Hello, coder choose 27236-22, but the physician is requesting additional codes and we would like a second opinion. Thank you
Preoperative Diagnosis: Right femoral neck fracture, closed, displaced, chronic, after previous injury greater than 4 months ago.
Postoperative Diagnosis:
1. Right femoral neck fracture, closed, displaced, chronic, after previous injury greater than 4 months ago.
2. Extensive synovial overgrowth due to malunion and synovial inflammatory changes due to chronic nonunion/malunion.
3. Heterotopic bone with extracapsular soft tissues in the gluteus medius musculotendinous junction, benign, 1.2 cm x 6 mm.
Procedure Performed:
1. Complex open treatment of femoral neck fracture using hemiarthroplasty (CPT 27236, modifier 22).
2. Extensive synovectomy of pathologic synovium to do malunion (CPT 27054).
3. Osteotomy of the proximal femur (CPT 27448).
4. Excision of heterotopic extracapsular ossification (CPT 27048).
Anesthesia: General.
Complications: None.
Estimated Blood Loss: 50 mL.
Specimens: Bony resections.
Implants Used: Zimmer Echo Hip System, bipolar head.
Indication for Procedure: The patient is a 76-year-old female presenting with a complex medical issue involving her right hip. She underwent a fall and was diagnosed with displaced femur fracture at outside country greater than 4 months ago. She elected to avoid surgery at that time and return back to United States. She eventually was seen by Dr. Osborne and was diagnosed with a nonunion of the right proximal femur. We discussed the risks, benefits, and alternatives in full detail with the patient and family and they have agreed to proceed with surgery understanding risks and benefits.
Procedure In Detail: Patient identified in the preoperative holding area and the operative extremity marked by the anesthesia team. Patient brought to the operating room where general endotracheal anesthesia was induced. The right lower extremity was prepped and draped in the usual sterile fashion after being positioned in the lateral decubitus position with all bony prominences well padded. At this time, an incision was made over the posterior aspect of the greater trochanter extending proximally and distally through the skin and fat down to the iliotibial fascia. The fascia was noted to be extremely contracted due to longstanding shortening of the limb. After the fascia was incised, a large amount of adhesive tissues were identified and difficult to mobilize. The quadratus femoris was released out to posterior femur and extended and this dissection was extended proximally to the posterior capsule. The posterior capsule was incised and a large amount of serous fluid was evacuated at this time. There was a large amount of callus formation. Anatomy was noted to be quite aberrant at this time already. The lesser trochanter had healed in a more posterior position and the proximal femoral shaft fracture unfortunately was healed in a malunion position as well. The fracture appeared to be an intratrochanteric femur fracture pattern. Sclerotic bone was present above the lesser trochanter and time was taken to perform a thorough excision of any sclerotic bone in the proximal femur at this time. Separate from the approach there was felt to be a hardened mass in the gluteus medius musculotendinous junction while not imperative for the use of approach or dissection. This mass was felt to possibly impede the function of the gluteus medius and excision was performed at this time of the heterotopic ossified mass. Attention was then turned back to the acetabulum. Encapsulated femoral head was loosened of its adhesion that were removed from the acetabulum and sized on the back table for the appropriate sized bipolar head at a later time. Attention was then turned back to the proximal femur which had extensive malunion changes. An osteotomy was performed of the proximal femur at this time and the canal finder was then used to direct the direction of the shaft. The osteotomized fragment was rotated into place after osteotomy with a saw and osteotomes. This fragment was the medial portion of the proximal femur that was malunited. It was held in place while broaching began to the appropriate sized broach and secured by the medial aspect of the broach eventually with cement. At this time the trial was performed and found to be appropriate, therefore, the appropriate sized cemented stem was opened and the cement was mixed on the back table. Cemented stem was impacted into place careful to hold the osteotomized post fragment in place while the cement hardened. At this time, the wounds were thoroughly irrigated and the bipolar head was impacted into place and the hip was reduced once more. A thorough excision of the inflamed synovium was performed at this time given the hypertrophic and extreme synovial thickening due to the likely inflammation from ongoing nonunion. This was performed using electrocautery to circumferentially excise the synovium in its 360 degree view around the implant stem. At this time, the wounds were thoroughly irrigated and closed with 0 Vicryl and #1 Stratafix, 2-0 Monocryl and 3-0 Monocryl. Sterile dressing was applied and the patient was awoken from anesthesia in stable condition.
For coding purposes, this case warrants the use of a 22 modifier during the 27236 portion. Patient presents with chronic fracture and nonunion with extensive adhesions and limited motion which increased the time, effort, surgical skill, surgical technique by greater than 100% and therefore warrants use of 22 modifier.
