Wiki Open 29885 (drilling for osteochondritis dissecans, with internal fixation

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twosmek

twosmek

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The md started out with doing the procedure arthroscopically and then had to open the incision. The applicable documentation is as follows. (He did scope other compartments for the knee prior to this)--Preforming MD wanted to code 27599 (unlisted), I was thinking 27514, or 29885 with a 22 modifier.

Please help @!>?%#

Postoperative DX; Chondral delaminated flap flexion surface of the lateral femoral condyle (18x15mm)
Procedure: Internal fixation of full thikness articular cartilage delamination lateral femoral condyle with Arthrex bioabsorbable compression screws.


The loose delaminating posterior flap of articular cartilage was felt to be unstable in the patient's young age and the large amount of weightbearing surface involved, it was felt indicated proceed with fixation of that fragment of cartilage. This was done with an Arthrex 2 mm compression screw. This was advanced initially arthroscopically. As the screw was fully seated there was a suprising amount of purchase obtained which did not allow full seating of the screw before the head stripped down. The remaining prominent 2 mm of the implant was then difficult to access arthroscopically. The lateral portal was therefore extended into a short lateral retinacular incision to visually expose the delamination site. The prominent end of the implant was trimmed back with the rongeur and then smoothed with an arthroscopic burr to be flush below the articular surface. This was noted to nicely secure the posterior most portion of the flap, hoever, the anterior leading edge was still somewhat unstable and then that was secured with a second screw placed in standard fashion, again despite drilling for 28 mm implant and selecting 24, the compression achieved stell exceeded tolerance of the insertion driver and was left somewhat prominent before stripping off the head, therefore, that was then also planed flush with teh articular surface. Probing the leading margin of the articular flap then proved stable. The wound was irrigated. A lateral retnacular split was closed with interrupted o vicry, buried 2-0 Monocryl was used subcutaneously followed by interrupted nylon suture for skin.
 
Can anyone take a look at this OP and comment? I have a similar situation and procedure performed.
The Physician feels the arthroscopic code can be billed. I don't think it is appropriate once he opened to do bill 29885 for the ORIF of osteochondral fragment of medial femoral condyle. Would 27514 need to be billed or the unlisted 27599 code?

PREOPERATIVE DIAGNOSIS: Osteochondritis dissecans medial femoral condyle right knee
M93.261, etThsion right knee M25.461, loose body tight knee M23.41
POSTOPERATIVE DIAGNOSIS: Same
ANESTHESIA: Regional anesthetic with supplemental general anesthetic.
OPERATION: Knee arthroscopy with removal of loose osteochondral fragment and open
reduction internal fixation of osteochondral fragment 29885
DESCRIPTION OF PROCEDURE
After the induction of adequate IV anesthetic1 under sterile conditions, the medial and lateral
portal sites and the intra-articular space were injected with local anesthetic. The entire leg was
then prepped and draped in the usual sterile orthopedic manner. Diagnostic arthroscopy
commenced through an anteroLateral portal. The medial portal was localized with a spinal needle,
and the operative probe was placed.
In the medial joint compartment, there was a huge defect in the medial femoral condyle
consistent with a diagnosis of osteochondritis dissecans. There was some granulation tissue in
the base of the lesion suggesting it was relatively acutely displaced. The tibial and meniscal
surfaces were normal.
In the intercondylar notch, ACL and PCL were intact.
In the lateral joint compartment, femoral-tibial meniscal surfaces were within normal limits.
In the patellofemoral joint, the articular surfaces and (racking were within normal limits.
There was a large osteochondral loose body in the suprapatellar pouch. Medial portal was
extended into a large enough incision to grasp and remove the fragment. Fragment did appear to
have some bone on the back of it. There were smooth edges consistent with a chronic process.
Fragment was taken in the back table and carefully protected. Leg was then elevated and
exsanguinated. Tourniquet was inflated to 250 mmHg. The medial incision was then extended
into the medial parapatellar arthrotomy through the skin. Incision was made deepened in the
knee joint along the medial border the patella extending to the distal quadriceps tendon down to
the tibia. Fat pad was excised for exposure. Femoral condylar defect was well exposed. A
curette was used to debride the base of it back to bleeding bone. It was felt that based on the size
of the lesion the fact that there was bone on the back of the lesion and relatively acute
displacement that open reduction internal fixation would be appropriate. Fixation was done with
two 1.8 mm knotless all suture Arthrex anchors. These were placed in the anterior and posterior
portions of the lesion. Drill holes were made through the fragment in appropriate positions and
the sutures were passed and tensioned into the the opposite anchor thus securing the fragment
securely in a anatomic fashion. The wound was then copiously irrigated. The fixation tolerated
motion well. Post fixation arthroscopic photo was obtained.
tie wound was copiously irrigated. The medial parapatellar arthrotomy was closed with
multiple interrupted and running #1 Vicryl sutures. Subcutaneous tissues closed with undyed 2-0
Vicryl. Tourniquet was released with a total tourniquet time of 45 minutes. A Zipline was
placed to close the skin. Dry sterile dressings were applied as well as a knee brace and a
cryotherapy device. Patient was awakened from the general anesthetic having tolerated the
procedure well.
 
