Orthopedic Coding Alert

Don't panic when your surgeon encounters unforeseen complications during surgery

Orthopedic surgery coding can sometimes hold surprises. For example, suppose your surgeon plans to perform a TKR and hardware removal, but he ends up performing what he refers to as a -custom- knee replacement with nonunion repair. You can overcome this challenge with a thorough review of the op note and careful use of modifiers.

Consider the following operative report, submitted to Orthopedic Coding Alert by Debi Scarfo, biller at Bannon Orthopaedics and Sports Medicine in Queensbury, N.Y. After you review the op report, code the procedure before you check out our expert advice below.

Preoperative diagnosis: Status post severe bicondylar proximal tibia fracture, and post open reduction internal fixation with bone grafting (failed).

Procedure overview: The surgeon scheduled a patient for hardware removal (from a tibia fracture), as well as a total knee replacement. When he opened the patient, he found it necessary to perform major deep hardware removal, tibial tubercle reconstruction, trabecular metal coil insertion, wedge medial tibial base plate, and long stem tibial component (total knee replacement). Op Note: Trace the Surgeon's Work The pertinent details of the op report follow: After I opened the patient, I noted an obvious nonunion of the tibial tubercle. I removed the tibial tubercle wires and removed the plates and found that the massive amount of bone grafts that we had used intraoperatively had not consolidated and there was a tremendous amount of necrotic bone. I ununited the medial tibial plateau and discarded the large (3-cm) piece.

I used a trabecular bone proximal tibial reinforcer and shaped the inner tibia, removing some of the remaining cancellous bone from the proximal tibia to incorporate the trabecular cone into the proximal tibia.

We placed a rod up through the femur, inserted the distal femoral cutting block jig, cut the distal femur, and measured the femur to a size F. We cut the anterior-posterior femurs and chamfered them. We removed medial and lateral meniscal remnants and the anterior-posterior cruciates.

We again debrided the proximal tibia and found that the anteromedial tibia was deficient for 5 or 6 cm. With the rod in place down through the tibia, we cut the proximal tibia at about 1 cm. We reamed the tibial canal to 13 mm for the rod and left the rod in place.

We shaped the inside of the proximal tibia to accept a cone, and then set the distal portion of the cone medially on the tibia and inserted it inside of the proximal tibial metaphysis. We settled on a #17 polyethylene that allowed us to full extend and flex with stability medially and laterally in both flexion and extension.

We then addressed the tubercle nonunion. We drilled [...]