lchiriac
Contributor
Hello everyone,
we would like a sec opinion regarding the following op report as some of the coders think the osteotomy is incidental to the conversion to THA, but the NCCI does not bundle 27132 with 27165. Thank you very much for your opinion!!
"Indication for Procedure: The patient is a 63-year-old female presenting with a very complex medical condition. She has severe destructive changes of her right hip, severe shortening and contractures and failure of previous fixation other right hip. She has extensive degenerative changes and destructive changes of the acetabulum as well. I discussed complex removal of her previous hardware with conversion to a total hip arthroplasty. There are extensive amounts of risks from a surgical standpoint and recovery standpoint given the extensive need for this type of procedure. The risks, benefits, alternatives were discussed and she elected to proceed with the procedure given stated benefits.
Description of Procedure: The patient identified in the preoperative holding area. Operative extremity marked by thesurgical team. Patient then brought to the operating room where general anesthesia induced. At this time the patientwas positioned in lateral position with all bony prominences well padded. She was prepped and draped in usualsterile fashion. Time-out was performed. At this time, a large curvilinear incision was made along the lateralproximal femur extending proximally and distally. Incision was taken through the skin and fat down to the level of thefascia. The fascia was incised. A large amount of adhesions noted in the proximal portion of the fascia. Time wastaken to resect adhesions in the trochanteric bursal layer to free up any attachments. The hip screw location wasreadily identified at this time. There was overgrown bone over the hip screw and a bur was used to remove overgrown bone to access the screw more easily at a later time. Attention was turned more distally. An incision was made through the vastus lateralis and the distal interlocking screw was identified. It was removed using a screwdriver, but only the head and a small portion of threads came loose. The remainder of the screw had been already fractured and broken due to hardware malfunction. Accessing this portion of the distal screw proved to be extremely difficult as the screw was embedded anteriorly and posteriorly within the confines of the nail and any extraction bits utilized would not grab the screw and free it from its distal cortex. It would be too dangerous to back the nail out without somehow removing the screw as that could cause fracturing of the cortex medially. Therefore, at this time, a bur was used to create a cortical window within the femoral shaft. This osteotomy was used to visualize the nail more distally more readily. At this time, a bur was used to continue to bur the titanium screw down through the nail to the other side until a small portion was attached into the medial cortex. This part of the screw would notimpede nail removal and attention was turned back to the proximal nail. The hip was found to be extensivelydeformed due to malunion in the subtrochanteric region. Extensive dissection was made to clear the soft tissuesposteriorly and access the hip joint. More extensive time was taken than usually needed due to the severe callusformation and adhesions in the proximal portion of the femur in this region. Once the hip was dislocated, attentionwas turned to the greater trochanter. The entry hole of the nail was identified and found. The set screw wasloosened and hip screw was removed at this time. Hip screw removal proved to be quite difficult due to overgrownbone, but at this time the nail was able to be removed entirely. Attention was then turned back to the distalinterlocking screw. Overdrill was used to drill through the medial cortex and remove the remaining portion of thescrew lodged medially. Attention was then turned back to the hip joint. An osteotomy was made within the femoralneck as low as possible above the malunited lesser trochanter. Time was taken to remove any excess bony callusand bony fragments that healed within the soft tissues to help free up the hip joint. Additionally, attention was thenturned to the acetabulum when appropriate soft tissue releases were performed and the osteotomes prepared foracetabular cup with sequential reaming. Acetabular cup was impacted with appropriate amount of version andinclination and acetabular screws were placed for additional stability. Liner was then placed in the acetabularcomponent. Attention was then turned back to the femur. The subtrochanteric region had healed in excessivemalunited position. This would likely need to be addressed for appropriate function of the hip. Therefore, osteotomywas used to create an osteotomy through the subtrochanteric region just below the malunited lesser trochanter andthe whole proximal fragment of femur was then angled more appropriately with the shaft and a reamer was placedwith sequential reaming through the osteotomized fragment and the shaft to allow straight reaming. Once the appropriate size reamer was identified, the appropriate size femoral stem was then impacted into place for the distalbody. Trialing was performed after preparing for proximal body. Trialing proved to be quite difficult given the severecontractures of the soft tissues and length needed to help further establish appropriate leg lengths, but once trialingwas performed the hip was brought through full range of motion and found to be satisfactory in terms of stability.Length remained to be somewhat short but acceptable given the lack of availability in further soft tissue releases ingaining more leg length. Therefore, at this time, the proximal body was inserted through the proximal femur and heldholding the osteotomy in place and tightened onto the distal body. The appropriate sized femoral head was impactedand the hip was reduced once more. This was found to be appropriate in terms of stability. Therefore, at this time,the wounds were thoroughly irrigated and closed with 0 Vicryl, #1 Stratafix, 2-0 Monocryl and 3-0 Monocryl. Steriledressings were applied. The patient awoken from anesthesia in stable condition. For coding purposes, this case warrants use of 22 modifier. The patient presents with multiple complexities thatincreased the time, effort, surgical skill, surgical technique by greater than 100% and therefore warrants use of 22modifier. These include encountering broken hardware which required more extensive need for removal, extensiveadhesions and callus formation as well as bony fragments from previous fracture healed in abnormal positions, etc."
we would like a sec opinion regarding the following op report as some of the coders think the osteotomy is incidental to the conversion to THA, but the NCCI does not bundle 27132 with 27165. Thank you very much for your opinion!!
