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Need Help With Knee Surgery

  1. #1
    Location
    Columbus, Ohio
    Posts
    105
    Cool Need Help With Knee Surgery
    Medical Coding Books
    Hello Coders, my surgeon did a knee surgery that combines a lot of open and Arthroscopic procedures. I wasn't sure what parts would be bundled and if I can bill the arthroscopic when so much was done open. I did bill the 29888 as the primary procedure along with 27405, 29876 and 27380. I thought the ligament repairs would be bundled with the ACL repair. It is quite a detailed op note and if someone has the time to review it, I would really appreciate some pointers on where to start on this big an op report. If I missed something that was billable, please let me know so I can appeal it. Thanks, Paula




    PROCEDURES
    1. Left knee arthroscopy with anterior cruciate ligament (ACL)
    reconstruction with allograft.
    2. Left knee open reconstruction fibular collateral ligament with
    allograft.
    3. Left knee open reconstruction of popliteal femoral ligament with
    allograft.
    4. Left knee open repair popliteus tendon rupture, femoral insertion.
    5. Left knee open repair, posterolateral capsule.
    6. Left knee arthroscopy with chondroplasty of the patellofemoral
    joint.
    7. Left knee arthroscopy with synovectomy.

    OPERATIVE PROCEDURE
    I did talk to the patient prior about use of allograft versus autograft
    for his reconstruction, and the patient did choose allograft for the
    reconstruction. I did choose 2 posterior tibial tendons and placed #2
    FiberWires in a whipstitch manner at both ends and then measured the
    tendons. The one tendon was a 9.5 mm in diameter tendon looped upon
    itself. The other tendon was a 9-mm tendon looped upon itself. I
    initially did the exposure to the posterolateral corner. I took an
    Esmarch bandage and exsanguinated the extremity. We inflated the
    tourniquet to 350 mmHg.
    A lateral incision was made staying on the posterior aspect of the
    iliotibial band proximally, and the incision was turned distally to
    around the posterior aspect of the proximal fibular head. The skin was
    incised with a scalpel. Blunt retractor was placed in the wound. All
    hemostasis obtained throughout the case with Bovie. Blunt dissection
    was taken with tenotomies and scissors down to the deep fascia. The
    patient had significant scarring from the injury. It was difficult to
    identify the structures. The iliotibial band could be identified. The
    biceps femoris was scarred in. The head of the fibula was scarred in
    too. I did dissect around posteriorly and did find the peroneal nerve.
    This was tagged and kept out of harm's way throughout the case. The
    biceps femoris was split anteriorly over the fibular head, and the
    fibular head was dissected out subperiosteally. Retractors were placed
    around the fibular head. Once this could be fully seen, the fibular
    collateral ligament and the popliteal fibular ligament were obviously
    torn and scarred in. The patient's knee was very grossly unstable.
    Once the fibular head was exposed, retractors were placed around this,
    and a guide pin was placed from anterior to posterior in the fibular
    head. A 5-mm reamer was taken with care to protecting the peroneal
    nerve posteriorly. Once this was completed, I split the iliotibial band
    over the lateral epicondyle proximally. Blunt dissection was taken down
    to the lateral epicondyle of the femur. The popliteus tendon could be
    seen and was avulsed off the femur. This was tagged with a #2
    FiberWire. This would be later repaired.
    I exposed the lateral epicondyle, and at this point with my exposure, I
    went to arthroscopy. I made 2 standard incisions inferomedial and
    inferolateral on the knee through the skin with a scalpel. Blunt trocar
    and cannula were placed in the inferolateral portal, and suprapatellar
    pouch was entered. Upon initial inspection, a significant amount of
    synovitis and scarring. A shaver was placed in the inferomedial portal,
    and a synovectomy was completed of the suprapatellar pouch, medial and
    lateral compartments. This allowed better visualization.
    Patellofemoral joint could be seen. There was some articular cartilage
    injury to the patellofemoral joint. There was some mild chondromalacia.
    A chondroplasty was completed on this with a shaver to a stable border
    when probed. There was just some mild flaking cartilage, but this was
    not significant. The medial and lateral gutters were inspected, and
    there were no loose bodies. Femoral notch was inspected, and the ACL
    stump could be seen and this was almost completely avulsed. PCL was
    intact. The medial compartment was entered, and the articular cartilage
    and meniscus were without injury.
    Lateral compartment was entered. The articular cartilage and meniscus
    were without injury. The popliteus tendon could be seen and was
    avulsed. There was a significant amount of hemorrhagic tissue and
    scarring from prior injury. I then removed the ACL stump with a shaver.
    I cleared the lateral wall of the femur with thermal wand by ArthroCare.
    I used a bur and completed a notchplasty as well. I placed the tibial
    guide by Arthrex through the inferomedial portal on the footprint of the
    ACL. This was placed anterior to the posterior cruciate ligament and
    beside the anterior horn of the lateral meniscus. The pin was placed up
    to the skin, and a small incision was made, and blunt dissection was
    taken down to the bone medially. This was done medially to the tibial
    I used a bur and completed a notchplasty as well. I placed the tibial
    guide by Arthrex through the inferomedial portal on the footprint of the
    ACL. This was placed anterior to the posterior cruciate ligament and
    beside the anterior horn of the lateral meniscus. The pin was placed up
    to the skin, and a small incision was made, and blunt dissection was
    taken down to the bone medially. This was done medially to the tibial
    tubercle. A pin was placed up through the tibia into the footprint.
    The guide was removed. This had excellent position.
    I did again size the graft to 9.5 mm. This was the posterior tibial
    tendon allograft. I reamed over the wire up into the tibia 9.5 mm in
