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Hip Arthroscopy with tenotomy, bursectomy

  1. #1
    Columbus, Ohio
    Question Hip Arthroscopy with tenotomy, bursectomy
    Medical Coding Books
    I need help coding the following op note. I cannot find the correct arthroscopic code for this hip surgery. I appreciate any helpful suggestions. Thanks, Paula

    1. Right hip arthroscopy with tenotomy of the iliotibial band.
    2. Right hip arthroscopy with bursectomy and extensive debridement.
    3. Vitagel soft tissue autograft insertion right hip wound, 20926.

    Patient was seen in preoperative holding by the department of
    orthopedics and anesthesia which time she identified the right lower
    extremity as the appropriate extremity for procedure. I placed my
    initials on the extremity for identification. She was given IV
    antibiotics preoperatively for prophylaxis. Taken back to the OR suite
    and placed supine on a well-padded OR table. Placed under general
    anesthesia without complication. She was then placed in the lateral
    decubitus position with the right side up. This was held with an Inamed
    positioner. Axillary roll was placed underneath the left axilla. The
    right lower chart was sterilely prepared and draped in normal fashion.
    The greater trochanter was palpated. One incision was made 4 cm distal
    and slightly posterior to the greater trochanter. Small incision was
    made in the skin and then a blunt trocar and cannula was placed
    underneath on top of the iliotibial band. The arthroscope was inserted.
    I could view the iliotibial band over the greater tuberosity. A
    separate portal was created 4 cm above and slightly anterior the greater
    tuberosity with a scalpel through skin. Shaver was placed in here. The
    fat and soft tissue were removed over the iliotibial band. A thermal
    wand was placed in the superior portal and a tenotomy was created the
    iliotibial band over the greater tuberosity. This revealed the bursa
    underneath the iliotibial band on top of the greater tuberosity. This
    was extensively debrided and removed with a shaver. The hip was moved
    and the greater trochanter could be seen very nicely. The bursa was
    removed very completely. Once this completed, instruments were
    withdrawn. Vitagel soft tissue autograft processed from the patient's
    blood for postop hemostasis and potential healing was injected deeply.
    Portals were closed with suture. Local anesthetic was injected.
    Sterile dressing was applied. The patient was then turned supine, awoke
    from anesthesia without complication and transferred to the
    post-anesthesia care unit in stable condition.

  2. Default
    I would use 29862 - and the graft code.

  3. Default
    Isn't it great that there's only four hip scope codes? I'd use 29862 and the graft code, along with 29999 for the tenotomy.
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

  4. #4
    Columbus, Ohio
    Default Thanks for the help...
    Thanks so much for all your help..I was afraid I would have to use the unlisted code for the arthroscopic tenotomy. I hope the 2009 cpt codes catch up with all the new arthroscopic procedures that the surgeons love to do..once again, thanks, Paula

  5. Default
    Sorry...forgot the Tenotomy. Bruce is correct... This is a great reference to keep on file:

    See page 4
    Last edited by PatriciaCPC; 10-14-2008 at 03:53 PM. Reason: added page #

  6. #6
    Columbus, Ohio
    Default Thanks
    Patricia, thanks for the great resource reference. I am meeting so many wonderful coders through this forum. I am so glad I found it. Thanks again, Paula

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