tsullivan22
New
Hello all, my boss and I are having a hard time coming up with a correct CPT code for this procedure, when we receive a work sheet to obtain prior auth this is the description of the procedure that we get- Knee arthroscopy open MPFL allograft reconstruction, chondroplasty VS. mircofx. When we got the OP report back our 3rd party coding company coded it as 27420 which explains the patella portion, they are stating that the open MPFL doesn't apply as it wasn't done. We have done many of these in the past but never had this situation come up. We are wondering based off the operative report how everyone else would code this before we go talk to the dr about the OP report. thank you for the input!
PRE-OPERATIVE DIAGNOSIS: Left knee recurrent patellar instability status post prior proximal realignment procedure with patellofemoral chondral damage.
POST-OPERATIVE DIAGNOSES: Left knee recurrent patellar instability status post prior proximal realignment procedure with patellofemoral chondral damage, with additional findings of small tear of the posterior root of the lateral meniscus, grade 4 chondral defect of the lateral trochlear groove, grade 2 chondral wear on the patella, residual foreign body, i.e., suture material in the joint, and adhesions.
PROCEDURE PERFORMED: Left knee arthroscopic extensive debridement including lysis of adhesions, patellar chondroplasty, removal of foreign body, patellofemoral microfracture for lateral trochlear groove, and partial lateral meniscectomy followed by an arthroscopic-assisted mini open MPFL reconstruction revision with autograft hamstring tissue; 22 modifier for the revision.
IMPLANTS: 1.8 Q-Fix, Smith & Nephew 6 x 25 BIOSURE soft tissue interference screw, Beath pin, nitinol wire.
COMPLICATIONS: None.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS: Candance has gone on to have severe recurrent patellar instability after failed prior proximal realignment with medial reefing and lateral release. She also has a lot of grinding, popping and swelling. Surgery is indicated to restore stability and treat torn cartilage after failure of nonoperative measures.
FINDINGS & PROCEDURE: Patient is taken to the operating room and placed supine on the operating table. An adductor canal block is placed by the anesthesiologist. General anesthesia is induced. Antibiotics are administered IV. Left lower extremity is prepped and draped in usual sterile fashion for knee surgery. Exam under anesthesia confirms a ligamentously stable knee with a dislocatable patella. The patella tilts well past neutral consistent with prior lateral release. She has an obvious J-sign and a clunk as the patella enters the trochlear groove with flexion. Standard arthroscopic portals are created. Blunt trocar and arthroscopic cannula are used to enter the joint. Lactated Ringer is infused by pump through the scope sheath. A superomedial Veress needle is placed for outflow. A probe is introduced. Complete diagnostic arthroscopy is performed. Suprapatellar pouch has adhesions and old suture material consistent with prior reefing. These are debrided. The patella sits in a grossly laterally subluxed position. She has grade 2 malacia in various areas on the patella. No fissures or flaps down to bone. The trochlear groove has a grade 4 chondral defect with delaminating cartilage at the superolateral aspect of the trochlea. Tracking reveals that the patella does not center at 30, 60 or even 90 degrees of flexion, hangs over laterally. The notch has normal ACL and PCL. The medial compartment is normal other than mild fibrillation and softening of the cartilage. Lateral compartment has some grade 2 change on the tibial plateau on the spine and upslope. The posterior root of the lateral meniscus has a small shredded tear; this is debrided. The root is stable. Loss of meniscal volume is less than 5%. The remainder of the meniscus is normal. Remainder of the cartilage surfaces are normal. Next, unstable cartilage is removed with a shaver, and the grade 4 chondral defect on the trochlea. A ring curette is used to resect delaminating cartilage at the margin until a nice stable defect is obtained. The sclerotic bone in the base of this defect is then lightly burred with the shaver in burr mode, taking care not to fully decorticate this. A 45-degree microfracture awl is then used to perforate subchondral plate at regular 3 mm intervals to allow extravasation of fat and marrow elements to form a healing regenerated cartilage. Arthroscopic equipment is then withdrawn, saved