# Help with coding MPFL reconstruction for Patellar instability



## Patricia Donegan (Apr 5, 2010)

My son had knee surgery several months ago.  The surgeon's office submitted codes 27422 and 29873 to my insurance carrier.  They paid well on
27422 but very little on 29873 (less than 10% of the fee)  I appealed the decision, but they denied any more payment and I am left paying off a very large balance.(thousands of dollars)  I am wondering if code 29873 is the correct code.  The office is looking into this for me, I want to pay the surgeon ,but I also want to be sure my insurance company pays correctly on the surgery as well.  I pay a lot for my coverage, and have rarely used it other than for well care visits.  Here's the report, any ortho coder's insight would be greatly appreciated.  I have been billing and coding for 20 years, I have my CPC, but my field is cardiothoracic.  Thanks

Operation: Left knee medial patellofemoral ligament reconstruction for patella stabilizaiton  and diagnostic arthroscopy with arthroscopic lateral release.

Findings: Diagnostic arthroscopy revealed chondral injury to the medial facet of the patella consistent with recurrent instability of the patella.  The menisci PCL were intact, The ACL had continuity from the intercondylar notch lateral wall to the tibial footprint.  However, it became attenuated at its femoral attachment indicating a partial tear dynamic.  Lachman and pivot shift did demonstrate tensioning and functioning of the ACL.  

Procedure: .......Standard anteromedial, anterolateral portals were created at the level of joint line by incising the skin and capsule.  Diagnostic arthroscopy revealed the above noted findings.   After thorough evaluation of the  ACL, dynamic testing and examination under anesthesia, the decision was made to go forward with an MPFL reconstruction.  There was a tight lateral retinaculum.  The camera was introduced in the medial and lateral portal.  The a 2cm incidiosn was made over the pes anserinus.  Dissection was carried down to the pes.  It was reflected at  the division between the semitendinosus and  gracilis and  the semitendinosus was freed of soft tissue attachments  controlled with #2 nonabsorbable suture, harvested brought on the back table.  Muscle was removed, folded over, whip stitched and it had a 6mm diameter and the 2cm incision was made midway between the medial patella and teh medial epicondyle.  The VMO was identified and an incision was made in the retinaculum from the medial epicondyle to the proximal 1/3 of the patella.  The medial aspect of the patella was prepared for a tunnel.  A pin was placed and a 6mm tunnel was drilled by 15mm and 2 divergent tunnels were drilled and teh graft was tensioned into these tunnels.  The sutures passed through these tunnels and were retrieved out the medial portal and tied.  Tensioning of the graft revealed excellent fixation.  Then the knee was flexed and medial erpicondyle was exposed.  The pin was placed just above the MCL and isometry was confirmed with fexion/extension.  Then a 7 x 25 mm tunnel was drilled and the graft at its appropriate length was controlled with #2 nonabsorbale suture and a  Biotenodesis driver was used to deliver the graft into the tunnel and  a 7 x 23 screw was placed.  This was with the knee held at 60 degrees of flexion.  Following, there was  a full range of motion.  excellent stabilithy of the patella at this time and inability to dislocate the patella and no loss of motion.  Then the redundant medial retinacular tissue was imbricated with 0 tycron suturues and this also advanced the VMO onto the MPFL reconstruction.  The wounds were irrigated.......


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## smcbroom (Apr 7, 2010)

I don't know...looks to me like it was only a diagnostic arthroscopy to see what he/she was looking for then they proceeded with the open portion of the surgery.  It's sort of difficult to tell as they aren't really specific about removing the scope and going in to make the incision.  I would have them look into the operative report more and take a closer look at it.

Just my two cents!


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## Patricia Donegan (Apr 7, 2010)

thanks....i know, seems like just a diagnostic arthroscopy, but he did the lateral release with that approach, problem is they charged about 85% of the charge for the reconstruction code, and my insurance paid less than 10% of the charge.  I checked the Medicare cci edits, and they consider it bundled, so I guess I should be happy my insurance paid anything on it at all. Problem is, the surgeon is non-par in my plan, and they seem to not be recognizing an any mulitple surgery rule, so I have the full balance to pay off...I was just wondering if it was coded correct....I'm not familiar with orthopedic coding or billing at all.  Thanks for your help


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## margiev6 (Jun 9, 2012)

I would appeal as per AAOS included in the 27422 is a lateral release, meaning it is considered inclusive.  In their CodeX it states included "11.	preparation and insertion of synthetic bone substitutes, osteoconductive and osteoinductive agents (eg, hydroxyapatite, calcium phosphates, coral, methylmethacrylate, demineralized bone matrix, bone morphogenetic proteins), except where specifically excluded
	12.	chondroplasty, patella (eg, 27437)
	13.	lateral retinacular release (eg, 27425)
	14.	arthrotomy, knee (eg, 27310, 27330, 27331)
	15.	diagnostic arthroscopy, knee (eg, 29870)"


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