"Indication for Procedure: The patient is a 63-year-old female presenting with a very complex medical condition. She has severe destructive changes of her right hip, severe shortening and contractures and failure of previous fixation other right hip. She has extensive degenerative changes and destructive changes of the acetabulum as well. I discussed complex removal of her previous hardware with conversion to a total hip arthroplasty. There are extensive amounts of risks from a surgical standpoint and recovery standpoint given the extensive need for this type of procedure. The risks, benefits, alternatives were discussed and she elected to proceed with the procedure given stated benefits.
Description of Procedure: The patient identified in the preoperative holding area. Operative extremity marked by thesurgical team. Patient then brought to the operating room where general anesthesia induced. At this time the patientwas positioned in lateral position with all bony prominences well padded. She was prepped and draped in usualsterile fashion. Time-out was performed. At this time, a large curvilinear incision was made along the lateralproximal femur extending proximally and distally. Incision was taken through the skin and fat down to the level of thefascia. The fascia was incised. A large amount of adhesions noted in the proximal portion of the fascia. Time wastaken to resect adhesions in the trochanteric bursal layer to free up any attachments. The hip screw location wasreadily identified at this time. There was overgrown bone over the hip screw and a bur was used to remove overgrown bone to access the screw more easily at a later time. Attention was turned more distally. An incision was made through the vastus lateralis and the distal interlocking screw was identified. It was removed using a screwdriver, but only the head and a small portion of threads came loose. The remainder of the screw had been already fractured and broken due to hardware malfunction. Accessing this portion of the distal screw proved to be extremely difficult as the screw was embedded anteriorly and posteriorly within the confines of the nail and any extraction bits utilized would not grab the screw and free it from its distal cortex. It would be too dangerous to back the nail out without somehow removing the screw as that could cause fracturing of the cortex medially. Therefore, at this time, a bur was used to create a cortical window within the femoral shaft. This osteotomy was used to visualize the nail more distally more readily. At this time, a bur was used to continue to bur the titanium screw down through the nail to the other side until a small portion was attached into the medial cortex. This part of the screw would notimpede nail removal and attention was turned back to the proximal nail. The hip was found to be extensivelydeformed due to malunion in the subtrochanteric region. Extensive dissection was made to clear the soft tissuesposteriorly and access the hip joint. More extensive time was taken than usually needed due to the severe callusformation and adhesions in the proximal portion of the femur in this region. Once the hip was dislocated, attentionwas turned to the greater trochanter. The entry hole of the nail was identified and found. The set screw wasloosened and hip screw was removed at this time. Hip screw removal proved to be quite difficult due to overgrownbone, but at this time the nail was able to be removed entirely. Attention was then turned back to the distalinterlocking screw. Overdrill was used to drill through the medial cortex and remove the remaining portion of thescrew lodged medially. Attention was then turned back to the hip joint. An osteotomy was made within the femoralneck as low as possible above the malunited lesser trochanter. Time was taken to remove any excess bony callusand bony fragments that healed within the soft tissues to help free up the hip joint. Additionally, attention was thenturned to the acetabulum when appropriate soft tissue releases were performed and the osteotomes prepared foracetabular cup with sequential reaming. Acetabular cup was impacted with appropriate amount of version andinclination and acetabular screws were placed for additional stability. Liner was then placed in the acetabularcomponent. Attention was then turned back to the femur. The subtrochanteric region had healed in excessivemalunited position. This would likely need to be addressed for appropriate function of the hip. Therefore, osteotomywas used to create an osteotomy through the subtrochanteric region just below the malunited lesser trochanter andthe whole proximal fragment of femur was then angled more appropriately with the shaft and a reamer was placedwith sequential reaming through the osteotomized fragment and the shaft to allow straight reaming. Once the appropriate size reamer was identified, the appropriate size femoral stem was then impacted into place for the distalbody. Trialing was performed after preparing for proximal body. Trialing proved to be quite difficult given the severecontractures of the soft tissues and length needed to help further establish appropriate leg lengths, but once trialingwas performed the hip was brought through full range of motion and found to be satisfactory in terms of stability.Length remained to be somewhat short but acceptable given the lack of availability in further soft tissue releases ingaining more leg length. Therefore, at this time, the proximal body was inserted through the proximal femur and heldholding the osteotomy in place and tightened onto the distal body. The appropriate sized femoral head was impactedand the hip was reduced once more. This was found to be appropriate in terms of stability. Therefore, at this time,the wounds were thoroughly irrigated and closed with 0 Vicryl, #1 Stratafix, 2-0 Monocryl and 3-0 Monocryl. Steriledressings were applied. The patient awoken from anesthesia in stable condition. For coding purposes, this case warrants use of 22 modifier. The patient presents with multiple complexities thatincreased the time, effort, surgical skill, surgical technique by greater than 100% and therefore warrants use of 22modifier. These include encountering broken hardware which required more extensive need for removal, extensiveadhesions and callus formation as well as bony fragments from previous fracture healed in abnormal positions, etc."