Joyce Burchett
Networker
Op Procedures: Arthroscopic Partial Lateral Meniscectomy (29881); Open distal femoral supracondylar trochlear groove deepening osteotomy (?); Open medial patellofemoral ligament reconstruction w/gracilis autograft harvest (27422); Lateral patellofemoral ligament lengthening (part of 27422?). Can anyone help with this coding?
A lateral arthrotomy incision made & identified the lateral retinaculum which caused subsequent patellar tilting. We performed a lengthening procedure by dissecting the superficial as well as deep layer of retinaculum in a Z-type fashion. The initial lengthening procedure was performed with the cuts. We identified the joint through the arthrotomy. There was a large supratrochlear bump noted consistent with trochlear dysplasia & there was a flat trochlea noted superiorly. There was a groove distally. We dissected the periosteal layer about 3mm inferior to the cartilage surfaces. We then placed drill holes through the lateral edge of the supracondylar trochlear region. We then used Arthrex trochlear or plastic guide to ostetomize the osteochondral region of the trochlea for the trochleoplasty. We then deepened the trochlear groove centrally with a curet as well as a rongeur & osteotomes. Once the trochlear osteochondral osteotomy was mobile, we then placed SwiveLock anchors with #2 vicryl at the apex of the trochlear groove. The placed 1 immediately superior to this along the metaphyseal region of the distal femur. This was impacted into place & tensioned. We were able to develop a trochlear groove superiorly. We then used a bone graft to pack it laterally. We then used a second fixation point with our #2 vicryl to perform from the secondary limb from the apex trochlear site. We then placed a third PushLock anchor laterally. This allowed for compression of the lateral osteotomy. We then us 0 vicryl suture to repair the periosteal layer. We then used Fibrin glue along the osteotomy site, bleeding control, as well as repair. The patella tracked well following this. We then performed patellofemoral lengthening. We placed our superficial & our deep layer after lengthening was performed using 0 vicryl suture in a figure-of-eight fashion to repair this in a Z fashion. Following this the tilt of the patella disappeared. The patella did track well.
A vertical incision was made over the gracilis through skin & subcutaneous tissue with a knife. We identified the sartorial fascia. It was split horizontally. We identified the underlying gracilis tendon. It was freed of its gastrocnemius attachments. Using hamstring stripper, we harvested the hamstring & freed it of its muscle attachments. We then tubularized the graft proximally & distally after it was detached. We then identified the medial border of the patella. Incision was mad through skin & subcutaneous tissue with a knife. We then went through the medial retinacular layer. There was tearing of the medial patellofemoral ligament. We identified the anatomic origin site of the medial patellofemoral ligament. This was confirmed with C-arm Fluoroscopy. Two parallel guide pins were placed & confirmed with C-arm Fluoroscopy. We reamed the guidepins for SwiveLock anchors, & these were reamed to approximately 25mm. We then found our medial patellofemoral ligament insertion site on radiographic imaging. We the made our incision & dissected through the sartorial layer. We identified the anatomic origin site under C-arm Fluoroscopy & the guidewire was placed, drilled & confirmed with C-arm Fluoroscopy in both AP & lateral planes. Then we over-reamed with a 7mm reamer. The graft was then inserted through the SwiveLock anchors along the proximal & distal drill holes into the patella. Central sutures placed in this location through the midpoint of the graft. It was then shuttled through the layer 2 to MPFL insertion site. It was then placed using a Beath pin into our tunnel. Tension was applied with a slightly medial directed force of the knee at about 30 degrees in knee flexion. The Arthrex 7 x 20mm screw inserted. Optium fixation was achieved. The graft was fixed well & no medial or lateral dislocation following reconstruction of the medial patellofemoral ligament.
Can I charge anything for obtaining the graft of for the C-arm fluoroscopy, or is that included with the procedure codes? Any help would be appreciated. Several coders have looked at this & we are not sure how to code.
A lateral arthrotomy incision made & identified the lateral retinaculum which caused subsequent patellar tilting. We performed a lengthening procedure by dissecting the superficial as well as deep layer of retinaculum in a Z-type fashion. The initial lengthening procedure was performed with the cuts. We identified the joint through the arthrotomy. There was a large supratrochlear bump noted consistent with trochlear dysplasia & there was a flat trochlea noted superiorly. There was a groove distally. We dissected the periosteal layer about 3mm inferior to the cartilage surfaces. We then placed drill holes through the lateral edge of the supracondylar trochlear region. We then used Arthrex trochlear or plastic guide to ostetomize the osteochondral region of the trochlea for the trochleoplasty. We then deepened the trochlear groove centrally with a curet as well as a rongeur & osteotomes. Once the trochlear osteochondral osteotomy was mobile, we then placed SwiveLock anchors with #2 vicryl at the apex of the trochlear groove. The placed 1 immediately superior to this along the metaphyseal region of the distal femur. This was impacted into place & tensioned. We were able to develop a trochlear groove superiorly. We then used a bone graft to pack it laterally. We then used a second fixation point with our #2 vicryl to perform from the secondary limb from the apex trochlear site. We then placed a third PushLock anchor laterally. This allowed for compression of the lateral osteotomy. We then us 0 vicryl suture to repair the periosteal layer. We then used Fibrin glue along the osteotomy site, bleeding control, as well as repair. The patella tracked well following this. We then performed patellofemoral lengthening. We placed our superficial & our deep layer after lengthening was performed using 0 vicryl suture in a figure-of-eight fashion to repair this in a Z fashion. Following this the tilt of the patella disappeared. The patella did track well.
A vertical incision was made over the gracilis through skin & subcutaneous tissue with a knife. We identified the sartorial fascia. It was split horizontally. We identified the underlying gracilis tendon. It was freed of its gastrocnemius attachments. Using hamstring stripper, we harvested the hamstring & freed it of its muscle attachments. We then tubularized the graft proximally & distally after it was detached. We then identified the medial border of the patella. Incision was mad through skin & subcutaneous tissue with a knife. We then went through the medial retinacular layer. There was tearing of the medial patellofemoral ligament. We identified the anatomic origin site of the medial patellofemoral ligament. This was confirmed with C-arm Fluoroscopy. Two parallel guide pins were placed & confirmed with C-arm Fluoroscopy. We reamed the guidepins for SwiveLock anchors, & these were reamed to approximately 25mm. We then found our medial patellofemoral ligament insertion site on radiographic imaging. We the made our incision & dissected through the sartorial layer. We identified the anatomic origin site under C-arm Fluoroscopy & the guidewire was placed, drilled & confirmed with C-arm Fluoroscopy in both AP & lateral planes. Then we over-reamed with a 7mm reamer. The graft was then inserted through the SwiveLock anchors along the proximal & distal drill holes into the patella. Central sutures placed in this location through the midpoint of the graft. It was then shuttled through the layer 2 to MPFL insertion site. It was then placed using a Beath pin into our tunnel. Tension was applied with a slightly medial directed force of the knee at about 30 degrees in knee flexion. The Arthrex 7 x 20mm screw inserted. Optium fixation was achieved. The graft was fixed well & no medial or lateral dislocation following reconstruction of the medial patellofemoral ligament.
Can I charge anything for obtaining the graft of for the C-arm fluoroscopy, or is that included with the procedure codes? Any help would be appreciated. Several coders have looked at this & we are not sure how to code.