bmeech
Networker
Sorry this note is so long.
Need help with bundling issue: I know the San Diego and proximal Varus denotational osteotomies would be code 27151, but the provider has also submitted for the 27001 = Adductor Longus done percutaneous.
Per note: She only had about 30 degrees of abduction bilaterally so a 15 blade was used to cut the adductor longus tendon percutaneously. This allowed abduction to 70 degrees. This was done bilaterally.
Besides this being a "separate procedure: This separate procedure by definition is usually a component of a more complex service and is not identified separately. Would a 59 be allowed?
the rest of the note:
We started with the left hip and a small incision made on the pelvis just lateral to the pelvic brim approximately 4 cm back from the ASIS to just distal. We then carefully released the obliques off of the brim of the pelvis exposing the cartilaginous apophysis. This was then split with a 15 blade in the midline and the apophysis popped off laterally. We then performed subperiosteal dissection down to the sciatic notch. This was then packed with a Ray-Tec. A 7 cm incision was made from just distal to the tip of the greater trochanter laterally on the thigh. We then dissected through the IT band and elevated the vastus off of the septum. From the vastus insertion, a L-shaped was cut from its insertion leaving a portion of this for later repair in the long-leg of the L brought distally posterior. The vastus was then brought off of the bone subperiosteally. Under fluoroscopy, a threaded K wire was inserted into the femoral neck just at the medial inferior portion of the physis for a planned varus of about 110 degrees. This was confirmed to be central on AP and lateral views. We measured and elected to use a 30 mm blade. The infant blade osteotome was then inserted into the femoral neck confirming this was orthogonal to the shaft so we did not create any flexion or extension proximally. Once this was seated in 30 mm, we used the hockey stick to confirm the location of the osteotomy. This was then marked with the Bovie and a marker used to mark the bone to help control our planned rotation. We then used the oscillating saw to cut the femur perpendicular to the shaft and then again parallel to the plate. The triangular wedge of bone was removed. We then beveled the edge of the proximal segment. The osteotome from the neck was removed and replaced with the infant blade plate. This was then reduced to the shaft with a clamp. With then rotated the femur to the appropriate position. 2 screws were placed in compression mode getting excellent purchase. We then took x-rays confirming incision of the plate in appropriate varus of the neck. Another screw was then placed in the shaft. A locking screw was placed proximally.
We then turned our attention to the acetabulum. Under x-ray we confirmed the level of her osteotomy and the outer table scored with a small osteotome. With the retractor protecting the sciatic notch, cover osteotomes were used to cut down to the triradiate cartilage. A small rongeur was used to cut through the inner and outer table anteriorly. With a large curved osteotome, we then were able to bend the acetabulum down getting excellent coverage over the head. We then placed the bone that was taken from the femur into the pelvis getting excellent stability coverage of the femoral head.
Thank you !
Need help with bundling issue: I know the San Diego and proximal Varus denotational osteotomies would be code 27151, but the provider has also submitted for the 27001 = Adductor Longus done percutaneous.
Per note: She only had about 30 degrees of abduction bilaterally so a 15 blade was used to cut the adductor longus tendon percutaneously. This allowed abduction to 70 degrees. This was done bilaterally.
Besides this being a "separate procedure: This separate procedure by definition is usually a component of a more complex service and is not identified separately. Would a 59 be allowed?
the rest of the note:
We started with the left hip and a small incision made on the pelvis just lateral to the pelvic brim approximately 4 cm back from the ASIS to just distal. We then carefully released the obliques off of the brim of the pelvis exposing the cartilaginous apophysis. This was then split with a 15 blade in the midline and the apophysis popped off laterally. We then performed subperiosteal dissection down to the sciatic notch. This was then packed with a Ray-Tec. A 7 cm incision was made from just distal to the tip of the greater trochanter laterally on the thigh. We then dissected through the IT band and elevated the vastus off of the septum. From the vastus insertion, a L-shaped was cut from its insertion leaving a portion of this for later repair in the long-leg of the L brought distally posterior. The vastus was then brought off of the bone subperiosteally. Under fluoroscopy, a threaded K wire was inserted into the femoral neck just at the medial inferior portion of the physis for a planned varus of about 110 degrees. This was confirmed to be central on AP and lateral views. We measured and elected to use a 30 mm blade. The infant blade osteotome was then inserted into the femoral neck confirming this was orthogonal to the shaft so we did not create any flexion or extension proximally. Once this was seated in 30 mm, we used the hockey stick to confirm the location of the osteotomy. This was then marked with the Bovie and a marker used to mark the bone to help control our planned rotation. We then used the oscillating saw to cut the femur perpendicular to the shaft and then again parallel to the plate. The triangular wedge of bone was removed. We then beveled the edge of the proximal segment. The osteotome from the neck was removed and replaced with the infant blade plate. This was then reduced to the shaft with a clamp. With then rotated the femur to the appropriate position. 2 screws were placed in compression mode getting excellent purchase. We then took x-rays confirming incision of the plate in appropriate varus of the neck. Another screw was then placed in the shaft. A locking screw was placed proximally.
We then turned our attention to the acetabulum. Under x-ray we confirmed the level of her osteotomy and the outer table scored with a small osteotome. With the retractor protecting the sciatic notch, cover osteotomes were used to cut down to the triradiate cartilage. A small rongeur was used to cut through the inner and outer table anteriorly. With a large curved osteotome, we then were able to bend the acetabulum down getting excellent coverage over the head. We then placed the bone that was taken from the femur into the pelvis getting excellent stability coverage of the femoral head.
Thank you !