connollyjenn
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Scenario: Surgical Report
Pathology: Synovial tissue. Deep joint fluid for Gram stain and cultures.
Complications: None
Patient transported to recovery room in stable condition.
This is an 75-year-old male status post right total hip arthroplasty over 4 years ago. Patient had continued pain over the last several years. Patient had evidence of loosening of his acetabulum. He was scheduled for a planned revision total hip arthroplasty. This week patient's twisted his hip and fell. Was evaluated and was shown to have a displaced acetabular component. Patient was transferred to our facility and required urgent revision of his total hip arthroplasty. The procedure was explained preoperatively in regards to risks and possible complications.
The patient was transported to the operating room, placed on the operating table in supine position. Upon administration of anesthesia. Transexamic acid and preoperative antibiotics were administered by the anesthesia department. The patient's right lower extremity was prepped and draped in a sterile fashion after placing the patient in the lateral position with the right hip facing up. Patient's previous posterior incision was utilized. Fascia was incised in the line of the incision. Upon arthrotomy through the pseudo capsular scar, significant amount of what appeared to be tannish-brown purulent copious aspirate was noted. At this point in time it was uncertain whether this patient's hip was septic in nature. The hip was irrigated. Aggressive debridement then followed. The femoral head was removed. Additional scar tissue was removed. The acetabulum was easily removed from the joint. I did send synovial tissue for fresh analysis by pathology. This did not reveal signs of chronic inflammation or polymorphonuclearcytes. Fluid was sent for cultures and Gram stain. The stat Gram stain revealed only rare PMNs with no organisms seen. Proximal femur was debrided where osteolysis was known to be present. There was no significant appearance of osteomyelitis. The femoral stem was well fixed without signs of loosening. At this point in time I was not able to tell definitively whether this hip was septic or the fluid was secondary to chronic osteolysis. I decided to proceed with placement of a bipolar hemiarthroplasty on top of the stem until definitive cultures are complete. A total of 3 L of pulsatile solution was utilized. The Stryker femoral bipolar head was impacted on the stem. Hip was then reduced. The joint was then irrigated with copious amounts of irrigant solution. Irricept irrigant solution was utilized. 1 L of Zimmer-Biomet bactisure irrigant solution was also provided. 1 g of vancomycin powder was sprinkled over the joint prior to closure. The capsule was approximated with Vicryl suture, the fascia was approximated with #1 Stratafix. Marcaine with epinepherine was injected into the subcutaneous tissue. A subcutaneous closure of Vicryl suture and the skin edges were approximated with Monocryl and Dermabond. An Aquacel Ag dressing was applied. The patient was transported to recovery room in stable condition.
When I received final cultures, if the cultures are negative for infection we will proceed to prepare the acetabular component to convert this back to a total hip arthroplasty. If cultures are positive for infection will proceed with a complete explantation of the femoral stem with placement of a antibiotic cement spacer for stage procedure.
Subsequent care report 4 days later:
(1) Failure of right total hip arthroplasty
Status: Acute
Assessment and Plan:
75 y.o M who is POD #4 s/p I&D right hip, revision right total hip arthroplasty, posterior approach with to rule out a septic total joint.
Upon arthrotomy, significant mount of what appeared to be tannish/brown purulent copious aspirate was noted. Hip was irrigated. Aggressive debridement then followed. The femoral head was removed. Additional scar was removed. The acetabulum was easily removed from the joint. Synovial tissue was sent for fresh analysis by pathology and fluid was sent for culture and Gram stain. Stat Gram stain revealed only rare PMNs and no organisms. Proximal femur was debrided. No evidence of osteomyelitis. The femoral stem was well-fixed. A bipolar hemiarthroplasty was placed on top of the stem until definitive cultures were completed. The patient is been maintained on IV Ancef and vancomycin since surgery.
This morning he feels well. He denies any infectious symptoms. The right lower extremity remains neurovascularly intact. His vital signs are currently stable and he has been afebrile since surgery. Urine output remains adequate.
Right hip culture 7/24 shows a few white blood cells but no organisms. No growth after 3 days. Gram stain from the right hip showed rare white blood cells and no organisms. Will keep cultures growing for 7 days total.
Questions are: How would you bill this? looks like reduced services? 27134 with a modifier 52 seeing it was attempted? Yet patient is awaiting a second surgery or a completion of the revision? Would you use the 27030 with a mod 59 in addition? is there enough documentation to support the modfiier 59, I am stumped. Any help would be appreciated. Perhaps a different CPT code I may be missing?
