Orthopedic Coding Alert

Confirm whether graft came from separate incision or fascial exposure

You may be familiar with coding ligament reconstructions for the ACL or rotator cuff, but what happens when the surgeon reconstructs the patellofemoral ligament with a semitendinosus graft? We'll show you how to select an accurate code in three easy steps.

Take a look at the following operative note, and review our experts' coding recommendations.

Procedure overview: The surgeon performed reconstruction of the medial patellofemoral ligament using a semitendinosus graft. He also performed partial anterior synovectomy arthroscopically.

Operative Note: Trace the Surgeon's Work

The pertinent details from the operative report are as follows: The surgeon examined the patella through an arthroscope. He noted some anterior synovitis and performed a partial anterior synovectomy for visualization. He thought reconstruction of the soft-tissue restraints medially was appropriate.

Through a small oblique incision over the medial border of the proximal tibia metaphyseal area, the surgeon identified the semitendinosus tendon and, using an open-face tendon stripper, stripped the tendon away from the muscle belly.

The surgeon made a second 2-cm incision over the medial patellar retinaculum midway between the patellar and the medial epicondyle.
 
The surgeon drilled a 3-mm hole centrally in the medial patella. He dissected free the medial collateral ligament proximally and passed the semitendinosus tendon through a subcutaneous tunnel, through the posterior third of the MCL as close to the insertion on the medial epicondyle as practical, and passed it through the drill hole in the patella.

Then, using a Pulver-Taft weave, he sutured the tendon back upon itself with multiple sutures in a figure of eight with 4-0 Vicryl.
 
Medical Coding Advice : Follow These Simple Steps

Step 1: Code the patellofemoral ligament reconstruction. Because the surgeon performed the reconstruction to stabilize a dislocating patella, the practice should report 27422 (Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release [e.g., Campbell, Goldwaite type procedure]) for the main procedure, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J. 
 
Step 2: Code the graft, if documented. Practices that perform patellofemoral ligament reconstruction with graft may be able to report 20924 (Tendon graft, from a distance [e.g., palmaris, toe extensor, plantaris]), if the surgeon documents that he harvested the graft "from a distance." The report should note that the surgeon obtained the graft through either a separate skin incision or fascial exposure, says Bill Mallon, MD, medical director at Triangle Orthopaedic Associates in Durham, N.C.

The operative report in our case study above does not document either of these situations, and the practice should therefore not report 20924. If, however, the surgeon in our study used the same skin incision and extended it, he should have documented separate fascial exposure to warrant reporting 20924.

If your surgeon appropriately documents the separate incision or fascial exposure, you should report 27422 with 20924. You need not append modifier -51 (Multiple procedures) to 20924 because it is modifier -51 exempt.

Step 3: Include the Synovectomy in the Main Procedure. "Although the surgeon documented an arthroscopic synovectomy, in the detailed procedure description he clearly states that he performed synovectomy to enhance visualization; therefore, you should not report it separately," Stout says.