Wiki 'failed healing' quad tendon s/p total knee

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debatortho

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"opened up the middle of the incision centered over the superior pole of the patella and dissection carried down to the extensor mechanism. There was significant scarring between the subcu fat and the quad which we freed up using scissors bluntly. After the lysis of adhesions we were able to evaluate the quad tendon. It looked good except for 1 small area about 2-1/2 cm in length just superior to the patella. The sutures were intact. We oversewed this area with running #2 Vicryl. " wound closed, etc.

My question is whether I should bill as a quad tendon repair, which was minimal, or more of a wound dehiscence, 13160 (extensive). I verified the quad tendon was initially repaired following the total knee replacement 4 weeks prior. Any input would be appreciated.
 
Did they go in due to arthrofibrosis following TKA and do a MUA too w/lysis? I don't really think that brief and minimal oversew would call for a quad tendon repair. If the intent was the MUA/lysis I might just go w/ that. Would he have gone back in only due to the quad tendon? Was that sort of incidental to going back in for the lysis?
 
The surgery was actually scheduled as a quad tendon repair, and the lysis was just in the area to get down to the quad tendon. Another reason why I'm struggling with coding this one.
 
Can you redact the op note and post the whole thing, or was the rest just noise and this was really it? Was the external wound disrupted/infected at all? Was that what the diagnosis was stated as, "failed healing"?

Seems the thinking and intent for the case was they thought they were going to do quad or extensor mechanism repair?

My issue is the statement that the quad tendon looked good and the sutures were intact. It would be better if this part, "except for 1 small area about 2-1/2 cm in length just superior to the patella" was described more and elaborated on. What was wrong with that area, what was seen, etc.? Why did he oversew it? I would almost want to send it back for a query and ask for more info/addendum. Otherwise, it seems really hard to code quad repair at all. The report is sort of contradictory. 13160 does not seem right either with what I am reading. Maybe if there was info that the wound was disrupted or open. 13160 v. 12020 or possible quad repair w/ 52? This one's weird. Also couldn't do 27310 since no arthrotomy, but it's more like this was just an exploration. Not infected (that I can see stated) so can't do 10180 either. Conundrum.
 
That is the meat of the op note. He does state 'a gentle manipulation' to get him to full extension, flexion good. Then the irrigation, placement of 1 g TXA and then wound closure. The Preop diagnosis is failure of healing quadriceps tendon s/p total knee. Post Op: arthrofibrosis w/subcu scarring, small area of failure of healing quad tendon approx 2-1/2 cm proximal to patella. Procedures listed: exploration, repair quad tendon and open lysis of adhesions.

So yes, no arthrotomy, no infection noted, external wound intact. The lysis of adhesions is fairly minimal since it's just the area around the incision, but I'm wondering if that is the direction to go. A mini-open, but still an open. Since there is no code for this, I would probably have to do an unlisted. With 13160 I would have added mod 52, but even that seems a huge stretch for services performed.
 
Ugh.
I might be inclined to either do the MUA or your idea. You may have to go the unlisted route. :( At least you have arthrofibrosis dx to support. It's just so minimal I don't think the quad repair would fly. I agree, it's not 13160.
 
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