for later use. Limb is exsanguinated with an Esmarch bandage. Tourniquet is inflated to 250 mmHg. A 1 inch longitudinal incision is made over the pes insertion and carried down through the skin and subcutaneous tissue to the sartorial fascia. Sartorial fascia is incised. The underlying gracilis and semitendinosus are identified. The gracilis is harvested. A tag stitch is placed in the free end. This is freed up from interconnected tissue and then harvested with a tendon stripper at the muscle-tendon junction. This is taken to the back table, prepared by my assistant while I proceeded with ongoing preparation. Graft preparation consists of stripping muscle from the muscle-tendon junction occurring on each side with a Krackow-style whipstitch 3 or 4 cm _____ [TIME: 04:31] tendon. The midline is marked. It is placed on a Graftmaster and a vancomycin-laden moist saline sponge awaiting later use. Next, a 2 to 3 cm incision is made along the superomedial aspect of the patella. Dissection is carried down through skin and scar tissue to the medial aspect of the superior half of the patella. Electrocautery is used dissect directly down to the medial edge from the superomedial corner to the midportion. A small anterior flap is elevated and a rongeur is used to create a small trough. 1.8 Q-Fix are placed at the superomedial corner and the midportion of the patella, taking care to avoid articular penetration. Good purchase is obtained. Dissection is then carried beneath the medial retinaculum outside of the joint over to the anatomic femoral insertion point of the MPFL. Due to scar tissue and prior surgery, some articular penetration occurs through the capsule. Next, the knee is brought into a figure-of-four position and the C-arm is used to obtain a perfect lateral view of the knee. The Schottle point is identified and a 1 inch incision is made directly over the anatomic insertion of the MPFL, carried down through the skin and subcutaneous tissue to the deep fascia. The fascia is incised in line with the surgical incision and the underlying bony insertion site is identified. A Beath pin is used to localize the exact Schottle point. To determine this point, the pin is advanced in a superolateral and anterior direction to exit through the cortex of the femur on the far side. The sutures from the anchors at the patella are then passed beneath the retinaculum, wrapped around the pin. Patella is manually centered in the groove and the sutures are clamped. Knee stability and patellar tracking are assessed and nice restoration of stability is achieved, confirming that this would be an ideal placement for the femoral tunnel. There is about 1 mm of loosening in terminal flexion which is physiometric. A 6 mm tunnel is created next over the Beath pin, stopping short of the far-cortex. The loose bony debris is lavaged and the edges of the tunnel are cleaned up. Next, the graft is brought onto the field and sutured with the previously placed sutures down onto the trough on the patella. A passing loop is used to pass this beneath the retinaculum of the femoral tunnel, a nitinol wire is placed, and the sutures are placed in the Beath attachment of the pin, which is used to pull the pin through laterally, and the graft is dunked down into the tunnel. The patella is manually centered in the groove at about 40 degrees of flexion and the suture is tensioned roughly 2 N of force. Care is taken to avoid overtensioning, particularly given the prior lateral release, to avoid over-correcting the position of the cap. A Smith & Nephew 6 x 25 BIOSURE soft tissue interference screw is advanced over the nitinol wire and bent all the way down. The tracking of the patella is checked and is found to be ideal. The arthroscopic appearance is assessed, and the patella centers nicely in the groove at 30 degrees of flexion. Tensioning of the graft was ideal and the patella is not over-corrected or brought too far medially. The patella is held in position while the screw is advanced down, so this is below or flush with the cortex to avoid hardware prominence. Tracking and mobility are assessed again, and then the arthroscopic equipment is withdrawn. The fascia is closed with 0 Vicryl. Tourniquet is deflated. Hemostasis is assured. Dermis is closed with 3-0 Vicryl, skin with 4-0 Monocryl, as are the portals. Xeroform is applied followed by dry sterile dressing, compression wrap and a rehab brace, set 0 to 90, locked in extension. Patient is taken to the recovery room in stable condition having tolerated the procedure well.
