# Open Ankle Synovectomy



## DButcher (Mar 22, 2017)

Could someone please help with this, I am looking at 27625 but not sure If can bill for posterior and anterior???


Preoperative Diagnosis: PIGMENTED VILLONODULAR SYNOVITIS
Postoperative Diagnosis: PIGMENTED VILLONODULAR SYNOVITIS

Procedure(s): Procedure(s):
OPEN SYNOVECTOMY LEFT ANKLE TALONAVICULAR SUBTALAR JOINT
synovectomy left ankle anterior. open synovectomy ankle posteior approach

A longitudinal incision was marked out on the posterolateral aspect of the leg.* A 15 blade scalpel was then used to incise skin.* Next, the tenotomy scissors were used to dissect through the soft tissue careful to protect all of the neurovascular structures. Meticulous hemostasis was obtained throughout the exposure.* The interval between the peroneals and FHL was developed and the posterior ankle joint and subtalar joint capsule was identified. There was obvious mass in the capsule and the posterior soft tissue of a brown nature. Cultures were obtained. Antibiotics were then given. The mass was meticulously excised and sent as specimen and complete synovectomy was performed with the combination of sharp excision and an assortment of ronguers. The subtalar joint was exposed through excision of os trigonum. There was no apparent extend of the soft tissue mass into the subtalar joint. The ankle joint was taken through range of motion and there were no osteochondral lesions appreciated on the posterior half of the talus. The FHL and tendon was traced into is tunnel distally as well as the lateral subfibular space and subtalar space. The torniquet was let down and excellent hemostasis was obtained. 

The wounds were coupiously irrigated with sterile saline prior to closure.* The deep tissue was closed with 2-0 vicryl, the subcutaneous tissue was closed with 3-0 vicryl, and the skin with 3-0 nylon. a sterile dressing was applied to the site.

The surgical drape was then removed and the patient was carefully transitioned to the supine position. All bony prominences were padded appropriately.* Pt was then padded, prepped and draped in the normal sterile fashion.* Prior to making incision, a timeout and keystone was performed and the operative site was confirmed.* The esmark was used and at the level of the calf.


The standard anterior ankle incision was marked over the anterior ankle. A 15 blade scalpel was then used to incise skin.* Next, the tenotomy scissors were used to dissect through the soft tissue careful to protect all of the neurovascular structures, the superficial peroneal nerve was identified at the distal aspect of the wound and was protected throughout the case. The EHL was identified and its shealth opened. The neurovascular bundle was identified deep to this and retracted laterally and protected throughout the remainder of the case. The anterior ankle joint was then exposed sharply. A simliar dark brown soft tissue mass was then identified which extended from the ankle joint distal over the TN joint however did not penetrated into the capsule or TN joint. Meticulous hemostasis was obtained throughout the exposure. Using a combination of electrocautery, sharp excision and an assortment of rongeurs the mass was excised. The medial and lateral gutters of the ankle were inspected and a complete synovectomy was performed. The ankle was taken through its range of motion and no defect was identified on the talus. The torniquet was removed and meticulous hemostasis was obtained.** 

The wounds were coupiously irrigated with sterile saline prior to closure.* The deep tissue was closed with 2-0 vicryl, the subcutaneous tissue was closed with 3-0 vicryl, and the skin with 3-0 nylon. a sterile dressing was applied to the site.

Bacitracin was applied to both wounds and a sterile dressing was applied to the site.* Next a well-padded splint was applied with a posterior mold and stirrup.*


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## AlanPechacek (Mar 27, 2017)

Having read this Op Report a couple of times, it is somewhat misleading and makes it difficult to code. The Postop Diagnosis should be Pigmented Villonodular Synovitis of the Ankle Joint (only), since no PVNS involvement of the posterior Subtalar or Talonavicular Joints was identified.  He did "Explore" the posterior Subtalar Joint through his posterior incision, so he did do an Arthrotomy of the posterior Subtalar Joint, but no Synovectomy or lesion excision.  Therefore, through the posterior approach, the first procedure, he did an Open Arthrotomy and Synovectomy of the Ankle Joint: 27625, and an Exploratory Arthrotomy of the posterior Subtalar Joint: 28020 (Arthrotomy, including "Exploration," of an Intertarsal Joint, which the Subtalar Joint is).  The 28020 would require a Modifier, 51 for Multiple Procedure, or 22 for Increased Procedural Service.  It is kind of a "toss up" but I lean toward 51 since they are separate joints.

Then he did a second procedure from anterior, an Open (Anterior) Synovectomy of the Ankle Joint (27625 again).  It does not appear that he actually did an Arthrotomy (Exploration) of the Talonavicular Joint, so the 28020 would not be applicable.  The second 27625 would also need to be modified as either 51, or possibly with 59: Distinct Procedural Service, which as described includes "separate incision/excision, separate lesions."  Modifier 59 can be used if it "best explains the circumstances" better than any other possible Modifier, such as 51.

So my best analysis is 27625 and 28020-51 for the first, posterior, procedure, then 27625-59 for the second, anterior procedure.  Of course, the documentation needs to go along with the claim.  I have to admit I don't know what the procedural "edits" will say, but I think your surgeon deserves to be paid for all of his work.

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


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