    diameter. Care was taken to protect the PCL while doing this. Once
    this was done, the pin and reamer were removed. The shaver was placed
    back into the joint, and the debris was excised. This had excellent
    position in front of the PCL and beside the anterior horn of the lateral
    meniscus. The over-the-top guide was placed to the tibial tunnel on the
    posterior wall of the femur. This was placed in a slightly more
    horizontal position at approximately the 1:30 to 2 o'clock position.
    The guide pin was placed up through the femur. A 9.5 mm reamer was
    taken to a depth of 40 mm over the guide pin into the femur. Care was
    taken to protect the PCL with probe. This was removed, and the debris
    was removed with a shaver. This had excellent position of the tunnel.
    I then took the U-shaped guide for the bioabsorbable cross pin by
    Arthrex up through the tunnels with the arm exiting laterally. The
    guide pin was placed up to the bone. I placed the guide pin through the
    femur from an inferolateral position to a superior medial position.
    This was taken out through the other side. I then reamed the lateral
    cortex over the guidewire with a reamer. I then placed a nitinol wire
    in the eyelet laterally and took this through the knee using the guide
    pin from lateral to medial. I put clamps on the nitinol wire. I then
    pulled the guide down to the tibial tunnel, pulling down the nitinol
    wire. The looped the posterior tibial tendon allograft onto the wire
    and pulled this up into the tunnels. This had excellent position. The
    wire slid nicely back-and-forth. The bioabsorbable cross pin was placed
    through the nitinol wire laterally through the graft, tapping this into
    place. This engaged very nicely. I pulled the graft, and this was very
    secure.
    Before fixing the graft on the tibial side, I went to the lateral side.
    I placed a guide pin on the anterior portion of the lateral femoral
    epicondyle. I placed a graft around this pin and took the knee through
    range of motion. This appeared to be the isometric point. I then
    reamed a 9-mm reamer at a depth of 25 mm into the femur over the pin. I
    took the 9-mm graft and then passed it through the fibula using a Hewson
    suture passer. The limbs were measured so that approximately 2 mm of
    graft would fit in the tunnel. I did have to place two more #2
    FiberWire whip stitches at both ends of the graft, cutting the excess
    graft proximally. The nitinol wire was loaded with 1 of the sutures
    through 1 of the limbs of the graft and then taken through the femur
    from lateral to medial. I then made a separate hole, exiting lateral to
    medial for the other #2 FiberWire for the other end of the graft so I
    could tie this over the bony bridge medially. The graft fit nicely into
    the femoral hole proximally. The graft was taken under the biceps
    femoris and iliotibial band before passed into the femoral tunnel. This
    was placed over the capsule as well. I tensioned this, pulling the
    suture with the knee in 30 degrees of flexion, internally rotating and a
    medial for the other #2 FiberWire for the other end of the graft so I
    could tie this over the bony bridge medially. The graft fit nicely into
    the femoral hole proximally. The graft was taken under the biceps
    femoris and iliotibial band before passed into the femoral tunnel. This
    was placed over the capsule as well. I tensioned this, pulling the
    suture with the knee in 30 degrees of flexion, internally rotating and a
    valgus stress. This was very tight.
    I cycled the knee several times for equal tension of the ACL graft. I
    placed the knee at 20 degrees of flexion and placed a nitinol wire over
    the graft in the tibial tunnel for the ACL. I placed a 10 mm
    biocomposite screw by Arthrex over the graft into the tunnel. This had
    excellent position and was very tight. This seated very nicely. I
    excised the remaining graft distally. I then secured the graft
    laterally, reconstructing the fibular collateral ligament and
    popliteofibular ligament. I made a small incision medially and then
    took the sutures through the same incision and then tied these down over
    a bony bridge. I then took a nitinol wire and placed this over the
    graft through the distal femoral hole where the graft was inserting. I
    placed a 9 mm bioabsorbable tenodesis screw by Arthrex over the graft in
    the hole. This had excellent purchase and was very tight. Nitinol wire
    was removed. I then repaired down the popliteus tendon to the graft as
    well and the capsule on the distal femur. This was done with a #2
    FiberWire. This had excellent repair. I then repaired the posterior lateral
    capsule with a #1 Vicryl. I then repaired the split in the iliotibial band and
    deep tissue with a running #2 FiberWire. I augmented this with a #1 Vicryl. I
    closed the interval through the biceps femoris over the proximal fibula with #1
    Vicryl as well.
    Once that was complete, I placed the scope back into the knee. The ACL
    was very tight in extension, slightly loosened in flexion. This had
    excellent position with no impingement on the notch. The lateral
    compartment was entered, and the popliteus tendon could be seen in its
    normal anatomic position. The lateral compartment was much tighter than
    it was prior. I did gently stress the knee in varus and 0 degrees and
    30 degrees of flexion. This was very stable. The patient had a
    negative anterior Lachman's. I irrigated out the wounds with normal
    saline. On the lateral side, I closed the deep tissue with 0 Vicryl and
    then placed 2-0 Vicryl to approximate the skin. Nylon was placed in a
    horizontal mattress manner on the skin. Portals were closed with
    suture. Medial incision was closed with 2-0 Vicryl, then nylon. Local
    anesthetic was injected around the knee as well as into the joint. At
    that point, sterile dressing was applied as well as a cold therapy pack
    placed over the dressing, wrapped with an Ace wrap from the foot to the
    thigh. The patient's knee was placed in an immobilizer. The tourniquet
    was released.
    The patient was then awoken from anesthesia without complication and
    transferred to the postanesthesia care unit in stable condition.

