peporter
Guru
I need help coding the following op note. I cannot find the correct arthroscopic code for this hip surgery. I appreciate any helpful suggestions. Thanks, Paula
1. Right hip arthroscopy with tenotomy of the iliotibial band.
2. Right hip arthroscopy with bursectomy and extensive debridement.
3. Vitagel soft tissue autograft insertion right hip wound, 20926.
PROCEDURE
Patient was seen in preoperative holding by the department of
orthopedics and anesthesia which time she identified the right lower
extremity as the appropriate extremity for procedure. I placed my
initials on the extremity for identification. She was given IV
antibiotics preoperatively for prophylaxis. Taken back to the OR suite
and placed supine on a well-padded OR table. Placed under general
anesthesia without complication. She was then placed in the lateral
decubitus position with the right side up. This was held with an Inamed
positioner. Axillary roll was placed underneath the left axilla. The
right lower chart was sterilely prepared and draped in normal fashion.
The greater trochanter was palpated. One incision was made 4 cm distal
and slightly posterior to the greater trochanter. Small incision was
made in the skin and then a blunt trocar and cannula was placed
underneath on top of the iliotibial band. The arthroscope was inserted.
I could view the iliotibial band over the greater tuberosity. A
separate portal was created 4 cm above and slightly anterior the greater
tuberosity with a scalpel through skin. Shaver was placed in here. The
fat and soft tissue were removed over the iliotibial band. A thermal
wand was placed in the superior portal and a tenotomy was created the
iliotibial band over the greater tuberosity. This revealed the bursa
underneath the iliotibial band on top of the greater tuberosity. This
was extensively debrided and removed with a shaver. The hip was moved
and the greater trochanter could be seen very nicely. The bursa was
removed very completely. Once this completed, instruments were
withdrawn. Vitagel soft tissue autograft processed from the patient's
blood for postop hemostasis and potential healing was injected deeply.
Portals were closed with suture. Local anesthetic was injected.
Sterile dressing was applied. The patient was then turned supine, awoke
from anesthesia without complication and transferred to the
post-anesthesia care unit in stable condition.
1. Right hip arthroscopy with tenotomy of the iliotibial band.
2. Right hip arthroscopy with bursectomy and extensive debridement.
3. Vitagel soft tissue autograft insertion right hip wound, 20926.
PROCEDURE
Patient was seen in preoperative holding by the department of
orthopedics and anesthesia which time she identified the right lower
extremity as the appropriate extremity for procedure. I placed my
initials on the extremity for identification. She was given IV
antibiotics preoperatively for prophylaxis. Taken back to the OR suite
and placed supine on a well-padded OR table. Placed under general
anesthesia without complication. She was then placed in the lateral
decubitus position with the right side up. This was held with an Inamed
positioner. Axillary roll was placed underneath the left axilla. The
right lower chart was sterilely prepared and draped in normal fashion.
The greater trochanter was palpated. One incision was made 4 cm distal
and slightly posterior to the greater trochanter. Small incision was
made in the skin and then a blunt trocar and cannula was placed
underneath on top of the iliotibial band. The arthroscope was inserted.
I could view the iliotibial band over the greater tuberosity. A
separate portal was created 4 cm above and slightly anterior the greater
tuberosity with a scalpel through skin. Shaver was placed in here. The
fat and soft tissue were removed over the iliotibial band. A thermal
wand was placed in the superior portal and a tenotomy was created the
iliotibial band over the greater tuberosity. This revealed the bursa
underneath the iliotibial band on top of the greater tuberosity. This
was extensively debrided and removed with a shaver. The hip was moved
and the greater trochanter could be seen very nicely. The bursa was
removed very completely. Once this completed, instruments were
withdrawn. Vitagel soft tissue autograft processed from the patient's
blood for postop hemostasis and potential healing was injected deeply.
Portals were closed with suture. Local anesthetic was injected.
Sterile dressing was applied. The patient was then turned supine, awoke
from anesthesia without complication and transferred to the
post-anesthesia care unit in stable condition.
I'd use 29862 and the graft code, along with 29999 for the tenotomy.