TJAlexander
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Hey all,
My provider performed a MPFL arthroscopically. See the op note below:
'We made a lateral portal incision using an 11 blade then placed our trocar and camera within the lateral portal. We noticed immediately the patella joint was subluxated laterally. We also noticed a tear in the MPFL and in the retinacular tissue on the medial side of the knee. Next, we explored the medial-lateral gutters and removed several small loose bodies. We evaluated the medial meniscus which was intact. Next, we evaluated the ACL which had some mild laxity but there was a firm endpoint. With the knee in a figure-of-four position, the lateral meniscus was evaluated and determined to be normal. At this point, we then prepared the medial portal with an 11 blade. We then placed our trocar within this region and burred the medial border of the patella. Next, we then focused our attention on our PDS suture through the MPFL. Next, we then made a small incision along the MPFL and passed our passing suture through this, and then passed our Ortho cord suture. Once we had the MPFL within our suture, we then used our guide pin and drilled the 2.8mm Arthrex push-lock drill in the medial aspect of the patella within, around the sutures through the anchor and reattached and repaired the MPFL back down to the medial border of the patella. Next, we then used our suture cutter to remove all 6 sutures. There is no evidence of any subluxation of the patella after our repair."
According to our PA who acted as an assistant, the OR staff were surprised that the repair was being done arthroscopically. Does this qualify as an unlisted procedure in your opinion?
Right now I have diagnosis code: S83.411A and S83.011A but wasn't sure what CPT code to use other than 29999.
Thanks for your help!
My provider performed a MPFL arthroscopically. See the op note below:
'We made a lateral portal incision using an 11 blade then placed our trocar and camera within the lateral portal. We noticed immediately the patella joint was subluxated laterally. We also noticed a tear in the MPFL and in the retinacular tissue on the medial side of the knee. Next, we explored the medial-lateral gutters and removed several small loose bodies. We evaluated the medial meniscus which was intact. Next, we evaluated the ACL which had some mild laxity but there was a firm endpoint. With the knee in a figure-of-four position, the lateral meniscus was evaluated and determined to be normal. At this point, we then prepared the medial portal with an 11 blade. We then placed our trocar within this region and burred the medial border of the patella. Next, we then focused our attention on our PDS suture through the MPFL. Next, we then made a small incision along the MPFL and passed our passing suture through this, and then passed our Ortho cord suture. Once we had the MPFL within our suture, we then used our guide pin and drilled the 2.8mm Arthrex push-lock drill in the medial aspect of the patella within, around the sutures through the anchor and reattached and repaired the MPFL back down to the medial border of the patella. Next, we then used our suture cutter to remove all 6 sutures. There is no evidence of any subluxation of the patella after our repair."
According to our PA who acted as an assistant, the OR staff were surprised that the repair was being done arthroscopically. Does this qualify as an unlisted procedure in your opinion?
Right now I have diagnosis code: S83.411A and S83.011A but wasn't sure what CPT code to use other than 29999.
Thanks for your help!