  2. #2
    Location
    Columbus, Ohio
    Posts
    105
    Default
    Good morning again, I'm hoping everyone has their end of month charges in and someone might have time to review the op note I submitted to the forum. I would really appreciate some feedback. Thanks again, Paula

  3. #3
    Location
    Columbus, Ohio
    Posts
    105
    Default
    I really could use some help with this knee surgery. Anyone have the time to review this question?? Thanks so much, Paula

  4. Lightbulb
    i code 29888,27405,27658,27435-59,29876-59,G0289,G0289-59 and i have a doubt on code 27658 since popliteal is a flexor tendon but graft has been placed so can v bill 20924 along with it.and acl recon by thermal wand done so can code 29888 or 29999

    thanks

  5. #5
    Location
    Columbus, Ohio
    Posts
    105
    Default
    Thank you so much for taking the time to read that op note. I tried using my AAOS global book to figure out what would be bundled. The surgeon didn't give me any codes so I was kind of lost with so many open and arthroscopic procedures done at the same time. I will have to review it all over again. Thanks once again for responding to my question....I love this forum so much and read it every morning. It is such a great learning tool. I appreciate the help, Paula

  6. Lightbulb
    please response by giving correct cpts and tank u

  7. #7
    Location
    Columbia, MO
    Posts
    12,531
    Default
    I disagree with the above listed codes. This was not an arthroscopic ACL repair it was open. You should code 27409 and 27427 for the cruciate and collateral ligament repair and reconstruction, the descriptor states the physician may accomplish part of this via arthroscopic portals. the tendon repair I would do as 27380, the capsule repair as 27435, the arthroscopic synovectomy I would not code as it was via the same portal and compartments as the the ACL repair and it will bundle in, the chondroplasty I would do as either the 29877 or the G0289 but only one not 2. also the 20924 should not be coded as this for harvesting of tendon via a separate incision. The allograft tenton is part of the procedure and there is no code for it. The above suggested 27658 is a procedure on a different part of the leg and is not in this op note. I hope this is of some benefit.
    Last edited by mitchellde; 06-15-2009 at 07:52 AM. Reason: gramatic

  8. #8
    Location
    Columbus, Ohio
    Posts
    105
    Default
    Thanks so much for all the help...I hope I don't get too many surgeries like this one..I don't have easy access to the surgeon to get help from him so I rely on this forum..thanks again, Paula in Dublin, OH.

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