Pathology: Synovial tissue. Deep joint fluid for Gram stain and cultures.
Complications: None
Patient transported to recovery room in stable condition.
This is an 75-year-old male status post right total hip arthroplasty over 4 years ago. Patient had continued pain over the last several years. Patient had evidence of loosening of his acetabulum. He was scheduled for a planned revision total hip arthroplasty. This week patient's twisted his hip and fell. Was evaluated and was shown to have a displaced acetabular component. Patient was transferred to our facility and required urgent revision of his total hip arthroplasty. The procedure was explained preoperatively in regards to risks and possible complications.
The patient was transported to the operating room, placed on the operating table in supine position. Upon administration of anesthesia. Transexamic acid and preoperative antibiotics were administered by the anesthesia department. The patient's right lower extremity was prepped and draped in a sterile fashion after placing the patient in the lateral position with the right hip facing up. Patient's previous posterior incision was utilized. Fascia was incised in the line of the incision. Upon arthrotomy through the pseudo capsular scar, significant amount of what appeared to be tannish-brown purulent copious aspirate was noted. At this point in time it was uncertain whether this patient's hip was septic in nature. The hip was irrigated. Aggressive debridement then followed. The femoral head was removed. Additional scar tissue was removed. The acetabulum was easily removed from the joint. I did send synovial tissue for fresh analysis by pathology. This did not reveal signs of chronic inflammation or polymorphonuclearcytes. Fluid was sent for cultures and Gram stain. The stat Gram stain revealed only rare PMNs with no organisms seen. Proximal femur was debrided where osteolysis was known to be present. There was no significant appearance of osteomyelitis. The femoral stem was well fixed without signs of loosening. At this point in time I was not able to tell definitively whether this hip was septic or the fluid was secondary to chronic osteolysis. I decided to proceed with placement of a bipolar hemiarthroplasty on top of the stem until definitive cultures are complete. A total of 3 L of pulsatile solution was utilized. The Stryker femoral bipolar head was impacted on the stem. Hip was then reduced. The joint was then irrigated with copious amounts of irrigant solution. Irricept irrigant solution was utilized. 1 L of Zimmer-Biomet bactisure irrigant solution was also provided. 1 g of vancomycin powder was sprinkled over the joint prior to closure. The capsule was approximated with Vicryl suture, the fascia was approximated with #1 Stratafix. Marcaine with epinepherine was injected into the subcutaneous tissue. A subcutaneous closure of Vicryl suture and the skin edges were approximated with Monocryl and Dermabond. An Aquacel Ag dressing was applied. The patient was transported to recovery room in stable condition.
When I received final cultures, if the cultures are negative for infection we will proceed to prepare the acetabular component to convert this back to a total hip arthroplasty. If cultures are positive for infection will proceed with a complete explantation of the femoral stem with placement of a antibiotic cement spacer for stage procedure.
Subsequent care report 4 days later:
(1) Failure of right total hip arthroplasty
Status: Acute
Assessment and Plan:
75 y.o M who is POD #4 s/p I&D right hip, revision right total hip arthroplasty, posterior approach with to rule out a septic total joint.
Upon arthrotomy, significant mount of what appeared to be tannish/brown purulent copious aspirate was noted. Hip was irrigated. Aggressive debridement then followed. The femoral head was removed. Additional scar was removed. The acetabulum was easily removed from the joint. Synovial tissue was sent for fresh analysis by pathology and fluid was sent for culture and Gram stain. Stat Gram stain revealed only rare PMNs and no organisms. Proximal femur was debrided. No evidence of osteomyelitis. The femoral stem was well-fixed. A bipolar hemiarthroplasty was placed on top of the stem until definitive cultures were completed. The patient is been maintained on IV Ancef and vancomycin since surgery.
This morning he feels well. He denies any infectious symptoms. The right lower extremity remains neurovascularly intact. His vital signs are currently stable and he has been afebrile since surgery. Urine output remains adequate.
Right hip culture 7/24 shows a few white blood cells but no organisms. No growth after 3 days. Gram stain from the right hip showed rare white blood cells and no organisms. Will keep cultures growing for 7 days total.
Questions are: How would you bill this? looks like reduced services? 27134 with a modifier 52 seeing it was attempted? Yet patient is awaiting a second surgery or a completion of the revision? Would you use the 27030 with a mod 59 in addition? is there enough documentation to support the modfiier 59, I am stumped. Any help would be appreciated. Perhaps a different CPT code I may be missing?