Hello,
Please review Op Report below and advise on CPT coding, especially on bundling between 29897 and 29894.
Thank you and have a nice holiday!
Operative Report
POSTOPERATIVE DIAGNOSES:
1. Left ankle recurrent instability. - M25.372
2. Left ankle free floating fragments and osteoarthritis. - M24.072, M19.072
PROCEDURE PERFORMED:
1. Left ankle lateral ligament repair of both collateral ligaments. - 27696
2. Left ankle arthroscopy with moderate debridement and removal of loose bodies. - 29897, 29894
INDICATIONS: Patient is a ?-year-old with longstanding left ankle lateral ligament instability and ankle osteoarthritis. Patient failed conservative treatment and was indicated for operative fixation. Risks and benefits were discussed with the patient in depth. Risk for recurrent instability, continued pain, need for further procedures along with a standard operative risk of bleeding, infection, damage to surrounding structures.
DESCRIPTION OF PROCEDURE: The patient was identified in the preop area. Patient was brought back, placed supine on the operating table. Left lower extremity was the correct. Extremity was prepped and draped in normal standard fashion. Preoperative antibiotics were given. A thigh tourniquet was used throughout the duration of the case for approximately 60 minutes. The surgery was started by making the 2 anterior portals on the ankle, anteromedial and anterolateral. Care was taken to protect the superficial peroneal nerve. The ankle was entered with the arthroscopy camera. The patient noted significant hypertrophic synovium and several loose bodies floating around the joint. A shaver was used to resect the hypertrophic synovium, grabber was used to grab the 2 loose bodies. There was frayed cartilage in the medial gutter, which was debrided with a shaver. There was no focal area of cartilage defect that was amenable to microfracture. The patient's medial tibial plafond had grade II osteoarthritic changes and the medial gutter had exposed bone. Once this was done, the scope was removed, these portals were closed.
Attention was then turned to lateral ankle ligaments. A 4 cm incision was made over the lateral mal. This was taken down through skin and subcutaneous tissue. The underlying neurovascular structures were identified. The collateral ligaments were dissected sharply at the end of the distal fibula. A rongeur was used to create a bony trough with the native footprint of the ATFL and CFL ligaments. Once this was done, Arthrex suture anchors were then placed in the footprint of the 2 ligaments. The FiberWire sutures were then used to grasp the redundant ATFL and CFL ligaments. These were then secured in place and secured back to the bone. Anterior drawer was negative after this. Once this was done, the Gould modification was then done with extensor retinaculum. The skin was then closed. Patient was then placed in a well-padded short-leg splint and then awoken and taken to recovery room in good and stable condition.
FINDINGS: Left ankle lax lateral ligaments, early osteoarthritis of ankle, free floating fragments in the ankle joint.
Please review Op Report below and advise on CPT coding, especially on bundling between 29897 and 29894.
Thank you and have a nice holiday!
Operative Report
POSTOPERATIVE DIAGNOSES:
1. Left ankle recurrent instability. - M25.372
2. Left ankle free floating fragments and osteoarthritis. - M24.072, M19.072
PROCEDURE PERFORMED:
1. Left ankle lateral ligament repair of both collateral ligaments. - 27696
2. Left ankle arthroscopy with moderate debridement and removal of loose bodies. - 29897, 29894
INDICATIONS: Patient is a ?-year-old with longstanding left ankle lateral ligament instability and ankle osteoarthritis. Patient failed conservative treatment and was indicated for operative fixation. Risks and benefits were discussed with the patient in depth. Risk for recurrent instability, continued pain, need for further procedures along with a standard operative risk of bleeding, infection, damage to surrounding structures.
DESCRIPTION OF PROCEDURE: The patient was identified in the preop area. Patient was brought back, placed supine on the operating table. Left lower extremity was the correct. Extremity was prepped and draped in normal standard fashion. Preoperative antibiotics were given. A thigh tourniquet was used throughout the duration of the case for approximately 60 minutes. The surgery was started by making the 2 anterior portals on the ankle, anteromedial and anterolateral. Care was taken to protect the superficial peroneal nerve. The ankle was entered with the arthroscopy camera. The patient noted significant hypertrophic synovium and several loose bodies floating around the joint. A shaver was used to resect the hypertrophic synovium, grabber was used to grab the 2 loose bodies. There was frayed cartilage in the medial gutter, which was debrided with a shaver. There was no focal area of cartilage defect that was amenable to microfracture. The patient's medial tibial plafond had grade II osteoarthritic changes and the medial gutter had exposed bone. Once this was done, the scope was removed, these portals were closed.
Attention was then turned to lateral ankle ligaments. A 4 cm incision was made over the lateral mal. This was taken down through skin and subcutaneous tissue. The underlying neurovascular structures were identified. The collateral ligaments were dissected sharply at the end of the distal fibula. A rongeur was used to create a bony trough with the native footprint of the ATFL and CFL ligaments. Once this was done, Arthrex suture anchors were then placed in the footprint of the 2 ligaments. The FiberWire sutures were then used to grasp the redundant ATFL and CFL ligaments. These were then secured in place and secured back to the bone. Anterior drawer was negative after this. Once this was done, the Gould modification was then done with extensor retinaculum. The skin was then closed. Patient was then placed in a well-padded short-leg splint and then awoken and taken to recovery room in good and stable condition.
FINDINGS: Left ankle lax lateral ligaments, early osteoarthritis of ankle, free floating fragments in the ankle joint.