I am new to ankle coding but I am having a hard time with this one so if anyone can assist, I would greatly appreciate it!
This patient underwent a left total ankle arthroplasty with attempted hindfoot arthrodesis by another surgeon. X-rays showed evidence of an existing total ankle arthroplasty with fibular osteotomy and attempted double hindfoot arthrodesis. There was no apparent healing across any of the arthrodesis sites nor the osteotomy site. There was significant subsidence and loosening of the implant with osteolysis surrounding both the tibial and talar components. Given elevated CRP, clinical findings and x-ray evidence of osteolysis and loosening surrounding components, a staged procedure was recommended including removal of all hardware, explant of total ankle arthroplasty, irrigation and debridement, placement of antibiotic cement spacer with bone biopsy.
Postoperative Diagnosis
1) Left total ankle subsidence and loosening (T84.038A for loosening)
2) Left subtalar, talonavicular arthrodesis nonunion (M96.0 for Pseudoarthrosis after fusion or arthrodesis?)
3) Left fibular osteotomy nonunion (included with M96.0?)
1st Operation
1) Left total ankle arthroplasty explant with antibiotic spacer placement (27704 but unable to find a placement code that can be billed with this code)
2) Left ankle irrigation and debridement to the level of bone (11044)
3) Removal of hardware from left subtalar, talonavicular and fibula (included in 27704?)
4) Open Reduction and Percutaneous Pinning of the left fibula (27726 is the closest I can relate with however I think these are more for fractures than osteotomy nonunion?)
Technique
Previous lateral incision was utilized. This was carried through skin and subcutaneous tissues. Superficial peroneal nerve was protected throughout the procedure. Dissection was carried down to the level of the lateral plate. A superficial fluid culture was taken at the level of the distal fibular plate. This was removed with the appropriate screwdriver and a key elevator. Fibular osteotomy site was identified. There was noted to be malunion at the osteotomy site without any evidence of healing. The fibula was reflected posteriorly. This gave us access to the tibiotalar joint. A deep fluid culture was taken at this level. Tibial and talar components were identified and easily removed with a rongeur. There was no evidence of bony ingrowth to either component. Polyethylene was removed with the tibial component.
At this time a tissue culture as well as a bone culture of both the tibial and talar surfaces was sent to pathology. All cultures were sent for Gram stain, aerobic, anaerobic, fungal, acid-fast. There was no frank pus identified throughout the ankle but there was an abnormal amount of synovial fluid within the joint space. After all cultures had been gathered, 2g of Ancef was given IV.
We then made a medial incision at the talonavicular joint. Previous incision was used. Dissection was carried down to the level of the talonavicular joint. Staple and screw across this joint were identified and removed appropriately.
Finally a small incision was made at the posterior aspect of the heel. The 2 screws across the subtalar joint were cannulated with a K wire and removed with the appropriate screwdriver.
We then returned to the lateral aspect of the ankle. Extensive debridement was carried out at the tibiotalar joint surface with a rongeur and curettes. There was noted to be some healing at the posterior facet of the subtalar joint arthrodesis site. Synovial tissue was removed from the sinus tarsi area. The patient was noted to have a brownish coloration to both entire talar dome and tibial joint surface.
After appropriate debridement had taken place, the wounds were thoroughly irrigated with 2L of normal saline. Next, gentamicin antibiotic cement was mixed with 1g of vancomycin powder. Antibiotic spacer was then placed across the tibiotalar joint surface. This was allowed to harden. Decision was made to percutaneously pin the fibula for some stability. A large threaded Steinmann pin was placed retrograde across the distal fibula and into the proximal segment. Final x-rays were taken which confirmed removal of all hardware and placement of antibiotic cement spacer as well as threaded Steinmann pin.
Wounds were once again irrigated with normal saline. Deep tissues were closed with 0 PDS suture. Subcutaneous tissues closed with 3-0 Monocryl suture. Skin reapproximated with 3-0 nylon suture throughout. Wounds were then dressed with Xeroform, 4 x 4, ABD, Sof-Rol, and a well-padded posterior plaster splint was applied. Tourniquet was let down at approximately 115 minutes.
2nd Operation
1) Left tibiotalar arthrodesis (29899?)
2) Left subtalar arthrodesis (28725)
3) Insertion of custom talus cage (?)
4) Local autograft harvest from the calcaneus, fibula and tibia (20902?)
5) PDGF allograft augmentation (unlisted and compare to spine code 20931?)
I will post the details from this second procedure in a separate post.
