# Other Opinions??



## ASC CODER (Dec 21, 2009)

INDICATIONS: The patient is a 65-year-old male with polio who has had increasing difficulty ambulating on his right foot, his less affected lower extremity. It is the extremity that he uses to bear weight. The patient was seen and evaluated in the office where after a physical exam and radiographs it was determined that his main problem is he is unable to heel-to-toe weightbear. It was discussed with the patient at great length the treatment options including percutaneous versus open heel cord lengthening, and open osteophyte excision. The patient was under the understanding that for complete correction he would probably also require a posterior tibialis lengthening and/or transfer and possible hindfoot arthrodesis. The patient, however, day of surgery stated that he absolutely needed to bear full weight on the extremity. It was determined in a discussion with him that both osteophyte excision and an open heel cord lengthening that protected weightbearing would need to be continued. Understanding the limitations of strictly a percutaneous heel cord lengthening consented and wished to proceed. He understands that it may limit his amount of correction obtainable. It also may limit and require a modification of his current AFO. Understanding all these risks and benefits he consented and wished to proceed. 

DETAILS OF PROCEDURE:
He was taken to the operating room and placed in the supine position. After adequate IV antibiotics were administered, general anesthesia was induced. The right foot and leg was then prepped and draped in the usual sterile fashion. A tourniquet was placed on the upper thigh but no inflated. At this point once he was adequately anesthetized, initially three and eventually four percutaneous puncture holes were made along the posterior aspect of his Achilles. The first was approximately 1.5 cm above his calcaneal insertion and spaced approximately 1-2 cm proximally. Under direct palpation, a percutaneous hemiresection of the Achilles was performed in these four areas. Once they were performed, forced dorsiflexion of the foot allowed the foot to come in approximately 5 to 7 degrees of dorsiflexion. Direct palpation was then completed over the Achilles and there was felt to be an additional amount of hemiresection that could be performed. Therefore, additional resection was performed, primarily on the proximal two. This allowed again increased dorsiflexion to approximately 10 degrees with the knee flexed. At this point, it was felt that probably either anterior osteophytes or chronic posterior capsular contracture limited additional range of motion. Again under the limitations of being able to bear full weight on it immediately postoperatively, no additional operative procedure was performed. 

The wounds were then irrigated. They were closed with a 5-0 nylon. The skin was closed with the 5-0 Prolene. The incisional sites were injected 0.5% Marcaine. A sterile dressing was applied, including a range of motion boot locked at the neutral to 5-degree dorsiflexed position. Overall he tolerated the procedure satisfactorily. He will be discharged to home. He will be allowed to weightbear as tolerated for transferring but should keep his leg elevated. A pain prescription will be administered. He should follow up in my office in approximately two weeks. He should call the office or on-call physician if any additional problems arise. 

I posted this under orthepedics however I need some advice 

27606 (would I be able to code 27606  59 due to additional hemiresection) how many times can you bill this?

HELP


----------



## Herbie Lorona (Dec 21, 2009)

I would think you would only bill for it once.


----------



## ASC CODER (Dec 21, 2009)

alot of my research says that it is considered a triple hemiresection so that is were I am getting stuck. He made 4 punctures. I can't find any documentation for 4 or am I just reading too much into this?


----------



## ASC CODER (Dec 22, 2009)

Could someone please shed some light on this for me. He did 4 incisions, and 27606 is  a seperate procedure (am I able to bill it twice or just by itself?)


----------



## Herbie Lorona (Dec 22, 2009)

I would like to know more too. In my opinion I think it is only billed once but would like to know if anybody else knows!


----------



## LLovett (Dec 22, 2009)

Ok, this is not my area at all but I can tell you what my encoder says.

It is telling me the Medically Unlikely Edits for Code 27606 limits units per practitioner to 2 per day. I am thinking this is because the probability of 2 feet not multiple entry sites on 1 foot.

My personal opinion would be to just use the code once but add a 22 modifier to it and up your fee some.

Again not my area but my opinion for what its worth,

Laura, CPC, CEMC


----------



## Herbie Lorona (Dec 22, 2009)

Yes Laura that is how I felt. I would believe you can only do 1 per foot.


----------



## ASC CODER (Dec 22, 2009)

I also felt strongly about only billing once however I am billing for the surgery center and 22 is a professional modifier. can't use it. I do appreciate your input and welcome anymore. 
Thanks


----------



## Anna Weaver (Dec 22, 2009)

Well, this isn't my area either, but from what I'm reading, this should only be reported once because you are actually only doing one tendon (achilles) not several different ones? So, if you use general anesthesia it gives you one code (27606) and if you use local it gives you another (27605). It's also listed as a separate procedure, so if anything else is done at that time a 59 modifier should be used on this one. So, in answer to your question, my thought is once on each tendon you do. Please, someone, if I'm wrong, let me know! Thanks


----------



## ASC CODER (Dec 22, 2009)

Thank you for your input. I just don't want to undercode or overcode. you know what I mean... In my research on this one it has only stated 3 punctures ugh!!

thanks again


----------



## KMorris23 (Dec 22, 2009)

I have done some research on this. I am a newbie, but everything that I can find refers to this, even though there is more than one incision, there is only one tendon being worked on. Therefore you can only bill the code once.


----------



## ASC CODER (Dec 23, 2009)

Thank you all for your help and I hope that you all have a Merry Christmas!!


----------

