Orthopedic Coding Alert

Question: Encounter notes indicate that the orthopedist treated a patient’s patellar dislocation. How should I choose an ICD-10 code to report for this encounter?

Florida Subscriber

Answer: To nail down the correct code, you’ll need some more information from the notes. Check the encounter form and see if you can answer these questions:

• Was the surgery open or closed?
• Did the surgery require anesthesia?
• Was the dislocation recurrent?
• On what side of the body did the dislocation occur?

Then, you can choose the most accurate CPT^® code for the surgery. For acute dislocations, choose from among these codes:

• 27560 (Closed treatment of patellar dislocation; without anesthesia)
• 27562 (… requiring anesthesia)
• 27566 (Open treatment of patellar dislocation, with or without partial or total patellectomy)

For recurrent dislocations, choose from among these codes:

• 27418 (Anterior tibial tubercleplasty (eg, Maquet type procedure))
• 27420 (Reconstruction of dislocating patella; (eg, Hauser type procedure))
• 27422 (…with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure))
• 27424 (Reconstruction of dislocating patella; with patellectomy)

Modifier alert: Regardless of code choice, be sure to append modifier RT (Right side) or LT (Left side) to the dislocation repair code to indicate laterality.