# Distal Femoral Fracture and Total Knee



## HeatherPeters (Aug 10, 2015)

I am trying to figure out how to code this surgery.  Originally coded as 27447-Rt with Dx of 821.23.  I know that Medicare LCD does not allow for this dx/cpt combo but I am at a loss of how to code it.  A re-determination was sent into Medicare and was denied as well. Please help! 

Post Op Dx: Marked Comminuted displaced right distal femoral fracture

Procedure: Right Distal Femoral Replacement Knee Arthroplasty utilizing depuy limb salvage system with an extra-small femoral component with a 15x120-MM cemented stem with 25-MM Augment and a 16-MM poly incert with a size 4 MBT revision tibial tray and a 30-MM all poly patella. 

Procedure in Detail: Informed consent was obtained. The patient was brought to the operating room where successful endotracheal anesthesia was achieved. A tourniquet was placed proximally on the left upper thigh and the left leg was prepped and draped in a routine fashion using chlorhexidine scrub and paint. The leg was then wrapped securely in an elastic bandage for exsanguination and the tourniquet inflated to 275 mmHg. 

At this point the anterior incision was made centered over the patella. This was carried sharpley through the skin and subcutaneous tissue. A medial parapatellar incision was then performed extending up into the quadriceps posterior. At this point the knee joint was entered. there was marked sever degenerative changes with large osteophyte formation of the knee joint itself with a markedly comminuted distal femoral fracture with a significant split comminuted component extending into the intracondylar area. 

At this point careful subperiosteal dissection was performed anteriorly to identify the proximal area of the fracture.  This was carefully marked. Appropriate leg length measurememts were made with teh mark on the tibia. At this point with careful soft tissue protection medially, laterally and posteriorly the femur was transected at this level. With careful meticulous dissection the distal shaft followed by the distal femoral condyles were carefully excised. This was done in a subperiosteal fashion. 

At this point the proximal tibia was carefully exposed. Using the intramedullary alignment system the proximal tibia cut was performed. Remaining osteophytes were removed. The proximal tibia was sized to a #4 component. The #4 MBT trial was sized. At this point this was pinned into position. The proximal tibia was then appropriately impacted. A size 4 MBT tray trial was then inserted. 

The distal femur was then again exposed. Gentle hand reaming was then carried out to a #17 sizing. At this point a 15x120 stem was selected. The trial was inserted. to recreated the length a 25-mm aug was inserted in the shaft. With this in place using a 16-mm insert there was excellent extension and flextion to approximately 90 degrees. The limitation in flextion was her quad tightness. With the patella subluxed she easily flexed to full flexion. Appropriate rotation was marked for the patella. 

At this point the trials were removed. The proximal tibia was thoroughly irrigated and dried. At this point the #4 MBT revision tray was cemented into place with gentamicin-containing antibiotics. The Patella cut had been performed and attached to a 38-mm component. Appropriate lug holes had been drilled and a 38-mm patella was cemented into place. Following this the distal femoral replacement was assembled. A cement restrictor was placed in the femoral shaft. The femoral shaft was carefully irrigated and dried, and the distal femoral placement was carefully cemented into position in an appropriate rotation. 

Following this again a trial reduction was carried out. Again with the 16-mm insert it provided extension, flexion to approximately 90 degrees right quad tendon with central tracking of the patella. 

At this point the trial liner was removed. All areas were again thoroughly irrigated with copious amounts of saline with the WaterPick irriation system. The permanent rotating 16 poly insert was placed and the (inaudible) placed. Following his again there was excellent stability. The knee easily came to full extnesion, flexed to approximately 90 degrees with central tracking of the patella. 

At this pint all areas were again thoroughly irrigated. A medium Hemova drain was placed deep within the wound. the Medial parapatellar incision was then closed with running #2 Quill suture. This was augmented with interrupted #1 Vicryl. Deep subcutaneous tissues were closed with interrupted 0 Vicryl, superficially with 2-0 monocryl. Skin was closed with stainless steel staples. The tourniquet was deflated prior to closure. The Patient was then allowed to recover from her anesthesia. She tolerated the procedure well and was transported to the recovery froom in excellent condition. Sponge, needle count verified correct.


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## coderguy1939 (Aug 11, 2015)

We were having the same issue with our MAC and the LCD guidelines governing total knee replacement.  Our LCD covered both Total Hip and Total Knee arthroplasty.  In reviewing the LCD, the DX codes supporting total hip replacement included 20 acute fracture codes but no acute fracture codes for the distal femur even though the most common indications listed in the LCD for total knee replacment stated distal femur fracture.

I wrote a letter to the medical director of our MAC with this information, they reviewed the LCD and agreed that they needed to add acute fracture codes for the total knee and they did.  

My suggestion is that you write to your MAC and request a review of the LCD policy.


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## abbycat333 (Aug 16, 2015)

*Distal femoral fracture with excision and TKR*

The example cited, says the patient also had severe degenerative arthritis of the knee, along with the acute distal femoral fracture. The severe arthritis alone, even without the fracture, should support this procedure. But, this was no ordinary TKR. The entire lower segment of the femur was excised, because it was not repairable, and also would not hold the femoral prosthesis component, either. So I would use the unlisted code for the knee section, and tell the carrier that it was an extraordinary situation, in which the distal femur had to be excised and reconstructed using a special femoral component with an augmentation, and the construct was cemented in place. This took considerably more time and expertise to do, than the ordinary TKR. Send the claim to CMS medical review, and you should have no problem with LCDs or medical necessity. Use the term given in the op, Limb Salvage. This connotes the severe and limb threatening situation.


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