Hi everyone. I need some help here.
This op report was coded with 29881, 29999 (arthroscopic allograft failed ACL tunnels) & 20680 (hardware removal) for ASC.
After the knee was appropriately prepared, standard arthroscopic portals were established. Looking into the medial compartment, there was a parrot-beak flap tear of the posterior horn of the medial meniscus. This was trimmed back to a stable base utilizing basket biters and a shaver. There was also Grade II-III chondromalacia throughout the medial femoral condyle. This was gently debrided back to a stable base utilizing the shaver. The anterior cruciate ligament was evaluated. Not only was the graft torn in half but it had dissolved. Entering the lateral compartment, there was just some fraying of the lateral meniscus. This was minimally debrided. There was minimal chondromalacia. Entering the patellofemoral joint, there was Grade III chondromalacia involving 60% of the trochlear groove, with some flaps and fissures. This was gently trimmed back to a stable base utilizing a shaver. The patella revealed extensive Grade II chondromalacia with multiple flaps and fissures. This was gently debrided back to a stable base utilizing the shaver.
Going back to the anterior cruciate ligament, the anterior cruciate ligament was debrided and then we began debriding into the femoral tunnel. The patient is status post-two previous surgical procedures. The first tunnel was more anterior and it appeared that the second tunnel had partially broken into the first tunnel. This created an approximately 11-12 mm tunnel. This was rasped, reamed and then partially drilled to a depth of 25 mm utilizing a 10 mm reamer. An 11-12 mm bone plug was then fashioned on a skewer, brought into the joint and then gently pounded into the femoral tunnel. This worked very well until the very end, when the cortical bone cracked in half and we had to place the two fragments in separately. Because the last fragment was a little bit loose, this was set aside.
The previous anterior incision over the patellar tendon was utilized, widened and scar revision was performed. Sharp dissection was then carried down to the previously placed tibial screw. The screw was located and then removed. It was a large metal interference screw. The surrounding bone was partially reamed and then fully reamed utilizing an 11 mm reamer after utilizing a pin to center it arthroscopically. Osteotomes were utilized to remove some wedges of bone around the tunnel.
These wedges of bone were then brought in arthroscopically and wedged up into the femoral tunnel, wedging the allograft bone into good position. On probing, it was well fixated.
Looking inside the tibial tunnel, all loose fragments were removed. We did not need to graft the lateral tunnel since it came up to the exact same hole as the medial side and there was just a small amount of tissue which will be connected. Also, it will not affect any windshield wipering or ingrowth with the later graft. A 12 x 30 mm allograft bone plug was then fashioned and gently tapped into the tibial tunnel, with excellent fixation. There was cortical bone to bone flush laterally and the tip of the bone allograft was right flush with the tibial plateau.
The surgeon is a bit upset by the fact that he did all this work and only reflected in 3 codes. Here is my e-mail address (jdewitte74@gmail.com) If anyone can help me break this down as to why certain procedures can and can't be coded and some documentation to back this up. it would be realy appreciated. This was outsourced to a coding company. I'm not savy enought in orthopedics to be able to get the informationt explain this better.
This op report was coded with 29881, 29999 (arthroscopic allograft failed ACL tunnels) & 20680 (hardware removal) for ASC.
After the knee was appropriately prepared, standard arthroscopic portals were established. Looking into the medial compartment, there was a parrot-beak flap tear of the posterior horn of the medial meniscus. This was trimmed back to a stable base utilizing basket biters and a shaver. There was also Grade II-III chondromalacia throughout the medial femoral condyle. This was gently debrided back to a stable base utilizing the shaver. The anterior cruciate ligament was evaluated. Not only was the graft torn in half but it had dissolved. Entering the lateral compartment, there was just some fraying of the lateral meniscus. This was minimally debrided. There was minimal chondromalacia. Entering the patellofemoral joint, there was Grade III chondromalacia involving 60% of the trochlear groove, with some flaps and fissures. This was gently trimmed back to a stable base utilizing a shaver. The patella revealed extensive Grade II chondromalacia with multiple flaps and fissures. This was gently debrided back to a stable base utilizing the shaver.
Going back to the anterior cruciate ligament, the anterior cruciate ligament was debrided and then we began debriding into the femoral tunnel. The patient is status post-two previous surgical procedures. The first tunnel was more anterior and it appeared that the second tunnel had partially broken into the first tunnel. This created an approximately 11-12 mm tunnel. This was rasped, reamed and then partially drilled to a depth of 25 mm utilizing a 10 mm reamer. An 11-12 mm bone plug was then fashioned on a skewer, brought into the joint and then gently pounded into the femoral tunnel. This worked very well until the very end, when the cortical bone cracked in half and we had to place the two fragments in separately. Because the last fragment was a little bit loose, this was set aside.
The previous anterior incision over the patellar tendon was utilized, widened and scar revision was performed. Sharp dissection was then carried down to the previously placed tibial screw. The screw was located and then removed. It was a large metal interference screw. The surrounding bone was partially reamed and then fully reamed utilizing an 11 mm reamer after utilizing a pin to center it arthroscopically. Osteotomes were utilized to remove some wedges of bone around the tunnel.
These wedges of bone were then brought in arthroscopically and wedged up into the femoral tunnel, wedging the allograft bone into good position. On probing, it was well fixated.
Looking inside the tibial tunnel, all loose fragments were removed. We did not need to graft the lateral tunnel since it came up to the exact same hole as the medial side and there was just a small amount of tissue which will be connected. Also, it will not affect any windshield wipering or ingrowth with the later graft. A 12 x 30 mm allograft bone plug was then fashioned and gently tapped into the tibial tunnel, with excellent fixation. There was cortical bone to bone flush laterally and the tip of the bone allograft was right flush with the tibial plateau.
The surgeon is a bit upset by the fact that he did all this work and only reflected in 3 codes. Here is my e-mail address (jdewitte74@gmail.com) If anyone can help me break this down as to why certain procedures can and can't be coded and some documentation to back this up. it would be realy appreciated. This was outsourced to a coding company. I'm not savy enought in orthopedics to be able to get the informationt explain this better.