Last edited:
A quick check of the NCCI edits between 27514 & 29885, so from a coding perspective you appear to be able to bill these procedures together during the operative session. A multiple procedure reduction is appropriate for 29885 so if your payers don't automatically reduce multiple procedures you need to remember to append modifier 51 to 29885. Additionally, per the coding tip info in EncoderPro for Payers there is the following note about coding arthroscopic procedures that are converted to open procedures as noted below:
1704906448864.png
So, these codes may be billable together and allowed by the payer depending on the payer's policies regarding this type of scenario. You may get lucky and the payer may make some type of payment or allow benefits for the 29885 it may just take some work on your part to figure out what the payer's policy is.
 
JPerry2000 said:
Can anyone take a look at this OP and comment? I have a similar situation and procedure performed.
The Physician feels the arthroscopic code can be billed. I don't think it is appropriate once he opened to do bill 29885 for the ORIF of osteochondral fragment of medial femoral condyle. Would 27514 need to be billed or the unlisted 27599 code?

PREOPERATIVE DIAGNOSIS: Osteochondritis dissecans medial femoral condyle right knee
M93.261, etThsion right knee M25.461, loose body tight knee M23.41
POSTOPERATIVE DIAGNOSIS: Same
ANESTHESIA: Regional anesthetic with supplemental general anesthetic.
OPERATION: Knee arthroscopy with removal of loose osteochondral fragment and open
reduction internal fixation of osteochondral fragment 29885
DESCRIPTION OF PROCEDURE
After the induction of adequate IV anesthetic1 under sterile conditions, the medial and lateral
portal sites and the intra-articular space were injected with local anesthetic. The entire leg was
then prepped and draped in the usual sterile orthopedic manner. Diagnostic arthroscopy
commenced through an anteroLateral portal. The medial portal was localized with a spinal needle,
and the operative probe was placed.
In the medial joint compartment, there was a huge defect in the medial femoral condyle
consistent with a diagnosis of osteochondritis dissecans. There was some granulation tissue in
the base of the lesion suggesting it was relatively acutely displaced. The tibial and meniscal
surfaces were normal.
In the intercondylar notch, ACL and PCL were intact.
In the lateral joint compartment, femoral-tibial meniscal surfaces were within normal limits.
In the patellofemoral joint, the articular surfaces and (racking were within normal limits.
There was a large osteochondral loose body in the suprapatellar pouch. Medial portal was
extended into a large enough incision to grasp and remove the fragment. Fragment did appear to
have some bone on the back of it. There were smooth edges consistent with a chronic process.
Fragment was taken in the back table and carefully protected. Leg was then elevated and
exsanguinated. Tourniquet was inflated to 250 mmHg. The medial incision was then extended
into the medial parapatellar arthrotomy through the skin. Incision was made deepened in the
knee joint along the medial border the patella extending to the distal quadriceps tendon down to
the tibia. Fat pad was excised for exposure. Femoral condylar defect was well exposed. A
curette was used to debride the base of it back to bleeding bone. It was felt that based on the size
of the lesion the fact that there was bone on the back of the lesion and relatively acute
displacement that open reduction internal fixation would be appropriate. Fixation was done with
two 1.8 mm knotless all suture Arthrex anchors. These were placed in the anterior and posterior
portions of the lesion. Drill holes were made through the fragment in appropriate positions and