Preoperative Diagnosis: Right femoral neck fracture, closed, displaced, chronic, after previous injury greater than 4 months ago.
Postoperative Diagnosis:
1. Right femoral neck fracture, closed, displaced, chronic, after previous injury greater than 4 months ago.
2. Extensive synovial overgrowth due to malunion and synovial inflammatory changes due to chronic nonunion/malunion.
3. Heterotopic bone with extracapsular soft tissues in the gluteus medius musculotendinous junction, benign, 1.2 cm x 6 mm.
Procedure Performed:
1. Complex open treatment of femoral neck fracture using hemiarthroplasty (CPT 27236, modifier 22).
2. Extensive synovectomy of pathologic synovium to do malunion (CPT 27054).
3. Osteotomy of the proximal femur (CPT 27448).
4. Excision of heterotopic extracapsular ossification (CPT 27048).
Anesthesia: General.
Complications: None.
Estimated Blood Loss: 50 mL.
Specimens: Bony resections.
Implants Used: Zimmer Echo Hip System, bipolar head.
Indication for Procedure: The patient is a 76-year-old female presenting with a complex medical issue involving her right hip. She underwent a fall and was diagnosed with displaced femur fracture at outside country greater than 4 months ago. She elected to avoid surgery at that time and return back to United States. She eventually was seen by Dr. Osborne and was diagnosed with a nonunion of the right proximal femur. We discussed the risks, benefits, and alternatives in full detail with the patient and family and they have agreed to proceed with surgery understanding risks and benefits.
Procedure In Detail: Patient identified in the preoperative holding area and the operative extremity marked by the anesthesia team. Patient brought to the operating room where general endotracheal anesthesia was induced. The right lower extremity was prepped and draped in the usual sterile fashion after being positioned in the lateral decubitus position with all bony prominences well padded. At this time, an incision was made over the posterior aspect of the greater trochanter extending proximally and distally through the skin and fat down to the iliotibial fascia. The fascia was noted to be extremely contracted due to longstanding shortening of the limb. After the fascia was incised, a large amount of adhesive tissues were identified and difficult to mobilize. The quadratus femoris was released out to posterior femur and extended and this dissection was extended proximally to the posterior capsule. The posterior capsule was incised and a large amount of serous fluid was evacuated at this time. There was a large amount of callus formation. Anatomy was noted to be quite aberrant at this time already. The lesser trochanter had healed in a more posterior position and the proximal femoral shaft fracture unfortunately was healed in a malunion position as well. The fracture appeared to be an intratrochanteric femur fracture pattern. Sclerotic bone was present above the lesser trochanter and time was taken to perform a thorough excision of any sclerotic bone in the proximal femur at this time. Separate from the approach there was felt to be a hardened mass in the gluteus medius musculotendinous junction while not imperative for the use of approach or dissection. This mass was felt to possibly impede the function of the gluteus medius and excision was performed at this time of the heterotopic ossified mass. Attention was then turned back to the acetabulum. Encapsulated femoral head was loosened of its adhesion that were removed from the acetabulum and sized on the back table for the appropriate sized bipolar head at a later time. Attention was then turned back to the proximal femur which had extensive malunion changes. An osteotomy was performed of the proximal femur at this time and the canal finder was then used to direct the direction of the shaft. The osteotomized fragment was rotated into place after osteotomy with a saw and osteotomes. This fragment was the medial portion of the proximal femur that was malunited. It was held in place while broaching began to the appropriate sized broach and secured by the medial aspect of the broach eventually with cement. At this time the trial was performed and found to be appropriate, therefore, the appropriate sized cemented stem was opened and the cement was mixed on the back table. Cemented stem was impacted into place careful to hold the osteotomized post fragment in place while the cement hardened. At this time, the wounds were thoroughly irrigated and the bipolar head was impacted into place and the hip was reduced once more. A thorough excision of the inflamed synovium was performed at this time given the hypertrophic and extreme synovial thickening due to the likely inflammation from ongoing nonunion. This was performed using electrocautery to circumferentially excise the synovium in its 360 degree view around the implant stem. At this time, the wounds were thoroughly irrigated and closed with 0 Vicryl and #1 Stratafix, 2-0 Monocryl and 3-0 Monocryl. Sterile dressing was applied and the patient was awoken from anesthesia in stable condition.
For coding purposes, this case warrants the use of a 22 modifier during the 27236 portion. Patient presents with chronic fracture and nonunion with extensive adhesions and limited motion which increased the time, effort, surgical skill, surgical technique by greater than 100% and therefore warrants use of 22 modifier.