I think you meant 27698 for the second procedure. That looks correct since the ligament repair happened after the original injury was treated. I think that code takes care of #3 and #4 so you should be good. Not sure you need the 22 modifier on the first procedure.See note below:
27792-78-22 for the Revision of the ORIF-- but for # 3 and # 4 ...the fixation 29698 for the repair of the deltoid lig? What about the syndesmosis sutures?
Provider: , M.D.
PREOPERATIVE DIAGNOSIS: Right ankle bimalleolar fracture with syndesmotic disruption and failure of fixation.
POSTOPERATIVE DIAGNOSIS: Right ankle bimalleolar fracture with syndesmotic disruption and failure of fixation.
1. Removal of plate and screws from right ankle.
2. Revision open reduction internal fixation of right ankle with fixation of the fibula.
3. Fixation of syndesmosis with 2 Arthrex tightrope sutures.
4. Repair of deltoid ligament on the medial side of the ankle.
ANESTHESIA: General with regional blocks.
SURGEON: , M.D.
ASSISTANT: , P.A.-C.
IMPLANTS USED: Arthrex locking fibular plate on the lateral aspect with 2 Arthrex tightrope sutures for syndesmotic fixation. We also used an Arthrex 5.5-mm corkscrew anchor for repair of the deltoid ligament.
HISTORY OF PRESENT ILLNESS: Mr. Waldahl is a 35-year-old male who sustained a displaced distal ankle fracture with fibular fracture, syndesmotic disruption, as well as disruption of the deltoid. I initially treated his ankle about a week after his injury with open reduction internal fixation. Reduction was very difficult, but overall initial reduction was appropriate. He returned at his 2-week postoperative visit, and the plate had bent and we had lost reduction of the entire construct. I discussed with him the alternatives and recommended return to the operating room for revision open reduction internal fixation.
PROCEDURE: The patient was seen in the preoperative holding area. The consent form was reviewed. The surgical site was identified and marked with a permanent marker. He was given preoperative antibiotics and then brought back to the operating room, placed on the operating room table. After induction of anesthesia, his right lower extremity was prepped and draped in the usual sterile fashion. A time-out was taken prior to beginning the procedure. I made an incision on the lateral aspect of his ankle and incised sharply down through the skin and subcutaneous tissues, spread the deep tissues, and identified the plate. This was removed with all the screws as well as a 4.5-mm screw. I then irrigated the wound, cleaned out the fracture site, and used an Arthrex locking distal fibular plate. I attached this initially to the distal aspect of the fibula with 4 locking screws to gain control of the distal fragment and then reduced the fracture and clamped this and placed 2 cortical screws proximally to hold reduction of the fibula. I checked the C-arm, and I was satisfied with the overall length of rotation of the fibula fracture. I then attempted to reduce again the syndesmosis with king tong reduction clamp, and I was unable to get appropriate reduction. So I made a medial incision and evaluated the deltoid. The deltoid ligament had avulsed off the anterior aspect of the talus. It was still attached to the medial malleolus. There were a few of the fibers that were displaced within the ankle joint itself. These were removed. I identified the posterior tibialis tendon, which was intact. I then was able to get the syndesmosis reduced, and I placed 2 Arthrex fiber wire sutures across and had good reduction of the syndesmosis. The mortise was still a little bit unstable, and so I repaired the deltoid ligament with a 5.5-mm Arthrex corkscrew anchor. I was satisfied with the overall alignment. There was still slight residual instability of the talus. Overall alignment looked very good. The wound was irrigated, closed with interrupted 2-0 Vicryl suture and staples. A sterile dressing was applied. I then placed him into a posterior splint with the foot in dorsiflexion and inversion. He was returned to recovery in stable condition.
Brenda L Meech, CPC
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