the sutures were passed and tensioned into the the opposite anchor thus securing the fragment
securely in a anatomic fashion. The wound was then copiously irrigated. The fixation tolerated
motion well. Post fixation arthroscopic photo was obtained.
tie wound was copiously irrigated. The medial parapatellar arthrotomy was closed with
multiple interrupted and running #1 Vicryl sutures. Subcutaneous tissues closed with undyed 2-0
Vicryl. Tourniquet was released with a total tourniquet time of 45 minutes. A Zipline was
placed to close the skin. Dry sterile dressings were applied as well as a knee brace and a
cryotherapy device. Patient was awakened from the general anesthetic having tolerated the
procedure well.
Click to expand...
Ewww. Good one.
It appears this OCD fragment migrated from the medial femoral condyle/medial compartment to the PF? This is essentially first, a diagnostic scope with LB removal. He got the fragment out via scope and converted to ORIF to put it back where it came from basically. As far as the 29885, there is no bone graft documented; also no drilling and he converted to open. What was the original plan, they didn't know there was a huge fragment in there?
While he stated, "Drill holes were made through the fragment in appropriate positions and the sutures were passed and tensioned into the the opposite anchor thus securing the fragment securely in a anatomic fashion." That's not OCD drilling, that was just holes to do the fixation. There was a curette used to debride the defect once open.
Hmm, this is a good one. I think you'll have to probably do 27514. Did you check CPT Assistant for any guidance? It's not 29887 either.
Conundrum. Unlisted and compare to 29892?

Too bad there's not a knee one like for the ankle (29892)!
 
amyjph said:
Ewww. Good one.
It appears this OCD fragment migrated from the medial femoral condyle/medial compartment to the PF? This is essentially first, a diagnostic scope with LB removal. He got the fragment out via scope and converted to ORIF to put it back where it came from basically. As far as the 29885, there is no bone graft documented; also no drilling and he converted to open. What was the original plan, they didn't know there was a huge fragment in there?
While he stated, "Drill holes were made through the fragment in appropriate positions and the sutures were passed and tensioned into the the opposite anchor thus securing the fragment securely in a anatomic fashion." That's not OCD drilling, that was just holes to do the fixation. There was a curette used to debride the defect once open.
Hmm, this is a good one. I think you'll have to probably do 27514. Did you check CPT Assistant for any guidance? It's not 29887 either.
Conundrum. Unlisted and compare to 29892?

Too bad there's not a knee one like for the ankle (29892)!
Click to expand...
Thank you so much for taking the time to look at this one. I coded it to the Unlisted procedure code as there was not a fitting code for the procedure. I bill for an ASC so there is no payment on unlisted codes.
 
JPerry2000 said:
Thank you so much for taking the time to look at this one. I coded it to the Unlisted procedure code as there was not a fitting code for the procedure. I bill for an ASC so there is no payment on unlisted codes.
Click to expand...
I was talking pro-fee for the physician billing. I am not schooled on ASC facility billing/coding so that may make a big difference depending on those rules! Good Luck! What did the surgeon bill, the 29885? May be an issue if your claim and their claim don't match? I know sometimes I have seen that happen with a hospital and the provider office when the payer gets the claim with different coding.
 
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