# 29882 29879 & bone grafting?? 29888??



## MELJNBBRB (Dec 23, 2014)

Hi list I am still a newbie to Ortho coding  For the bone grafting portion 29888?? Also I am assuming 20680 cannot be billed?
I am not coding for 29877.

TIA
Melissa Bedford,CCS,CPC

PREOPERATIVE DIAGNOSIS:
Left recurrent anterior cruciate ligament tear with medial
collateral ligament tear and medial meniscus tear.

POSTOPERATIVE DIAGNOSIS:
Left recurrent anterior cruciate ligament tear with medial
collateral ligament tear and medial meniscus tear.

PROCEDURES:
1.  Arthroscopic left medial meniscus repair (29882).
2.  Arthroscopic microfracture, left knee (29879).
3.  Bone grafting, left knee/tibial tunnel.
4.  Arthroscopic shaving chondroplasty, left mediofemoral
condyle and patellofemoral joint, (29877).
5.  Hardware removal, left knee (20680).

SURGEON:


ASSISTANT:
was crucial for the
entirety of the procedure.  There was no qualified resident
available.

ANESTHESIA:
General with a block.

ESTIMATED BLOOD LOSS:
Minimal.

INTRAVENOUS FLUIDS:
See anesthesia record.

INDICATIONS FOR PROCEDURE:
The patient is a 21-year-old sophomore at University of Texas
who is formally high jumper on the track team.  He injured his
left knee at track practice in May 2013.  He underwent right
ACL reconstruction and partial lateral meniscectomy with Dr.
at that time.  He had recurrent injury and in
July 2014, his knee was still swollen and having instability
with no mechanical symptoms.  He had an MRI that showed
recurrent ACL tear and was referred to my clinic for second
opinion.  After discussion of the treatment options he wanted
to have the surgery with me as far as his ACL revision surgery
and possible MCL reconstruction.  He understood the risks and
benefits and agreed to proceed with surgery today.  He also
understood there was a chance that it would be 1 versus 2
stage surgery.

DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine
on the OR table, underwent general anesthesia without
difficulty.  Preop time-out was done, identifying his left
knee as the operative knee.  His exam under anesthesia
revealed a 2-3+ Lachman and anterior drawer as well a 2-3+
pivot shift.  He was stable to varus stress and had a stable
posterior drawer as well as a negative Dials test at 30 and 0
degrees.  He did have 2+ opening to valgus stress at both 0
and 30 degrees and without a good endpoint.  We placed in
nonsterile tourniquet and prepped and draped in sterile
fashion using ChloraPrep.  His limb was elevated,
exsanguinated and tourniquet was raised.  Standard diagnostic
arthroscopy was begun using anteromedial and anterolateral
portals with the following findings.  He did have some
chondral fragments along his anterior knee that were removed
with the arthroscopic shaver.  We then turned our attention to
the patellofemoral joint that showed grade II/III wear on the
superior pole of patella that was debrided back to stable rim
using oscillating shaver.  His trochlea had grade 1 wear.  His
medial joint had some grade II chondromalacia that was
debrided back to stable rim using oscillating shaver.  He also
had a vertical tear along the periphery of his meniscus from
his mid posterior horn through the mid body.

His intercondylar notch revealed an intact PCL but no ACL.  
His lateral joint had minimal chondromalacia, but did have
evidence of a near total partial meniscectomy including nearly
the entire posterior horn and half of the body.  We first
turned our attention to the meniscal repair.  The meniscus was
liberally rasped and repaired with 4 Mitek Omnispan meniscal
repair devices in a vertical mattress fashion.  This gave us
excellent coaptation reduction of the meniscus.  We then
identified the tibial tunnel along his ACL footprint, it was
the centered well over the medial side of the footprint;
however, it was too posterior and too near the posterior
cruciate ligament, which may have been a contributing factor
for the ACL failure.  It was, at this time, we decided to
abandon a 1-stage approach and do a 2-stage approach with
hardware removal and bone grafting of the tibial tunnel and
then coming back 4 months later to do revision ACL and MCL
reconstruction at that time.

We then turned our attention to the incision over his medial
knee and identified the screw post and washer over his medial
tibia.  These were removed without difficulty.  We then
identified the tibial tunnel and with the rongeur and curette
removed disintegrating absorbable screw.  We then placed a
guide wire into the tibia and first dilated and then
sequentially reamed up to a size 9.5 reamer.  We then placed 2
allograft bone dowels and impacted them into place with a nice
press-fit using the dilator.  Of note, both bone dowels were
soaked with PRP in order to stimulate healing into the tunnel.
 We then identified the tunnel placement on the femur, which
was not bad.  However, it was little anterior and little
superior to the anatomic footprint of the ACL.  It has healed
in fairly well, but *** bone grafting.  We then used the
microfracture awl along the lateral femoral condyle after
performing notchplasty for visualization.  We made 2 Pilot
holes and had good bleeding from those 2 Pilot holes.  Once
this was completed, we then removed the arthroscopic tools
from the joint, copiously irrigated all wounds and closed the
portals using interrupted 3-0 nylon stitches.  The tibial
wound was closed using 2.0 Vicryl stitches on subcutaneous
layer and a 3-0 Prolene in a subcuticular fashion on the skin.
 Steri-Strips were placed over the tibial wound, Xeroform over
the portals.  Xeroform dressing sponges, Webril, Ace wrap were
applied.  The patient was placed in hinged knee brace from
0-90 degrees.  He tolerated the procedure well and was
transferred to recovery room in stable condition.

Postoperatively, he can be touchdown weight bearing for the
first 6 weeks and start physical therapy in 1-3 days on my
meniscal repair protocol.  We will see him back in clinic in
10-14 days for repeat evaluation and suture removal and to
discuss the second stage revision likely 4 months from the
index procedure today.


----------



## dclark7 (Jan 2, 2015)

Since the doctor used an allograft, the bone grafting is not separately billable.  your codes would be 29882, 29879 and 20680.  Because the hardware removal was not an integral part of the other procedures (i.e. he could have done them without removing the hardware), the removal is separately billable.  None of these codes are bundled according to NCCI edits.  The 29888 (ACL repair) would be billed at the second stage.


----------

