# Arthroscopic microfracture?



## smcbroom (May 19, 2010)

Ok, so I need my fellow coders to help me with this one.  Please read the op report and let me know what you think.  Not sure if it should just be 

29879
20926 (is this supposed to be for the plasmax?)

PREOPERATIVE DIAGNOSES:
1.	Anterior cruciate ligament tear, complete versus partial, proximal.
2.	Rule out internal arrangement.

POSTOPERATIVE DIAGNOSES:
1.	Complete anterior cruciate ligament tear, proximal, of femoral notch.
2.	Grade IV chondral defect, femoral trochlea, nonweightbearing.

OPERATIONS PERFORMED:
1.	Examination under anesthesia.
2.	Arthroscopic healing response ACL repair.
3.	Chondroplasty, microfracture, grade IV chondral lesion, trochlea.
4.	Plasmax, PRP supplementation.

ANESTHESIA:  General.

DESCRIPTION OF PROCEDURE:  This patient was placed supine on the operating room table.  Satisfactory anesthesia was administered by Dr. Mailander.  The extremity was examined and found to have a 1 to 2+ positive Lachman, 1 to 2+ pivot shift, and otherwise a stable knee medial and lateral.  Prepping and draping was followed by diagnostic arthroscopy, which was carried out through the anterolateral and anteromedial portals and established was a tear of the ACL.  This was coming off the femoral notch and the actual substance of the ACL other than the proximal disruption was intact.  In other words, there was no Z-type extension into the midsubstance.  The tibial footprint and attachment was completely normal.  Therefore, with mid flexion and extension, the ACL fit very nicely into the notch and so called "tucked in" way.  Therefore considering the patient's age and demand, a healing response repair of the ACL was felt appropriate.  The procedure involved curettage of the area of the footprint and all the way to the level of the 9 o'clock "down the lateral wall" of the femoral notch and thereafter, multiple microfracture-type holes were created through the bone so as to promote mesenchymal cell invasion of this footprint area.


The rest of the joint was very closely examined.  The menisci were intact.  The joint compartments were normal except for a grade IV lesion that was noted on the femoral trochlea and this was treated by chondroplasty microfracture.  This was unstable and measured approximately 1 cm to 1.5 cm in maximal dimension.  Multiples holes were created as described by Steadman and a stable surrounding articular cartilage "wall" at 90 degrees and adherent was appreciated.  The pointed awl was used to breakthrough the subchondral plate again to encourage mesenchymal cell invasion this level of the joint likewise.

As the blood was placed into the centrifuge and properly prepared onto the back table per protocol using the Plasmax system, the PRP component of approximately 6 mL was utilized.

This was instilled with a spinal needle into the level of the femoral notch.  As flow was diminished, streaming of blood noted and approximately 4 mL was instilled with excellent fibrin glue response accomplished and then the remainder was placed onto the microfracture site where again there was streaming of blood.  Photographs were obtained.

No further irrigation was carried out thereafter as the instruments were removed.  The knee was kept in full extension, and the wound was closed with nylon x2 to each portal site and then the subcutaneous and portal site area only infiltrated with 0.5% Marcaine with epinephrine and dressing was with 4x8's, Coban, thigh-high TED stocking, and then 6-inch Ace bandage for further compression as the tourniquet was released.  A knee immobilizer was secured to keep the knee in extension.

The patient was extubated, awakened from her anesthesia, and returned to the recovery room.  She tolerated the procedure well with no known complications

I would appreciate any help regarding this.  It is a non-Medicare payer.

Thank you!!!
Susan, CPC-H


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## delphinus777 (May 20, 2010)

*PRP Article from the Coding Institute*

Here is an article I found regarding PRP [plasma].  It has some useful information regarding the codes used.  


http://www.codinginstitute.com/articles/pull_the_plug_on_PRP_denials.html


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## smcbroom (May 20, 2010)

That did help tremendously. I appreciate it!  I was thinking it was part of the primary procedure but wasn't sure.

Have a good day!


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