jhaleycoder
Networker
Hi Everyone-
I wanted to get a second opinion in my coding below. I coded 27488, 20245, 27324. The provider is questioning if I can bill CPT 27360 for the tibia and femur. The op note is below. Any feedback would be great!
The patient was seen in the preoperative holding area. Consent was obtained and operative site was marked. The patient was brought back to the operating room and placed supine on the operating table. Patient was given appropriate anesthesia as well as preoperative antibiotics and TXA. A tourniquet was applied and the patient was prepped and draped in normal sterile manner. A timeout was performed confirming patient, laterality, and procedure.
The leg was elevated for 3 minutes and the tourniquet was inflated to 300 mmHg. The previous incision was marked. Skin incision was made with a 10 blade and the previous incision was excised including skin and subcutaneous fat. Small medial and lateral flaps were raised. The previous arthrotomy site was identified and a medial parapatellar arthrotomy was performed. A complete synovectomy and debridement of skin, subcutaneous fat, fascia, muscle, scar tissue, and nonviable tissue was performed. Cultures were taken and sent to the lab including medial gutter, lateral gutter, suprapatellar, infrapatellar, notch. After a thorough debridement, the polyethylene insert was removed with the aid of an osteotome and a mallet. Attention was then turned to the femur. The femur was able to be removed with the aid of a reciprocating saw as well as a flexible osteotome with minimal bone loss. Attention was then turned back to the tibia. The tibia was able to be removed again with the aid of a reciprocating saw and a flexible osteotome also with minimal bone loss. Attention was then turned to the patella which was removed with the aid of an oscillating saw as well as a drill bit to remove the pegs and cement. All nonviable fascia, scar tissue, and bone were thoroughly debrided and sharply excised. At this point the knee was copiously irrigated with 3 L of normal saline.
Attention was then turned to the intramedullary canals of both the femur and the tibia. A guidewire was placed up the femur and using the Synthes RIA system the femur was saucerized. Fluoroscopic images confirmed intramedullary placement. The guidewire was then transferred to the tibia and the Synthes RIA system was used to thoroughly debride the intramedullary canal of the tibia. Again, fluoroscopic images confirmed intramedullary placement. Bone cultures of both the intramedullary canal of the femur and tibia were sent to the lab for culture. The knee was then irrigated with a dilute Betadine solution that was let to sit for 3 minutes. The knee was then irrigated again with 3 L of normal saline. Following this the knee was irrigated with Irrisept which was let to sit for 3 minutes.
At this point all remaining tissues appeared healthy. A trial tibia was then placed and the proximal tibia was prepared. A trial femur was placed and the lug holes as well as box cut were made. The knee was taken through range of motion and found to be stable. Fluoroscopic images were obtained at this point which showed appropriate alignment. 20 cc of Stimulan was mixed on the back table with 2 g of vancomycin and 2.4 g of tobramycin. This was then injected into the intramedullary canals of both the femur and the tibia. Antibiotic cement was then prepared on the back table with 2 bags total of cement mixed with 6 g of vancomycin and 7.2 g of tobramycin. The bone was prepared for cementation and the femur and all poly tibia were cemented in place. Two screws were then placed through the all polyethylene tibia after predrilling and countersinking. Fluoroscopic images showed appropriate implant placement and appropriate alignment. After the cement had cured the knee was taken through a range of motion and found to be completely stable with a full ROM. The tourniquet was let down and hemostasis was achieved
The knee was irrigated once more with normal saline followed by Irrisept. The knee was then closed in layers with #1 PDS strata fix reinforced with #1 PDS for the arthrotomy, 0–PDS and 2-0 PDS for deeper tissues, and staples for skin. An incisional VAC was applied as well as a sterile dressings and a knee immobilizer. The patient was then awakened and transported to the PACU in stable condition
I wanted to get a second opinion in my coding below. I coded 27488, 20245, 27324. The provider is questioning if I can bill CPT 27360 for the tibia and femur. The op note is below. Any feedback would be great!
The patient was seen in the preoperative holding area. Consent was obtained and operative site was marked. The patient was brought back to the operating room and placed supine on the operating table. Patient was given appropriate anesthesia as well as preoperative antibiotics and TXA. A tourniquet was applied and the patient was prepped and draped in normal sterile manner. A timeout was performed confirming patient, laterality, and procedure.
The leg was elevated for 3 minutes and the tourniquet was inflated to 300 mmHg. The previous incision was marked. Skin incision was made with a 10 blade and the previous incision was excised including skin and subcutaneous fat. Small medial and lateral flaps were raised. The previous arthrotomy site was identified and a medial parapatellar arthrotomy was performed. A complete synovectomy and debridement of skin, subcutaneous fat, fascia, muscle, scar tissue, and nonviable tissue was performed. Cultures were taken and sent to the lab including medial gutter, lateral gutter, suprapatellar, infrapatellar, notch. After a thorough debridement, the polyethylene insert was removed with the aid of an osteotome and a mallet. Attention was then turned to the femur. The femur was able to be removed with the aid of a reciprocating saw as well as a flexible osteotome with minimal bone loss. Attention was then turned back to the tibia. The tibia was able to be removed again with the aid of a reciprocating saw and a flexible osteotome also with minimal bone loss. Attention was then turned to the patella which was removed with the aid of an oscillating saw as well as a drill bit to remove the pegs and cement. All nonviable fascia, scar tissue, and bone were thoroughly debrided and sharply excised. At this point the knee was copiously irrigated with 3 L of normal saline.
Attention was then turned to the intramedullary canals of both the femur and the tibia. A guidewire was placed up the femur and using the Synthes RIA system the femur was saucerized. Fluoroscopic images confirmed intramedullary placement. The guidewire was then transferred to the tibia and the Synthes RIA system was used to thoroughly debride the intramedullary canal of the tibia. Again, fluoroscopic images confirmed intramedullary placement. Bone cultures of both the intramedullary canal of the femur and tibia were sent to the lab for culture. The knee was then irrigated with a dilute Betadine solution that was let to sit for 3 minutes. The knee was then irrigated again with 3 L of normal saline. Following this the knee was irrigated with Irrisept which was let to sit for 3 minutes.
At this point all remaining tissues appeared healthy. A trial tibia was then placed and the proximal tibia was prepared. A trial femur was placed and the lug holes as well as box cut were made. The knee was taken through range of motion and found to be stable. Fluoroscopic images were obtained at this point which showed appropriate alignment. 20 cc of Stimulan was mixed on the back table with 2 g of vancomycin and 2.4 g of tobramycin. This was then injected into the intramedullary canals of both the femur and the tibia. Antibiotic cement was then prepared on the back table with 2 bags total of cement mixed with 6 g of vancomycin and 7.2 g of tobramycin. The bone was prepared for cementation and the femur and all poly tibia were cemented in place. Two screws were then placed through the all polyethylene tibia after predrilling and countersinking. Fluoroscopic images showed appropriate implant placement and appropriate alignment. After the cement had cured the knee was taken through a range of motion and found to be completely stable with a full ROM. The tourniquet was let down and hemostasis was achieved
The knee was irrigated once more with normal saline followed by Irrisept. The knee was then closed in layers with #1 PDS strata fix reinforced with #1 PDS for the arthrotomy, 0–PDS and 2-0 PDS for deeper tissues, and staples for skin. An incisional VAC was applied as well as a sterile dressings and a knee immobilizer. The patient was then awakened and transported to the PACU in stable condition