Hello all,

This patient had CPT 27472 done on 7/24/09. How would you code this?
Thanks in advance!

27507-78= insertion of 2 bone bolts?
Removal of hardware would be inclusive
Wound Exploration/drainage of the serosangiuneous drainage...that is where I am not sure. My mind is going in different directions with the wording in the op.

Here is what the Dr. states:

1.) Wound Exploration, distal femur, right leg
2.) Removal for free locking screw
3.) Insertion of 2 titanium bone bolts with a deep wound washout

PROCURE: Patient was taken back to OR because x-ray taken 2 days ago showed significant loosening of the distal locking screws It looked as if the bone was following the course that it had previously with the failure of the fixation, and I felt that this should be added. I was prepared to put in locking bolts as well as new cables.

As I was prepping and positioning her, we had the fluro come in and I examined her femur. On 2 views, it looked as if the screws and plate were exactly as they had been originally put in. I attempted to manipulate this under anesthesia ans was not really convinced that there was free motion or failure of the screws, but first, because there was a question of it, and secondly, because there was one screw that had displaced itself, I felt that we should at least explore and make sure that the plate was stable. I had already ordered titanium locking bolts to supplement our fixation, so we proceeded after the patient was asleep, after the full time-out, and after the patient had been through the full ortho prep and drape. The time-out was done after the drapes were in lace. We opened the wound. There was still some serosangiuneous drainage deep in the wound. This was evacuated, and then we were able to explore the plate. Count not demonstrate motion between the plate and the femoral shaft. Nonetheless, I felt that sine we had free access at this joint to the plate and the screws, we should add some insurance by putting 2 locking bolts in, one was distal and the other was sort of in the middle of the lower fracture fragment. I felt that these added further stability to her construct We did identify the loose screw that had been seen on x-ray, and this was easily removed. Then we were finished, the wound was again lavaged thoroughly with sterile saline. Hemovac was inserted, and the wound was closed in layers. Because we were going through a previous scar, we used nylon.