mfranks
Contributor
I have a surgeon that is telling me that I should have added the modifier 22 to this claim. Please see the below report and let me know if you would have added it. I don't see anything that would support it.
Codes billed were 29888, 29880, 20924, 20900
The patient was brought to the operating room and placed on the operating table in supine position. Following satisfaction induction using intravenous and inhalation anesthesia, the patient was maintained with an LMA airway. The patient was given a test dose of Ancef and no reaction was noted. 1 gram of Ancef was given for perioperative prophylactic antibiotic IV.
After a good level of anesthesia was noted, we examined the knee. The patient had a subtle pivot shift. There was a 3 mm Lachman. There was a click which was reproducible with the knee in full extension into 60� of flexion, palpated posterolaterally. No posterolateral or other instability was noted. No posterior drawer was noted. No instability with varus or valgus stressing in either full extension or 20� of flexion. This was compared to the uninjured left knee. Because the pivot shift was subtle, we were concerned that she may have sustained a partial tear. Therefore, a diagnostic arthroscopy was initiated.
Routine prepping and draping of the knee was performed and the tourniquet cuff was placed on the right upper thigh. It was not elevated initially. Arthroscopic anatomy was marked. Arthroscopic portals were developed over the inferomedial and inferolateral aspects of the knee anteriorly. We entered the knee from anteromedially. The knee joint was distended using lactated Ringer's solution. No additives to the effluent was used. We evaluated the suprapatellar pouch. There was some reactive hyperemia, but no significant synovitis noted. No loose bodies were noted. The patellofemoral joint was unremarkable. No fissuring or softening of either facet of the patella, medially, laterally, or the trochlea was encountered. The scope was brought down through the lateral recess and no loose bodies were encountered. There was reactive synovitis noted. The scope was then visualized in the lateral compartment. The knee was placed into a figure four position. At the junction between the middle and posterior third of this lateral meniscus there was 4 mm radial tear at the inner surface of this meniscus. It was unstable and probably representing the source of the popping which we noted on preoperative exam. The posterior root was intact. The popliteus was intact. In the anterior horn, although somewhat irritated with synovial reaction. It did not show tearing or instability. We therefore performed a partial meniscectomy of the unstable inner surface of this lateral meniscus. We visualized the intercondylar notch. There were some fibers of the anterolateral ACL which were intact, although stretched, but there was disruption of the posteromedial fibers off of the lateral femoral condyle. The patient also was noted to have a very tight intercondylar notch. PCL was intact. Anterior meniscal-ligament complex was intact. The medial compartment was then visualized. No irregularity of the articular surface of the medial plateau or femoral condyle was noted. There was a prominence of the posterior horn of the medial meniscus with palpation. With a probe, there was a horizontal tear in the mid third of this posterior horn. Again, the posterior root was palpated and no instability was noted. Middle and anterior horns were intact. We therefore performed a partial meniscectomy of this inner unstable horizontal tear and transitioned this back to a normal meniscus using both hand instruments as well as a meniscal resector. We then performed excision of the ACL using Arthrex electric cautery. Because of the narrowing of the intercondylar notch, we also performed a lateral and superior notchplasty using a 5 mm burr. We debrided the footprint of the ACL to visualize its reconstruction attachment proposed.
After this had been accomplished, we then performed harvesting of the bone-patellar tendon-bone central third. A tourniquet was elevated to 270 mmHg pressure after exsanguination of the extremity with an Esmarch. A 9 mm graft consisting of inferior anterior patella, central third of the patellar tendon, and central third tibial tuberosity was accomplished using Arthrex guides, oscillating saw. The total length of this graft harvested was 90 mm.
Bone plugs of 25 mm on both the patella and tibia were harvested. These bone plugs were trimmed so that they fit appropriately through a 9 mm guide without excess tightness. This graft was then set aside after preparing partial and distal bone plugs with FiberWire sutures.
