# Help with arthroscopic stress fracture coding!



## djreiff (Aug 21, 2017)

*Our doctor often performs stress fracture repairs using Knee Creations calcium phosphate cement and I have trouble with coding this. In this case, it seems he is doing it arthroscopically or percutaneously, and he likes to try to code it as 27509. I'm not sure I feel this is the appropriate code. Does anyone have experience with a similar procedure? How do you code it? I know for the tibial plateau stress fracture, there is the arthroscopic repair code of 29855, but there is not one for the femur. Would we do the 29999 and send with records indicating to compare to 29855?

Any help is appreciated!*
*PREOPERATIVE DIAGNOSES:*
Right knee mechanical pain with MRI evidence of medial meniscal tear with some areas of chondromalacia of the medial femoral
condyle and medial tibial plateau with associated stress reaction/stress fracture of the medial femoral condyle and medial tibial
plateau.

*POSTOPERATIVE DIAGNOSES:*
Large radial flap tear of the medial meniscus with grade 2 chondromalacia of the medial femoral condyle and medial tibial plateau
with area of grade 4 chondromalacia of the far medial aspect of the medial femoral condyle and medial tibial plateau. This was 7 x 20
mm of the medial femoral condyle and 5 x 10 of the medial tibial plateau, hypertrophic synovium including a large medial plica, and
grade 2 chondromalacia of patellofemoral joint.

*PROCEDURES:*
Right knee arthroscopy with partial medial meniscectomy, debridement chondroplasty of the medial patellar compartments with
extensive synovectomy including excision of medial plica with internal fixation, stress reaction/stress fracture of the medial tibial
plateau and medial femoral condyle with 4 and 3 mL of Knee Creations calcium phosphate cement mixed with autologous blood,
respectively.


After risks and benefits of surgery were presented to the patient which included, but were not limited to, bleeding, infection, damage
to nerves or blood vessels, reaction to anesthesia, death, need for further treatment, pulmonary embolism, consent was signed, taken to
operative suite, placed on operating table. General endotracheal intubation was undertaken by Anesthesia staff. Antibiotics were
given 30 minutes prior to procedure. All bony prominences were padded. Tourniquet was placed to the right upper thigh. A leg
holder was placed to the right lower thigh, and the right lower extremity was then sterilely prepped and draped. An Esmarch was used
to exsanguinate the right lower extremity. A tourniquet was placed to 275 mmHg and remained inflated throughout the entire case.
Anterolateral portal was established using an 11 blade. Blunt trocar was placed in the intercondylar notch and patellofemoral space,
and a diagnostic arthroscopy ensued. Patella tracked normally in the femoral trochlea; however, there was grade 2 chondromalacia of
the lateral facet of the patella as well as the inferior medial facet of the patella. Lateral gutter was clear. Medial gutter was clear.
There was a large medial plica noted. In the anteromedial compartment, we established an anteromedial portal using needle
localization and 11 blade. We removed the hypertrophic synovium at the anteromedial and lateral joint lines using a 4.0 shaver. We
then brought our attention to the medial compartment whereas a large flap tear noted of the medial meniscus. Basket biter was used
to remove the torn rim. A 4.0 shaver was used to smooth the remainder down a stable rim. Remainder of the meniscus was stable to
probing. There was an area of grade 4 chondromalacia of the anterior and medial tibial plateau, 5 x 10 mm in area with essentially
grade 4 chondromalacia as well of the medial aspect of the medial femoral condyle. This was approximately 7 x 20 mm in area. We
debrided the fibrillated and delaminated cartilage off the medial femoral condyle and medial tibial plateau using a 4.0 shaver down to
stable rim. We brought our attention to the intercondylar notch. The ACL was probed and was intact. In the anterolateral
compartment, there was a minimal chondromalacia, and the meniscus was stable. We brought our attention back to the patellofemoral
joint. Remainder of the hypertrophic synovium as well as the medial plica was excised. We also debrided the fibrillated cartilage
from the undersurface of the medial and lateral facets of the patella. We then copiously irrigated the joint and removed our
arthroscopic equipment. Under fluoroscopic guidance and needle localization, we made a small stab incision over the lateral aspect of
the proximal metaphysis of the tibia. An obturator trocar cannula device was then drilled from lateral to the subchondral bone of the
medial tibial plateau. Location was confirmed using 2 orthogonal fluoroscopic views. We then injected 4 mL of Knee Creations
calcium phosphate cement mixed with autologous blood, confirmed adequate placement of 2 orthogonal fluoroscopic views. We then
removed the cannula, made another incision over the superior aspect and medial aspect of the knee, and the trocar cannula device was
then drilled from the medial metaphysis of the femur into the subchondral bone of the medial femoral condyle. Again, appropriate
placement was confirmed with 2 orthogonal fluoroscopic views, and we injected approximately 3 mL of Knee Creations calcium
phosphate cement mixed with autologous blood, and we confirmed adequate placement of 2 orthogonal fluoroscopic views. We then
placed the trocar and removed the cannula, and placed this in a scope intra-articularly to confirm there was minimal intra-articular
cement. We then copiously irrigated the joint, removed our arthroscopic equipment. We repaired the portal sites with 3.0 simple
interrupted nylon sutures. We injected 20 mL of 0.25% Marcaine without epinephrine in the incision sites. Incisions were washed,
dressed with Adaptic, 4 x 4, ABD, soft roll, and Ace bandage. Tourniquet was removed at the completion of the case. Patient
tolerated the procedure well, was taken to PACU in stable condition.

*The codes I'm fiddling with right now for this entire surgery are:
29855, RT
29881,RT
29999, RT (COMPARE TO 29855)

Thank you!*


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## sequester25@gmail.com (Aug 21, 2017)

djreiff said:


> We then copiously irrigated the joint and removed our
> arthroscopic equipment. Under fluoroscopic guidance and needle localization, we made a small stab incision over the lateral aspect of
> the proximal metaphysis of the tibia. *An obturator trocar cannula device was then drilled from lateral to the subchondral bone* of the
> medial tibial plateau. Location was confirmed using 2 orthogonal fluoroscopic views. We then injected 4 mL of Knee Creations
> ...




One of our Orthopedic Surgeon does this also. This is a percutaneous procedure and i underlined the first line as he removed all the arthroscopic equipment and used a Trocar to drill into the subschondral bone to inject the cement mix. he used the arthroscope to check for extraneous cement in the joint. 

I code these with 27599 (unlisted procedure, femur or knee) and compare it to code 29855 

i would only report as follows:
29881 -RT
27599 (compare to 29855) -no modifiers, send the operative note with the claim, 
(77002) - fluoroscopy for placement

hope this helps


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## djreiff (Aug 21, 2017)

sequester25@gmail.com said:


> One of our Orthopedic Surgeon does this also. This is a percutaneous procedure and i underlined the first line as he removed all the arthroscopic equipment and used a Trocar to drill into the subschondral bone to inject the cement mix. he used the arthroscope to check for extraneous cement in the joint.
> 
> I code these with 27599 (unlisted procedure, femur or knee) and compare it to code 29855
> 
> ...



Since he did both the tibial plateau and the medial femoral condyle would you report the 29855 for the tibia and the 27599 for the femur? Or just 27599 for both?


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## sequester25@gmail.com (Aug 21, 2017)

you would report the 27599 only once for both

29855 - is specifically for the cartilage. Your physician is going under that (subchondral) to the bone where the stress fracture is located.


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## daedolos (Mar 23, 2018)

Thanks for the insight.

Peace
@_^
This helps a bunch!


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