, and patellar tracking was assessed. A lateral release was not required to obtain central tracking.
Adequate hemostasis was achieved using the Bovie coagulation system. The wound was thoroughly pulse‑irrigated, and hemostasis was rechecked. The medial capsulotomy was closed with a running #1 looped PDS suture. Just prior to completing capsular closure, 200 mg of Zynrelef was injected for non‑narcotic postoperative pain control. The subcutaneous layer was closed with a running #0 Monoderm suture, followed by skin closure with running #2‑0 Monoderm. A sterile, compressive knee dressing was applied.
The patient was transferred to the recovery room in stable condition. Estimated blood loss was 400 mL. Sponge and needle counts were correct. There were no complications.
Thanks for all the answers and help you can give me!
Jodi