We then made a tibial plateau graft tunnel. First, we drilled with a drill bit over an Arthrex ACL guide set at 55�. This was then over-reamed using a coring reamer of 9 mm. A 60 mm tunnel was obtained. We then used the flag reamers over a beathe pin in the central anatomic footprint of the ACL on the femoral condyle. This was drilled to 25 mm depth. We then passed a pull-out suture between the tibial tunnel and the femoral tunnel. We brought the graft from the tibial tunnel out into the femoral tunnel. Tendon graft was positioned posteriorly. Graft prominence was placed anteriorly and this was held in place using an 8 x 23 mm absorbing Arthrex interference screw. This was placed after tapping of the tunnel with a hand tap. We then placed the knee through a full range of motion and appropriately tensioned the tibial attachment. Two minor adjustments of tensioning of this distal fixation were performed to get good tension without greater than 1 mm of anterior drawer. An 8 x 28 mm absorbable screw was placed into the tibial tunnel after being hand tapped. Arthroscopic visualization showed no impingement. There was no cyclops lesion or scar tissue, anterior or superior to the tibial graft site.
We then split the cord tibial cancellous bone graft into 2 pieces. We placed each piece into the patellar as well as the tibial tuberosity harvest sites. These sites were then closed and the periosteum closed over with sutures of 2-0 Vicryl. The periosteum over the proximal and medial tibial tunnel was also closed using interrupted sutures of 2-0 Vicryl. The defect within the patellar tendon was loosely reapproximated using interrupted sutures of 2-0 PDS. Subcutaneous tissues were then closed using interrupted sutures of 3-0 Vicryl. The 2 arthroscopy incisions were also closed using interrupted sutures of 3-0 Vicryl, and the skin edges were reapproximated using a running subcuticular suture of 2-0 Prolene. Tincture of benzoin and Steri-Strips were applied to all wounds. We infiltrated the skin and subcutaneous tissues with 20 cc of 0.5% Marcaine with epinephrine. An additional 10 cc of 0.5% Marcaine with epinephrine was infiltrated into the knee joint itself. Adaptic gauze, sterile dressings were applied. ABDs had been placed with the Kerlix as well as long 6” Ace wraps and the patient was placed into a knee immobilizer. She was sent to the recovery room in stable condition and tolerated the procedure well. Total tourniquet time is less than 94 minutes. No intraoperative transfusions were required. Blood loss is less than 100 cc.
POSTOPERATIVE PLAN: She is written a prescription for Vicodin 7.5/325 mg 1-2 q.6 h. for pain, #40 with 1 refill. Also, 50 mg Vistaril tabs, #30, are written. She is to be foot flat weightbearing with crutches. We will plan to see her back in our office in a week, sooner if increasing problems occur.
Codes billed were 29888, 29880, 20924, 20900
The patient was brought to the operating room and placed on the operating table in supine position. Following satisfaction induction using intravenous and inhalation anesthesia, the patient was maintained with an LMA airway. The patient was given a test dose of Ancef and no reaction was noted. 1 gram of Ancef was given for perioperative prophylactic antibiotic IV.
After a good level of anesthesia was noted, we examined the knee. The patient had a subtle pivot shift. There was a 3 mm Lachman. There was a click which was reproducible with the knee in full extension into 60� of flexion, palpated posterolaterally. No posterolateral or other instability was noted. No posterior drawer was noted. No instability with varus or valgus stressing in either full extension or 20� of flexion. This was compared to the uninjured left knee. Because the pivot shift was subtle, we were concerned that she may have sustained a partial tear. Therefore, a diagnostic arthroscopy was initiated.
Routine prepping and draping of the knee was performed and the tourniquet cuff was placed on the right upper thigh. It was not elevated initially. Arthroscopic anatomy was marked. Arthroscopic portals were developed over the inferomedial and inferolateral aspects of the knee anteriorly. We entered the knee from anteromedially. The knee joint was distended using lactated Ringer's solution. No additives to the effluent was used. We evaluated the suprapatellar pouch. There was some reactive hyperemia, but no significant synovitis noted. No loose bodies were noted. The patellofemoral joint was unremarkable. No fissuring or softening of either facet of the patella, medially, laterally, or the trochlea was encountered. The scope was brought down through the lateral recess and no loose bodies were encountered. There was reactive synovitis noted. The scope was then visualized in the lateral compartment. The knee was placed into a figure four position. At the junction between the middle and posterior third of this lateral meniscus there was 4 mm radial tear at the inner surface of this meniscus. It was unstable and probably representing the source of the popping which we noted on preoperative exam. The posterior root was intact. The popliteus was intact. In the anterior horn, although somewhat irritated with synovial reaction. It did not show tearing or instability. We therefore performed a partial meniscectomy of the unstable inner surface of this lateral meniscus. We visualized the intercondylar notch. There were some fibers of the anterolateral ACL which were intact, although stretched, but there was disruption of the posteromedial fibers off of the lateral femoral condyle. The patient also was noted to have a very tight intercondylar notch. PCL was intact. Anterior meniscal-ligament complex was intact. The medial compartment was then visualized. No irregularity of the articular surface of the medial plateau or femoral condyle was noted. There was a prominence of the posterior horn of the medial meniscus with palpation. With a probe, there was a horizontal tear in the mid third of this posterior horn. Again, the posterior root was palpated and no instability was noted. Middle and anterior horns were intact. We therefore performed a partial meniscectomy of this inner unstable horizontal tear and transitioned this back to a normal meniscus using both hand instruments as well as a meniscal resector. We then performed excision of the ACL using Arthrex electric cautery. Because of the narrowing of the intercondylar notch, we also performed a lateral and superior notchplasty using a 5 mm burr. We debrided the footprint of the ACL to visualize its reconstruction attachment proposed.
