# Reefing of the medial parapatellar retinaculum for patellar subluxation



## Ccgerson (Sep 21, 2017)

Reefing of the medial parapatellar retinaculum and distal quadriceps along with a lateral release was done for lateral subluxation of the patella.  I looked up reefing, and it's described as plication.  
As far as I can tell, 27420-27422 involves cutting of the tibia tubercle and moving it.?  Making that incorrect for this case.
I thought of 27405 for repair of ligament, even though it's not torn.
OR perhaps this is unlisted. ??

Any input is appreciated,
Cindy


----------



## Orthocoderpgu (Sep 21, 2017)

Notice that 27405 is for a TORN ligament. I use 28427 in this case. The description of this code is that the ligament can be "damaged". Well, if the ligament is stretched too far and needs reefing to tighten it back up, I would call this damaged. So this is the code that I use. I would appreciate input from other coders as these knee codes can be a bit tricky.


----------



## AlanPechacek (Sep 21, 2017)

The procedure being sited is usually done for chronic Patellofemoral Malalignment/Maltracking disorders such as Lateral Patellar Tracking/Subluxation.  This can occur without necessarily any previous injury or trauma (i.e. ligamentous injury) and is a "constitutional" problem for the patient due to their anatomy or their soft tissues that support their patella to keep it in line and on track.  But, it can also be the result of old and/or chronic Patellofemoral Instability from previous and/or recurrent patellar dislocations that have left the medial patellar soft tissue support "stretched out" and too loose.  Currently the popular "culprit" is the torn/damaged Medial Patellofemoral Ligament, such that "Reconstruction of the Medial Patellofemoral Ligament" is the procedure in vogue for the last several years.  
     What was done in the case sited here is what is referred to as a "Soft Tissue Proximal Realignment Procedure" in which the Lateral Reticular Release is done to take excess tension off the lateral side of the Patella and allow it to move back medially where it belongs when gliding over/along the femur (Trochlea).  The Medial Retinacular "reefing" is essentially "tightening" the "too loose" medial soft tissues (from whatever source) so as to hold/keep/restore the Patella to its correct position relative to the femur during motion.  This does not involve doing anything to the Tibial Tubercle, transfer or osteotomy.  In the current vernacular, procedures involving the Tibial Tubercle for these problems are called "Distal Realignment Procedures," which usually also includes some/most/or all of the elements of the "Proximal Realignment Procedure" as well.
     As it regards the CPT Codes for these, the 27420 would apply to the "Distal Realignment Procedure" and would include the those elements of the "Proximal Realignment Procedure" that were done.  The code 27422 would be correct for the "Proximal Realignment Procedure" alone.  The Lateral Reticular Release, so far as I am concerned, is an included element of both, not an "Add On" procedure.
     I hope this helps sort some of this out.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


----------



## Ccgerson (Sep 22, 2017)

Ok, thank you for the information.  Do you think 27422 is the correct code?   27422 references Goldwaite type procedure.  I had researched that a few days ago, and it's described as a distal realignment where the patella tendon is split and the lateral side is  side pulled under the medial side to tighten/ stabilize the patella.  Is that not correct?
It's actually for a proximal relalignment?  OR is there not an exact code for proximal realignment, so 27422 is used as it's the best option.?
Also, I should mention the lateral subluxation of the patella is d/t medial retinacular 'disruption', found 3 months after RT TKA.   Does that change the CPT, i.e 27405 or 27427 ?


----------



## AlanPechacek (Sep 22, 2017)

Yes, 27422 would still be the correct code for the procedure done by your surgeon even though the "reticular disruption" was found 3 months post TKR.  By that time, the problem had become "chronic."  Even if it had been identified earlier in the postoperative period I would probably use the same code.  The others you refer to, 27405 for Primary Repair of Torn Ligament of the Knee is designated as applying to "collateral" ligaments, which would not include the medial retinacular disruption, and 27427 for Ligamentous Reconstruction/Augmentation of the Knee, Extra-articular, also is restricted to the Collateral &/or Cruciate Ligaments.  These really don't apply to Patellar Instability/Malalignment/Maltracking problems/surgery.
     Unfortunately, some of the procedures and procedural names for treating Patellofemoral Disorders have gone by the wayside and replaced with newer terminology, but are still referenced in the CPT Codes.  You will not see your surgeon doing a Hauser, Goldwaite, or Campbell Procedure.  These have been replaced by newer terminology such as Proximal (Soft Tissue) Realignment (27422) and Distal Realignment (27420) as in my earlier discussion.  You may very well see the "Fulkerson Procedure," which a Distal Realignment, by your surgeon.  This does involve an osteotomy of the Tibial Tubercle, plus some/other elements of the Proximal Realignment as discussed.  This is the "updated" version of the Hauser Procedure.
     As for "Reconstruction of the Medial Patellofemoral Ligament" procedure, this is a relatively recently developed procedure (5-10 years) which is done arthroscopically for the most part or with very limited open exposure.  I have to be honest to say that I do not know whether it has been given a CPT Code of its own yet. 
     Again, I hope this all helps.  This is a very complex issue and territory of knee surgery, and unfortunately the code descriptors in CPT have not been updated to reflect current thinking and vernacular.

Respectfully, Alan Pechacek, M.D.


----------



## Ccgerson (Sep 25, 2017)

Thank you.  That does help.


----------