Plan postoperatively is going to be MPFL plus patellofemoral microfracture rehab protocol.
An assistant was needed throughout this surgical case for manipulation and positioning the surgical site, as well as positioning the surgical instruments. During the surgical case, the surgical tech was working the back table and was not available for assistance.
PRE-OPERATIVE DIAGNOSIS: Left knee recurrent patellar instability status post prior proximal realignment procedure with patellofemoral chondral damage.
POST-OPERATIVE DIAGNOSES: Left knee recurrent patellar instability status post prior proximal realignment procedure with patellofemoral chondral damage, with additional findings of small tear of the posterior root of the lateral meniscus, grade 4 chondral defect of the lateral trochlear groove, grade 2 chondral wear on the patella, residual foreign body, i.e., suture material in the joint, and adhesions.
PROCEDURE PERFORMED: Left knee arthroscopic extensive debridement including lysis of adhesions, patellar chondroplasty, removal of foreign body, patellofemoral microfracture for lateral trochlear groove, and partial lateral meniscectomy followed by an arthroscopic-assisted mini open MPFL reconstruction revision with autograft hamstring tissue; 22 modifier for the revision.
IMPLANTS: 1.8 Q-Fix, Smith & Nephew 6 x 25 BIOSURE soft tissue interference screw, Beath pin, nitinol wire.
COMPLICATIONS: None.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS: Candance has gone on to have severe recurrent patellar instability after failed prior proximal realignment with medial reefing and lateral release. She also has a lot of grinding, popping and swelling. Surgery is indicated to restore stability and treat torn cartilage after failure of nonoperative measures.
FINDINGS & PROCEDURE: Patient is taken to the operating room and placed supine on the operating table. An adductor canal block is placed by the anesthesiologist. General anesthesia is induced. Antibiotics are administered IV. Left lower extremity is prepped and draped in usual sterile fashion for knee surgery. Exam under anesthesia confirms a ligamentously stable knee with a dislocatable patella. The patella tilts well past neutral consistent with prior lateral release. She has an obvious J-sign and a clunk as the patella enters the trochlear groove with flexion. Standard arthroscopic portals are created. Blunt trocar and arthroscopic cannula are used to enter the joint. Lactated Ringer is infused by pump through the scope sheath. A superomedial Veress needle is placed for outflow. A probe is introduced. Complete diagnostic arthroscopy is performed. Suprapatellar pouch has adhesions and old suture material consistent with prior reefing. These are debrided. The patella sits in a grossly laterally subluxed position. She has grade 2 malacia in various areas on the patella. No fissures or flaps down to bone. The trochlear groove has a grade 4 chondral defect with delaminating cartilage at the superolateral aspect of the trochlea. Tracking reveals that the patella does not center at 30, 60 or even 90 degrees of flexion, hangs over laterally. The notch has normal ACL and PCL. The medial compartment is normal other than mild fibrillation and softening of the cartilage. Lateral compartment has some grade 2 change on the tibial plateau on the spine and upslope. The posterior root of the lateral meniscus has a small shredded tear; this is debrided. The root is stable. Loss of meniscal volume is less than 5%. The remainder of the meniscus is normal. Remainder of the cartilage surfaces are normal. Next, unstable cartilage is removed with a shaver, and the grade 4 chondral defect on the trochlea. A ring curette is used to resect delaminating cartilage at the margin until a nice stable defect is obtained. The sclerotic bone in the base of this defect is then lightly burred with the shaver in burr mode, taking care not to fully decorticate this. A 45-degree microfracture awl is then used to perforate subchondral plate at regular 3 mm intervals to allow extravasation of fat and marrow elements to form a healing regenerated cartilage. Arthroscopic equipment is then withdrawn, saved for later use. Limb is exsanguinated with an Esmarch bandage. Tourniquet is inflated to 250 mmHg. A 1 inch longitudinal incision is made over the pes insertion and carried down through the skin and subcutaneous tissue to the sartorial fascia. Sartorial fascia is incised. The underlying gracilis and semitendinosus are identified. The gracilis is harvested. A