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Thread: Knee Release - PLEASE HELP!

  1. #1

    Default Knee Release - PLEASE HELP!

    AAPC: Back to School
    Very confused about what to code for this surgery. I have codes 27310 and 11981, but obviously way more was done and I dont know how to bill for this. A copy of the Op Note is below. Any help would be greatly appriciated.


    Previously infected left total knee with 90 degrees or more
    flexion contracture spasticity and potential persistent

    1. Arthrotomy removal of infection
    2. Debridement and soft tissue contracture release.
    3. Placement of articulating antibiotic spacer.

    After identification of the patient, induction of general
    anesthetic, the patient was positioned on the table. Bony
    prominences were appropriately padded. A tourniquet applied to
    left upper thigh. Left leg was prepped and draped in usual
    sterile fashion. It should be mentioned that prior to prepping
    and draping, we did exam under anesthesia. She has a fair amount
    of Aquinas in both feet. Worse on the right and the left. Her
    right foot barely comes to neutral. Actually probably 10 degrees
    plantar flexion and neutral pronation supination type position.
    With her asleep and paralyzed, her flexion contracture is
    probably in the neighborhood 50 the 55 degrees and quite solid.
    She can flex it up to 120 degrees. Her hip would extend off the
    table to basically neutral. Once the leg was prepped and draped
    in usual sterile fashion, Esmarch exsanguination was carried out,
    and the tourniquet was inflated to 300 mmHg. We opened through a
    standard midline incision, a standard medial parapatellar
    approach. The entire knee was all soft and scar tissue. We
    actually looked fairly destroyed. The bone was quite soft. The
    tissue was very fibrotic. A little bit juicer than dry.
    Cultures and frozen sections were taken which again were all
    called back as negative for acute inflammation and negative Gram
    stains. Additional exposure was gained by elevating the tissue
    off the proximal medial tibia around the posterior medial corner.
    Ultimately we would perform a fairly dramatic posterior medial
    corner. Release all the way across the back of the tibia to
    release the capsule. The fat pad was resected. The patella was
    identified. Complete medial and lateral synovectomies were
    performed to free up the gutters again. The patella was able to
    be everted. We resected the medial and lateral menisci as well.
    It was fairly dramatic bone destruction on both the tibia and
    the femur. We resected the anterior posterior cruciate
    ligaments. The tibia was subluxed forward and in anteriorly and
    cut. Ultimately we cut the tibia total 3 times removing
    conservative initially but ultimately removing some additional
    bone to make room for the prothesis. Each time, we recut the
    tibia. We were able to work all around the posterior medial
    corner, posterior lateral corner freeing up the posterior
    capsule. We did a fair amount work behind the femur as well.
    Completely releasing all the scar tissue off the back of the
    condyle through the notch and up the back of the femur. This
    gave us basically a full capsular release. Once we had with the
    tibia cut, we could bring the leg out and just about full
    extension. We still had a significant amount of balance
    posteriorly. The drill hole was made in the canal of the femur.
    We resected 11 mm off the femur. We then continued to do some
    more additional work. We were out the full extension with the
    cut bony surfaces but not on the components. We ended up cutting
    another 3 mm off the distal femur before it is all said and done.
    We went back and forth in flexion and extension doing more and
    more releases posteriorly around the medial and lateral side
    freeing up the iliotibial band, etc. Ultimately, we could get a
    spacer block in for a 10 mm insert with probably a 10 degree
    residual balance to the knee. It was felt that this was at least
    getting in the direction of adequate. The tibia was prepared for
    3 prosthesis. The femur was then cut for a 3. We balanced the
    rotation off the soft tissues. Took very little posterior bone
    trying to recreate as much flexion space as possible. We dropped
    the size 3 block the back 2 mm and escaped without notching.
    Again, we took very little posterior bone. We had mixed a size
    3 Sigma mold on the back table with 2 bags of cement, each 1
    containing 3 g of vancomycin, 1 g of tobramycin plus 1 g gent per
    bag for total of 6, 2, and 2. This fit the bone quite nicely.
    We trialed the metal component and the 10 polyethylene. With
    this we could get the leg out into extension about probably 10
    degrees short. Feeling that this was adequate, the tourniquet
    was deflated. Hemostasis was achieved. We mixed up two more
    bags of cement with the same antibiotic mixture. These were
    allowed to get good and we. We curetted out the metaphysis
    segment of both the femur and the tibia. The tibial component
    was cemented into place and compacted into place. The femoral
    component was cemented into place as well. The leg was brought
    out into extension. With some work, we were again able to get to
    that same 10 to 15 degree flexion contracture range. The cement
    was allowed to completely harden. The wound was copiously
    irrigated with antibiotic solution. A single drain was placed,
    and the arthrotomy was closed with 0 Vicryl suture. Subcutaneous
    tissue was also resurfaced the patella. The size 35 patellar
    button. The tracking was quite nice although the plan was to the
    leg to be in full extension. The arthrotomy was closed with 0
    Vicryl suture in interrupted fashion. Subcutaneous tissues were
    reapproximated with 2-0 Vicryl suture. Skin was reapproximated
    with staples. Sterile dressing was applied as was the brace and
    10 degrees of flexion to keep around the full extension, as was
    the plan. The patient was awakened and transferred to the
    recovery room in stable.

  2. #2


    Seems to me this is a Total Knee Arthoplasty. You should confirm with your Surgeon, but I would bill out 27447, 11981.


  3. #3
    Join Date
    Apr 2007


    Totally agree, Total Knee

    If your doc thinks extra work above and beyond TKA , he could dictate cover letter stating what, why, how much extra time it took and put "22" mod on it. A lot of things are included in TKA, but it seems to me there was quite a contracture as well as scar tissue??

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