After this had been accomplished, we then performed harvesting of the bone-patellar tendon-bone central third. A tourniquet was elevated to 270 mmHg pressure after exsanguination of the extremity with an Esmarch. A 9 mm graft consisting of inferior anterior patella, central third of the patellar tendon, and central third tibial tuberosity was accomplished using Arthrex guides, oscillating saw. The total length of this graft harvested was 90 mm.
Bone plugs of 25 mm on both the patella and tibia were harvested. These bone plugs were trimmed so that they fit appropriately through a 9 mm guide without excess tightness. This graft was then set aside after preparing partial and distal bone plugs with FiberWire sutures.
We then made a tibial plateau graft tunnel. First, we drilled with a drill bit over an Arthrex ACL guide set at 55�. This was then over-reamed using a coring reamer of 9 mm. A 60 mm tunnel was obtained. We then used the flag reamers over a beathe pin in the central anatomic footprint of the ACL on the femoral condyle. This was drilled to 25 mm depth. We then passed a pull-out suture between the tibial tunnel and the femoral tunnel. We brought the graft from the tibial tunnel out into the femoral tunnel. Tendon graft was positioned posteriorly. Graft prominence was placed anteriorly and this was held in place using an 8 x 23 mm absorbing Arthrex interference screw. This was placed after tapping of the tunnel with a hand tap. We then placed the knee through a full range of motion and appropriately tensioned the tibial attachment. Two minor adjustments of tensioning of this distal fixation were performed to get good tension without greater than 1 mm of anterior drawer. An 8 x 28 mm absorbable screw was placed into the tibial tunnel after being hand tapped. Arthroscopic visualization showed no impingement. There was no cyclops lesion or scar tissue, anterior or superior to the tibial graft site.
We then split the cord tibial cancellous bone graft into 2 pieces. We placed each piece into the patellar as well as the tibial tuberosity harvest sites. These sites were then closed and the periosteum closed over with sutures of 2-0 Vicryl. The periosteum over the proximal and medial tibial tunnel was also closed using interrupted sutures of 2-0 Vicryl. The defect within the patellar tendon was loosely reapproximated using interrupted sutures of 2-0 PDS. Subcutaneous tissues were then closed using interrupted sutures of 3-0 Vicryl. The 2 arthroscopy incisions were also closed using interrupted sutures of 3-0 Vicryl, and the skin edges were reapproximated using a running subcuticular suture of 2-0 Prolene. Tincture of benzoin and Steri-Strips were applied to all wounds. We infiltrated the skin and subcutaneous tissues with 20 cc of 0.5% Marcaine with epinephrine. An additional 10 cc of 0.5% Marcaine with epinephrine was infiltrated into the knee joint itself. Adaptic gauze, sterile dressings were applied. ABDs had been placed with the Kerlix as well as long 6” Ace wraps and the patient was placed into a knee immobilizer. She was sent to the recovery room in stable condition and tolerated the procedure well. Total tourniquet time is less than 94 minutes. No intraoperative transfusions were required. Blood loss is less than 100 cc.
POSTOPERATIVE PLAN: She is written a prescription for Vicodin 7.5/325 mg 1-2 q.6 h. for pain, #40 with 1 refill. Also, 50 mg Vistaril tabs, #30, are written. She is to be foot flat weightbearing with crutches. We will plan to see her back in our office in a week, sooner if increasing problems occur.