tag stitch is placed in the free end. This is freed up from interconnected tissue and then harvested with a tendon stripper at the muscle-tendon junction. This is taken to the back table, prepared by my assistant while I proceeded with ongoing preparation. Graft preparation consists of stripping muscle from the muscle-tendon junction occurring on each side with a Krackow-style whipstitch 3 or 4 cm _____ [TIME: 04:31] tendon. The midline is marked. It is placed on a Graftmaster and a vancomycin-laden moist saline sponge awaiting later use. Next, a 2 to 3 cm incision is made along the superomedial aspect of the patella. Dissection is carried down through skin and scar tissue to the medial aspect of the superior half of the patella. Electrocautery is used dissect directly down to the medial edge from the superomedial corner to the midportion. A small anterior flap is elevated and a rongeur is used to create a small trough. 1.8 Q-Fix are placed at the superomedial corner and the midportion of the patella, taking care to avoid articular penetration. Good purchase is obtained. Dissection is then carried beneath the medial retinaculum outside of the joint over to the anatomic femoral insertion point of the MPFL. Due to scar tissue and prior surgery, some articular penetration occurs through the capsule. Next, the knee is brought into a figure-of-four position and the C-arm is used to obtain a perfect lateral view of the knee. The Schottle point is identified and a 1 inch incision is made directly over the anatomic insertion of the MPFL, carried down through the skin and subcutaneous tissue to the deep fascia. The fascia is incised in line with the surgical incision and the underlying bony insertion site is identified. A Beath pin is used to localize the exact Schottle point. To determine this point, the pin is advanced in a superolateral and anterior direction to exit through the cortex of the femur on the far side. The sutures from the anchors at the patella are then passed beneath the retinaculum, wrapped around the pin. Patella is manually centered in the groove and the sutures are clamped. Knee stability and patellar tracking are assessed and nice restoration of stability is achieved, confirming that this would be an ideal placement for the femoral tunnel. There is about 1 mm of loosening in terminal flexion which is physiometric. A 6 mm tunnel is created next over the Beath pin, stopping short of the far-cortex. The loose bony debris is lavaged and the edges of the tunnel are cleaned up. Next, the graft is brought onto the field and sutured with the previously placed sutures down onto the trough on the patella. A passing loop is used to pass this beneath the retinaculum of the femoral tunnel, a nitinol wire is placed, and the sutures are placed in the Beath attachment of the pin, which is used to pull the pin through laterally, and the graft is dunked down into the tunnel. The patella is manually centered in the groove at about 40 degrees of flexion and the suture is tensioned roughly 2 N of force. Care is taken to avoid overtensioning, particularly given the prior lateral release, to avoid over-correcting the position of the cap. A Smith & Nephew 6 x 25 BIOSURE soft tissue interference screw is advanced over the nitinol wire and bent all the way down. The tracking of the patella is checked and is found to be ideal. The arthroscopic appearance is assessed, and the patella centers nicely in the groove at 30 degrees of flexion. Tensioning of the graft was ideal and the patella is not over-corrected or brought too far medially. The patella is held in position while the screw is advanced down, so this is below or flush with the cortex to avoid hardware prominence. Tracking and mobility are assessed again, and then the arthroscopic equipment is withdrawn. The fascia is closed with 0 Vicryl. Tourniquet is deflated. Hemostasis is assured. Dermis is closed with 3-0 Vicryl, skin with 4-0 Monocryl, as are the portals. Xeroform is applied followed by dry sterile dressing, compression wrap and a rehab brace, set 0 to 90, locked in extension. Patient is taken to the recovery room in stable condition having tolerated the procedure well.
Plan postoperatively is going to be MPFL plus patellofemoral microfracture rehab protocol.
An assistant was needed throughout this surgical case for manipulation and positioning the surgical site, as well as positioning the surgical instruments. During the surgical case, the surgical tech was working the back table and was not available for assistance.