Question: In a patient diagnosed with right ankle osteochondritis dessicans (OCD), our surgeon did the following procedures:
How do we code these procedures?
Colorado Subscriber
Answer: The procedure is open and not arthroscopic as it involves a medial malleolus osteotomy. You report this with code 28446 (Open osteochondral autograft, talus [includes obtaining graft(s)]). For the OATS on the ankle or foot, the only coding option for you is 29999 (Unlisted procedure, arthroscopy). This code will cover the right ankle arthroscopy, OATS procedure, medial talus, with harvest from right knee. For resection of loose body, lateral ankle, right side, you will report 29894 (Arthroscopy, ankle [tibiotalar and fibulotalar joints], surgical; with removal of loose body or foreign body). In addition, you can report the diagnosis code 732.7 (Osteochondritis dissecans).