Hello everyone!
I am in need of some assistance in making sure I am coding this op report correctly. Dr performed an Arthroscopic ACL reconstruction 29888 along with what he says is a ALL reconstruction 27427, but I am not sure with the documentation provided that the ALL is done separately or is combined with the ACL procedure. Here is the op report.
Thank you all in advance!
DESCRIPTION OF PROCEDURE: The patient was placed supine on the
operating table. General anesthetic was given satisfactorily.
He was identified and marked in the holding area and brought to
the operating table. General anesthetic was done. The right
leg was examined under anesthesia. Range of motion was 0 to
145. Positive anterior Lachman, grade 3C. Grade 2 pivot shift.
No significant medial lateral joint line opening. Negative dial
test. Grade 0 posterior drawer. The lower lib was prepped and
draped in a sterile manner. The limb was exsanguinated.
Tourniquet was inflated to 275 mmHg. A time-out was down.
Ancef was given prior to beginning the surgery and the whole
patella bone tendon bone allograft had been prepared to a 9.5
and a 10 prior to the patient being put to sleep. It was
prestretched at 15 to 20 pounds for 10 minutes and an
InternalBrace as well as Arthrex TightRope RT was applied. A
semitendinosus allograft was also prepared and then prestretched
as well too. It was prepared with a TightRope. Both were
irrigated and stored. A small incision was made at the Gerdy’s
tubercle and just at the junction between the lateral distal
femur and the femoral condyle. Dissection was taken down both
prepared region on the femur, which was in the region of
McIntosh point and then a region just behind the Gerdy’s
tubercle. An inferomedial, inferolateral, and superolateral
portals were made. Findings were as noted above. The scope was
placed into the joint through the inferomedial portal and
inferolateral portal was used as well too. As it was placed
through the inferolateral portal, the knee was examined
systematically. Findings were as noted. A rasp was used to
debride the underside of the medial meniscus and 4.0 shaver was
used to debride the lateral meniscus. The anterior cruciate
ligament footprint was then prepared and a chondral pick was
used to mark the lateral femoral condyle. I marked this and I
confirmed this was appropriate. I then debrided the tibial
footprint and marked the location with the electrocautery in the
center. I then drilled using a supplemental inferomedial
incision about 2 to 3 cm outside in, confirmed fluoroscopically
in extension that the pin was impingement free, then overreamed
this to a 10.
Then, using a FlipCutter was applied through a separate
percutaneous incision, I made a 9.5 femoral tunnel with
retrograde reaming. Excess bone was removed. I then confirmed
isometry after I placed a guidepin at the McIntosh point right
at the distal femoral connection with the femoral condyle. This
looked acceptable. I drilled the tibia to a 6 and the femur to
a 6. Subsequently, the anterior cruciate ligament graft was
pulled in to position and confirmed the button was appropriately
positioned fluoroscopically, pulled the graft in, cycled it
about 40 times, then pulled the ALR femoral graft femoral side,
pulled it in place, dunked it and then pulled this down through
and dunked the tibia side with a 6.25 Bio-Screw, tightened the
femur, TightRope in full extension. I had confirmed that the
button was appropriately positioned here as well too. The graft
felt tight. I then cycled the knee 40 times and then in full
extension I placed a 20 mm ABS button and then I placed the
InternalBrace with a slight slack on the TightRope. Once this
was done, I cycled the knee in about 10 to 20 more times and
then tightened in full extension the tightening sutures as in
tibia and the femur. Tourniquet was let down. Hemostasis was
achieved with pressure and electrocautery. A 2-0 Vicryl was
used to close the subcutaneous tissues, 3-0 Monocryl was used to
close the subcuticular skin. Benzoin and Steri-Strips were
applied. Naropin was injected. Sterile dressing was applied.
I am in need of some assistance in making sure I am coding this op report correctly. Dr performed an Arthroscopic ACL reconstruction 29888 along with what he says is a ALL reconstruction 27427, but I am not sure with the documentation provided that the ALL is done separately or is combined with the ACL procedure. Here is the op report.
Thank you all in advance!
DESCRIPTION OF PROCEDURE: The patient was placed supine on the
operating table. General anesthetic was given satisfactorily.
He was identified and marked in the holding area and brought to
the operating table. General anesthetic was done. The right
leg was examined under anesthesia. Range of motion was 0 to
145. Positive anterior Lachman, grade 3C. Grade 2 pivot shift.
No significant medial lateral joint line opening. Negative dial
test. Grade 0 posterior drawer. The lower lib was prepped and
draped in a sterile manner. The limb was exsanguinated.
Tourniquet was inflated to 275 mmHg. A time-out was down.
Ancef was given prior to beginning the surgery and the whole
patella bone tendon bone allograft had been prepared to a 9.5
and a 10 prior to the patient being put to sleep. It was
prestretched at 15 to 20 pounds for 10 minutes and an
InternalBrace as well as Arthrex TightRope RT was applied. A
semitendinosus allograft was also prepared and then prestretched
as well too. It was prepared with a TightRope. Both were
irrigated and stored. A small incision was made at the Gerdy’s
tubercle and just at the junction between the lateral distal
femur and the femoral condyle. Dissection was taken down both
prepared region on the femur, which was in the region of
McIntosh point and then a region just behind the Gerdy’s
tubercle. An inferomedial, inferolateral, and superolateral
portals were made. Findings were as noted above. The scope was
placed into the joint through the inferomedial portal and
inferolateral portal was used as well too. As it was placed
through the inferolateral portal, the knee was examined
systematically. Findings were as noted. A rasp was used to
debride the underside of the medial meniscus and 4.0 shaver was
used to debride the lateral meniscus. The anterior cruciate
ligament footprint was then prepared and a chondral pick was
used to mark the lateral femoral condyle. I marked this and I
confirmed this was appropriate. I then debrided the tibial
footprint and marked the location with the electrocautery in the
center. I then drilled using a supplemental inferomedial
incision about 2 to 3 cm outside in, confirmed fluoroscopically
in extension that the pin was impingement free, then overreamed
this to a 10.
Then, using a FlipCutter was applied through a separate
percutaneous incision, I made a 9.5 femoral tunnel with
retrograde reaming. Excess bone was removed. I then confirmed
isometry after I placed a guidepin at the McIntosh point right
at the distal femoral connection with the femoral condyle. This
looked acceptable. I drilled the tibia to a 6 and the femur to
a 6. Subsequently, the anterior cruciate ligament graft was
pulled in to position and confirmed the button was appropriately
positioned fluoroscopically, pulled the graft in, cycled it
about 40 times, then pulled the ALR femoral graft femoral side,
pulled it in place, dunked it and then pulled this down through
and dunked the tibia side with a 6.25 Bio-Screw, tightened the
femur, TightRope in full extension. I had confirmed that the
button was appropriately positioned here as well too. The graft
felt tight. I then cycled the knee 40 times and then in full
extension I placed a 20 mm ABS button and then I placed the
InternalBrace with a slight slack on the TightRope. Once this
was done, I cycled the knee in about 10 to 20 more times and
then tightened in full extension the tightening sutures as in
tibia and the femur. Tourniquet was let down. Hemostasis was
achieved with pressure and electrocautery. A 2-0 Vicryl was
used to close the subcutaneous tissues, 3-0 Monocryl was used to
close the subcuticular skin. Benzoin and Steri-Strips were
applied. Naropin was injected. Sterile dressing was applied.