This patient underwent a left total ankle arthroplasty with attempted hindfoot arthrodesis by another surgeon. X-rays showed evidence of an existing total ankle arthroplasty with fibular osteotomy and attempted double hindfoot arthrodesis. There was no apparent healing across any of the arthrodesis sites nor the osteotomy site. There was significant subsidence and loosening of the implant with osteolysis surrounding both the tibial and talar components. Given elevated CRP, clinical findings and x-ray evidence of osteolysis and loosening surrounding components, a staged procedure was recommended including removal of all hardware, explant of total ankle arthroplasty, irrigation and debridement, placement of antibiotic cement spacer with bone biopsy.
Postoperative Diagnosis
1) Left total ankle subsidence and loosening (T84.038A for loosening)
2) Left subtalar, talonavicular arthrodesis nonunion (M96.0 for Pseudoarthrosis after fusion or arthrodesis?)
3) Left fibular osteotomy nonunion (included with M96.0?)
1st Operation
1) Left total ankle arthroplasty explant with antibiotic spacer placement (27704 but unable to find a placement code that can be billed with this code)
2) Left ankle irrigation and debridement to the level of bone (11044)
3) Removal of hardware from left subtalar, talonavicular and fibula (included in 27704?)
4) Open Reduction and Percutaneous Pinning of the left fibula (27726 is the closest I can relate with however I think these are more for fractures than osteotomy nonunion?)
Technique
Previous lateral incision was utilized. This was carried through skin and subcutaneous tissues. Superficial peroneal nerve was protected throughout the procedure. Dissection was carried down to the level of the lateral plate. A superficial fluid culture was taken at the level of the distal fibular plate. This was removed with the appropriate screwdriver and a key elevator. Fibular osteotomy site was identified. There was noted to be malunion at the osteotomy site without any evidence of healing. The fibula was reflected posteriorly. This gave us access to the tibiotalar joint. A deep fluid culture was taken at this level. Tibial and talar components were identified and easily removed with a rongeur. There was no evidence of bony ingrowth to either component. Polyethylene was removed with the tibial component.
At this time a tissue culture as well as a bone culture of both the tibial and talar surfaces was sent to pathology. All cultures were sent for Gram stain, aerobic, anaerobic, fungal, acid-fast. There was no frank pus identified throughout the ankle but there was an abnormal amount of synovial fluid within the joint space. After all cultures had been gathered, 2g of Ancef was given IV.
We then made a medial incision at the talonavicular joint. Previous incision was used. Dissection was carried down to the level of the talonavicular joint. Staple and screw across this joint were identified and removed appropriately.
Finally a small incision was made at the posterior aspect of the heel. The 2 screws across the subtalar joint were cannulated with a K wire and removed with the appropriate screwdriver.
We then returned to the lateral aspect of the ankle. Extensive debridement was carried out at the tibiotalar joint surface with a rongeur and curettes. There was noted to be some healing at the posterior facet of the subtalar joint arthrodesis site. Synovial tissue was removed from the sinus tarsi area. The patient was noted to have a brownish coloration to both entire talar dome and tibial joint surface.
After appropriate debridement had taken place, the wounds were thoroughly irrigated with 2L of normal saline. Next, gentamicin antibiotic cement was mixed with 1g of vancomycin powder. Antibiotic spacer was then placed across the tibiotalar joint surface. This was allowed to harden. Decision was made to percutaneously pin the fibula for some stability. A large threaded Steinmann pin was placed retrograde across the distal fibula and into the proximal segment. Final x-rays were taken which confirmed removal of all hardware and placement of antibiotic cement spacer as well as threaded Steinmann pin.
Wounds were once again irrigated with normal saline. Deep tissues were closed with 0 PDS suture. Subcutaneous tissues closed with 3-0 Monocryl suture. Skin reapproximated with 3-0 nylon suture throughout. Wounds were then dressed with Xeroform, 4 x 4, ABD, Sof-Rol, and a well-padded posterior plaster splint was applied. Tourniquet was let down at approximately 115 minutes.
2nd Operation
1) Left tibiotalar arthrodesis (29899?)
2) Left subtalar arthrodesis (28725)
3) Insertion of custom talus cage (?)
4) Local autograft harvest from the calcaneus, fibula and tibia (20902?)
5) PDGF allograft augmentation (unlisted and compare to spine code 20931?)
I will post the details from this second procedure in a separate post.
Nothing like trial by fire! If you can laminate a foot and ankle anatomical picture blown up or have copies of some foot and ankle anatomical diagrams, that will really help you. You can use it to mark the areas being worked on in most cases to help. Outlining, highlighting and underlining the op note can help. You will need to read and understand NCCI edits (if the payer follows), anatomy, and I would highly recommend a foot and ankle coding companion, CPT Assistant and/or course or book from AAOS/Zupko. The AAOS Global Surgical Data books as well so you can understand what is included or not in a code. AHA coding clinic may also help sometimes.