The doctor labeled this as a Revision, but he did not remove either component.
Post OP Diagnosis: 18 month post op right total knee joint arthroplasty with extensive grade 4 heterotopic ossification involving primarily the distal femur and the parapatellar area.
OPERATION PERFORMED: Revision right knee arthoplasty, exploration and excision of grade 4 heterotopic ossification.
"The proximal 40% of the median parapatellar incision was reenterd and was extended proximally for three inches. The incision was carried down through subcutaneous tissue to the incision into the distal quad tendon identified by the green colored Tevdek sutures which are removed. Upon dissecting through the subcutaneous tissue, the heterotopic bone as much as possible although a Bovie knife was necessary to free the large portions of bone from the strong attachment of the surrounding soft tissue which even involved the previously placed sutures. Large portions of bone were then removed.
The patellofemoral joint was examined and further bone was removed from the superior portion of the trochlea and the dorsal medial aspect of the remaining bony patella. The polyethylene prosthetic patella was examined but was seen to be solid. Extensive irrigation was carried out throughout the procedure using antibiotic solution and the pulsatile lavage unit. Once the heterotopic bone had been excised, patella mobility appeared to have improved particularly with passive motion with active movement not able to be determined on the operating table.
At this point, the deep remaining fascial structures were closed........"
Would this be an unlisted?
Any thoughts are appreciated. Thanks in advance!
- Exam Preparation
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Software / Digital
- Code Lookup (AAPC Coder)
- Practicode (online coding simulation)
- E/M Analyzer
- CPT RVU Calculator
- Health Plan Search (Provider Policies)
- Book Store
- Log In / Join