littlelora
Networker
Hello. I have a provider asking if dislocation reduction can be coded at the same time as an arthrodesis, so CPT's 28730, 28615 and possibly 28555x2.
I will post the op note below, but the back story is this patient had an injury in September, saw us for the first time the following March, and then had surgery at the end of March. The patient had no treatment during this time until the surgery. We are trying to figure out if the joint reduction is an inclusive component of the arthrodesis, or when this can be separated to bill. I don't quite see the medical necessity here to code for the dislocation reduction, if the arthrodesis is being performed, and the joint is being reduced to an acceptable alignment for the fusion anyway. Thanks in advance for any help!
I began by performing a stress of the right midfoot using manual manipulation. There was instability of the medial column, with subluxation medially through the naviculocuneiform joint. There was also widening at the medial intercuneiform space. There was no substantial instability at the first tarsometatarsal joint.
I made a dorsal midfoot incision in between the first and second metatarsal bases, extending proximally to the naviculocuneiform joint. Full-thickness skin flap was developed. Blunt dissection was performed to subcutaneous tissues to prevent any inadvertent injury to cutaneous nerves. EHL was identified and carefully retracted out of harm's way. The neurovascular bundle was mobilized and retracted out of harm's way. I left the dorsal capsule at the first TMT joint intact. I began by denuding the articular surface at the medial intercuneiform joint using a curette and sharp osteotome. A power bur and frequent irrigation was used to help further prepare the joint. I carried this dissection proximally to the naviculocuneiform joint, utilizing an lamina spreader/hinterman to distract the joint. I prepared the medial and middle naviculocuneiform joint facets using a curette and sharp osteotome. I attempted to reduce the naviculocuneiform joint, as well as compress. However, I had to prepare more of the lateral facet to allow for improved compression and this was difficult to achieve through the dorsal medial incision. Therefore, I made an accessory dorsal lateral incision over the lateral facet of the naviculocuneiform joint using a 15 blade. Blunt dissection was performed to subcutaneous tissues to prevent a injury to cutaneous nerves. A raphae was identified and the short extensor muscle belly and developed using cautery. The capsule over the lateral facet was incised using a 15 blade. I removed to the remaining articular cartilage using a curette and sharp osteotome. I irrigated out the medial intercuneiform joint, as well as the naviculocuneiform joint. I trephinated the articular surfaces at the medial intercuneiform and naviculocuneiform joints using a 2.0 mm drill to promote further bleeding. I made a skin incision over the lateral aspect of the calcaneus with a 15 blade. I bluntly dissected through subcutaneous tissues prevent any anteverting injury to the peroneal tendons or cutaneous nerves. I passed a large dowel Acumed bone graft reamer unicortical 3 times to obtain bone graft. I placed the bone graft into the medial intercuneiform and naviculocuneiform joints. I have began by reducing the medial cuneiform to the middle cuneiform using a large pointed reduction clamp. I placed a guidewire for the Arthrex 4.0 mm headless cannulated titanium screws to hold the reduction. I then reduced the cuneiforms to the navicular. I placed 0.062 K wires to hold the reduction. I then placed a large reduction time from the second metatarsal base to the medial cuneiform to reduce the Lisfranc widening. I placed a guidewire for the Arthrex 3.5 mm headless cannulated titanium screws in a retrograde fashion from the second metatarsal base into the medial cuneiform. I began by placing a 4.0 mm headless screw across the medial intercuneiform joint to compress for fusion. I then placed a 3.5 mm headless screw from the second metatarsal base into the medial cuneiform for the open reduction internal fixation of the tarsometatarsal joint. I then placed 3 nitinol staples across the naviculocuneiform joint to compress the naviculocuneiform joint for the NC joint arthrodesis. I placed the lateral staple through the dorsal lateral foot incision. The medial and middle staples were placed through the dorsal incision.
I will post the op note below, but the back story is this patient had an injury in September, saw us for the first time the following March, and then had surgery at the end of March. The patient had no treatment during this time until the surgery. We are trying to figure out if the joint reduction is an inclusive component of the arthrodesis, or when this can be separated to bill. I don't quite see the medical necessity here to code for the dislocation reduction, if the arthrodesis is being performed, and the joint is being reduced to an acceptable alignment for the fusion anyway. Thanks in advance for any help!
I began by performing a stress of the right midfoot using manual manipulation. There was instability of the medial column, with subluxation medially through the naviculocuneiform joint. There was also widening at the medial intercuneiform space. There was no substantial instability at the first tarsometatarsal joint.
I made a dorsal midfoot incision in between the first and second metatarsal bases, extending proximally to the naviculocuneiform joint. Full-thickness skin flap was developed. Blunt dissection was performed to subcutaneous tissues to prevent any inadvertent injury to cutaneous nerves. EHL was identified and carefully retracted out of harm's way. The neurovascular bundle was mobilized and retracted out of harm's way. I left the dorsal capsule at the first TMT joint intact. I began by denuding the articular surface at the medial intercuneiform joint using a curette and sharp osteotome. A power bur and frequent irrigation was used to help further prepare the joint. I carried this dissection proximally to the naviculocuneiform joint, utilizing an lamina spreader/hinterman to distract the joint. I prepared the medial and middle naviculocuneiform joint facets using a curette and sharp osteotome. I attempted to reduce the naviculocuneiform joint, as well as compress. However, I had to prepare more of the lateral facet to allow for improved compression and this was difficult to achieve through the dorsal medial incision. Therefore, I made an accessory dorsal lateral incision over the lateral facet of the naviculocuneiform joint using a 15 blade. Blunt dissection was performed to subcutaneous tissues to prevent a injury to cutaneous nerves. A raphae was identified and the short extensor muscle belly and developed using cautery. The capsule over the lateral facet was incised using a 15 blade. I removed to the remaining articular cartilage using a curette and sharp osteotome. I irrigated out the medial intercuneiform joint, as well as the naviculocuneiform joint. I trephinated the articular surfaces at the medial intercuneiform and naviculocuneiform joints using a 2.0 mm drill to promote further bleeding. I made a skin incision over the lateral aspect of the calcaneus with a 15 blade. I bluntly dissected through subcutaneous tissues prevent any anteverting injury to the peroneal tendons or cutaneous nerves. I passed a large dowel Acumed bone graft reamer unicortical 3 times to obtain bone graft. I placed the bone graft into the medial intercuneiform and naviculocuneiform joints. I have began by reducing the medial cuneiform to the middle cuneiform using a large pointed reduction clamp. I placed a guidewire for the Arthrex 4.0 mm headless cannulated titanium screws to hold the reduction. I then reduced the cuneiforms to the navicular. I placed 0.062 K wires to hold the reduction. I then placed a large reduction time from the second metatarsal base to the medial cuneiform to reduce the Lisfranc widening. I placed a guidewire for the Arthrex 3.5 mm headless cannulated titanium screws in a retrograde fashion from the second metatarsal base into the medial cuneiform. I began by placing a 4.0 mm headless screw across the medial intercuneiform joint to compress for fusion. I then placed a 3.5 mm headless screw from the second metatarsal base into the medial cuneiform for the open reduction internal fixation of the tarsometatarsal joint. I then placed 3 nitinol staples across the naviculocuneiform joint to compress the naviculocuneiform joint for the NC joint arthrodesis. I placed the lateral staple through the dorsal lateral foot incision. The medial and middle staples were placed through the dorsal incision.