valerieeanderson
Networker
Hello,
We are questioning the coding for the tibia shaft fracture. My thinking is CPT 27759 is supported but I have a coder suggesting an UNL CPT 27899 and compare to CPT 27756. I see an incision was made for the tibial fracture and my thought process has been to follow the approach, but Ortho is new to me. Any discussion and/or resource links are appreciated.
POST-OPERATIVE DIAGNOSIS:
1. Closed, oblique Right distal 1/3 tibia shaft fracture
2. Closed Right posterior malleolus fracture
PROCEDURE:
1. Intramedullary nail fixation of Right tibia shaft fracture
2. Open Reduction Internal Fixation of Right posterior malleolus fracture
IMPLANTS:
1. Synthes tibial nail; size 9mm x 300mm
2. Synthes 4.0mm cannulated screw
INDICATION FOR SURGERY:
Pt. slipped & fell down the stairs resulting in a closed, oblique Right distal 1/3 tibia shaft fracture and closed Right posterior malleolus fracture. The recommendation for operative fixation of their Right tibia shaft fracture and open reduction internal fixation of posterior malleolus fracture was made. The risks of surgery including but not limited to infection, bleeding, nonunion, malunion, compartment syndrome, wound healing issues, persistent pain, stiffness, prominent or symptomatic hardware, damage to surrounding nerves/vessels/tendons/ligaments, blood clots in the legs (deep vein thrombosis), blood clots in the lungs (pulmonary embolus), intra- or perioperative complications including heart attack/stroke/death were discussed. They understands these risks and wished to proceed. A signed consent was obtained & placed in the medical record.
OPERATIVE DESCRIPTION:
The patient was brought to the operating room and placed in the supine position where general anesthesia was obtained. 2g of Ancef was administered. A bump was placed under the Right hip and all bony prominences well padded. The Right lower extremity was prepped and draped sterilely. A time out involving the surgical team was performed, identifying the correct patient, side, site and procedure to be performed.
The posterior malleolus fracture was reduced with confirmation of reduction performed using C-arm fluoroscopy. A 1cm incision over the anterolateral distal tibia was made sharply with a #15 blade scalpel. An anterior to posterior 4.0mm cannulated screw was placed using C-arm fluoroscopic guidance for fixation of her posterior malleolus fracture.
A 3cm suprapatellar incision was made midline through the quadriceps tendon sharply. This was followed by atraumatic passage of a blunt trocar cannula into the patellofemoral joint in the retropatellar space. A terminally threaded guidewire was advanced into the central location in the proximal tibia as based on C-arm fluoroscopy, AP and lateral views. This was followed by passage of an entry reamer and a ball-tip guide wire to the fracture site. The fracture was reduced and held with a pointed reduction tenaculum. Reduction was confirmed using C-arm fluoroscopy. The ball-tipped guide wire was then advanced across the fracture site into a central location in the distal tibia. This was followed by sequential reaming up to a size 10.5mm reamer. A 9mm x 300mm nail was selected and passed over the wire and impacted into position. Using perfect circles technique, two distal interlock screws were placed. Using the outrigger guide, one proximal interlock screw was placed. External rotation stress examine of the ankle was performed using C-arm fluoroscopy with no instability or translation of the talus noted. The wounds were copiously irrigated as was the intra-articular space of the knee to be completely free of debris. The quadriceps tendon was closed using 0 Vicryl. Subcutaneous tissues were closed using 2-0 Monocryl. Skin was closed with staples. Sterile Xeroform, 4x4 gauze, Webril and an ACE wrap were applied. Patient was placed into a well-padded CAM boot.
POST OPERATIVE PLAN:
- Nonweightbearing Right lower extremity
- Ancef 24h post-op
We are questioning the coding for the tibia shaft fracture. My thinking is CPT 27759 is supported but I have a coder suggesting an UNL CPT 27899 and compare to CPT 27756. I see an incision was made for the tibial fracture and my thought process has been to follow the approach, but Ortho is new to me. Any discussion and/or resource links are appreciated.
POST-OPERATIVE DIAGNOSIS:
1. Closed, oblique Right distal 1/3 tibia shaft fracture
2. Closed Right posterior malleolus fracture
PROCEDURE:
1. Intramedullary nail fixation of Right tibia shaft fracture
2. Open Reduction Internal Fixation of Right posterior malleolus fracture
IMPLANTS:
1. Synthes tibial nail; size 9mm x 300mm
2. Synthes 4.0mm cannulated screw
INDICATION FOR SURGERY:
Pt. slipped & fell down the stairs resulting in a closed, oblique Right distal 1/3 tibia shaft fracture and closed Right posterior malleolus fracture. The recommendation for operative fixation of their Right tibia shaft fracture and open reduction internal fixation of posterior malleolus fracture was made. The risks of surgery including but not limited to infection, bleeding, nonunion, malunion, compartment syndrome, wound healing issues, persistent pain, stiffness, prominent or symptomatic hardware, damage to surrounding nerves/vessels/tendons/ligaments, blood clots in the legs (deep vein thrombosis), blood clots in the lungs (pulmonary embolus), intra- or perioperative complications including heart attack/stroke/death were discussed. They understands these risks and wished to proceed. A signed consent was obtained & placed in the medical record.
OPERATIVE DESCRIPTION:
The patient was brought to the operating room and placed in the supine position where general anesthesia was obtained. 2g of Ancef was administered. A bump was placed under the Right hip and all bony prominences well padded. The Right lower extremity was prepped and draped sterilely. A time out involving the surgical team was performed, identifying the correct patient, side, site and procedure to be performed.
The posterior malleolus fracture was reduced with confirmation of reduction performed using C-arm fluoroscopy. A 1cm incision over the anterolateral distal tibia was made sharply with a #15 blade scalpel. An anterior to posterior 4.0mm cannulated screw was placed using C-arm fluoroscopic guidance for fixation of her posterior malleolus fracture.
A 3cm suprapatellar incision was made midline through the quadriceps tendon sharply. This was followed by atraumatic passage of a blunt trocar cannula into the patellofemoral joint in the retropatellar space. A terminally threaded guidewire was advanced into the central location in the proximal tibia as based on C-arm fluoroscopy, AP and lateral views. This was followed by passage of an entry reamer and a ball-tip guide wire to the fracture site. The fracture was reduced and held with a pointed reduction tenaculum. Reduction was confirmed using C-arm fluoroscopy. The ball-tipped guide wire was then advanced across the fracture site into a central location in the distal tibia. This was followed by sequential reaming up to a size 10.5mm reamer. A 9mm x 300mm nail was selected and passed over the wire and impacted into position. Using perfect circles technique, two distal interlock screws were placed. Using the outrigger guide, one proximal interlock screw was placed. External rotation stress examine of the ankle was performed using C-arm fluoroscopy with no instability or translation of the talus noted. The wounds were copiously irrigated as was the intra-articular space of the knee to be completely free of debris. The quadriceps tendon was closed using 0 Vicryl. Subcutaneous tissues were closed using 2-0 Monocryl. Skin was closed with staples. Sterile Xeroform, 4x4 gauze, Webril and an ACE wrap were applied. Patient was placed into a well-padded CAM boot.
POST OPERATIVE PLAN:
- Nonweightbearing Right lower extremity
- Ancef 24h post-op