karismithx
Contributor
Hello all,
I've got an op note here that is giving me some trouble. My doctor says he did a hardware removal, but I'm just not sure how to bill it since he didn't remove the screw completely. Any ideas would be greatly appreciated.
Here's the op note:
PATIENT NAME: ***********
DATE OF SURGERY: 03/25/10
PREOPERATIVE DIAGNOSIS: Left knee internal derangement with painful proximal
tibial hardware.
POSTOPERATIVE DIAGNOSES:
1. Left knee medial gutter synovitis.
2. Left knee chondral debridement about 8 x 8 mm on the weightbearing portion of the
medial femoral condyle.
3. Somewhat prominent retained hardware consisting of both graft and biocomposite
screw of proximal tibia.
PROCEDURE PERFORMED:
1. Left knee examination under anesthesia.
2. Left knee diagnostic arthroscopy with synovectomy.
3. Left knee diagnostic arthroscopy with chondral debridement of medial femoral
condyle.
4. Left knee hardware removal centrally flattening and burning down prominent
hardware.
SURGEON: *********, MD
ASSISTANT: None.
INDICATION: A 27-year-old who is a number of months status post left ACL
reconstruction. The patient has persistent medial joint space tenderness as well as
tenderness directly over his retained hardware. Even though understanding that this is a
biocomposite fixation, the patient opted for debulking or removal of his proximal painful
hardware and knee arthroscopy at the same setting to better evaluate his medial meniscus
where he had this medial joint discomfort.
EXAMINATION UNDER ANESTHESIA: Full range of motion. Negative Lachman.
Negative pivot shift. Firm end point. No varus or valgus instability.
ARTHROSCOPIC FINDINGS: Patellofemoral joint normal. Somewhat of reformation
of a thickened scarified medial synovial fold. Lateral gutter is normal. Lateral
compartment reveals normal meniscus and articular surface. Notch reveals intact PCL
and completely revascularized intact ACL with good tension. Posterior medial
compartment reveals no meniscal capsular or separation and the root of the meniscus
could be seen and probed and was noted to be stable.
Medial compartment reveals normal tibia plateau, normal medial meniscus including
probing of the superior and inferior surface of the entire meniscus and previous
debridement of a very small meniscal tear that has healed completely. There was an area
of about 1 x 1 cm of early grade 2 chondromalacia on the weightbearing more of the
lateral aspect of the medial femoral condyle. This was unstable to probing with flap
tearing and fissuring.
PROCEDURE: The patient was brought to the Operating Room and placed supine in the
OR table and the anesthesia was induced smoothly. The left lower extremity was sterily
prepped and draped, and after exsanguination with Esmarch, tourniquet was inflated to
250 mmHg.
Next, standard superomedial outflow and anterolateral viewing and anteromedial working
portals were made. The arthroscope was introduced and all the above structures were
noted. Next, using a full-radius resector, the medial synovial fold was resected back to a
stable capsular rim.
Next, using a full-radius resector, a general chondral debridement of the grade 2
chondromalacia was performed down to a base which was further contoured and
stabilized using just whisping general motion with a Vulcan TAC-C chondral debrider.
Following this, the lesion was probed and was noted to be completely stable. There were
no high grade 3 or grade 4 lesions noted.
Next, all instruments were removed from the knee. The previous incision for the graft
harvest was incised only at its bottom approximately 3 cm. Preoperatively, the area of the
maximum pain was marked and with dissection transversely of the hamstring insertion
and pes anserinus bursa, the bioabsorbable screw and the part of the bone plug were
evaluated and noted to be moderately prominent. There was excellent healing of the bone
plug to the surrounding bone and then this and the biocomposite screws were burred
down completely flushed with the surrounding tibia. No further prominences or hardware
could be found. This wound was thoroughly irrigated with dilute Betadine solution. The
hamstring longitudinal release were sutured side to side with 2-0 Vicryl. Subcutaneous
tissue was closed with 2-0 Vicryl. Skin and all portals were closed with 4-0 nylon.
Approximately 15 cc of 5% ropivacine with epinephrine was instilled into the knee and
into the subcutaneous tissue. The sterile dressing was applied. The patient was awake in
the Operative Room and taken to the Recovery Room in stable condition.
TOURNIQUET TIME: 41 minutes.
COMPLICATIONS: None.
DISPOSITION: To the Recovery Room and home when stable.
I've got an op note here that is giving me some trouble. My doctor says he did a hardware removal, but I'm just not sure how to bill it since he didn't remove the screw completely. Any ideas would be greatly appreciated.
Here's the op note:
PATIENT NAME: ***********
DATE OF SURGERY: 03/25/10
PREOPERATIVE DIAGNOSIS: Left knee internal derangement with painful proximal
tibial hardware.
POSTOPERATIVE DIAGNOSES:
1. Left knee medial gutter synovitis.
2. Left knee chondral debridement about 8 x 8 mm on the weightbearing portion of the
medial femoral condyle.
3. Somewhat prominent retained hardware consisting of both graft and biocomposite
screw of proximal tibia.
PROCEDURE PERFORMED:
1. Left knee examination under anesthesia.
2. Left knee diagnostic arthroscopy with synovectomy.
3. Left knee diagnostic arthroscopy with chondral debridement of medial femoral
condyle.
4. Left knee hardware removal centrally flattening and burning down prominent
hardware.
SURGEON: *********, MD
ASSISTANT: None.
INDICATION: A 27-year-old who is a number of months status post left ACL
reconstruction. The patient has persistent medial joint space tenderness as well as
tenderness directly over his retained hardware. Even though understanding that this is a
biocomposite fixation, the patient opted for debulking or removal of his proximal painful
hardware and knee arthroscopy at the same setting to better evaluate his medial meniscus
where he had this medial joint discomfort.
EXAMINATION UNDER ANESTHESIA: Full range of motion. Negative Lachman.
Negative pivot shift. Firm end point. No varus or valgus instability.
ARTHROSCOPIC FINDINGS: Patellofemoral joint normal. Somewhat of reformation
of a thickened scarified medial synovial fold. Lateral gutter is normal. Lateral
compartment reveals normal meniscus and articular surface. Notch reveals intact PCL
and completely revascularized intact ACL with good tension. Posterior medial
compartment reveals no meniscal capsular or separation and the root of the meniscus
could be seen and probed and was noted to be stable.
Medial compartment reveals normal tibia plateau, normal medial meniscus including
probing of the superior and inferior surface of the entire meniscus and previous
debridement of a very small meniscal tear that has healed completely. There was an area
of about 1 x 1 cm of early grade 2 chondromalacia on the weightbearing more of the
lateral aspect of the medial femoral condyle. This was unstable to probing with flap
tearing and fissuring.
PROCEDURE: The patient was brought to the Operating Room and placed supine in the
OR table and the anesthesia was induced smoothly. The left lower extremity was sterily
prepped and draped, and after exsanguination with Esmarch, tourniquet was inflated to
250 mmHg.
Next, standard superomedial outflow and anterolateral viewing and anteromedial working
portals were made. The arthroscope was introduced and all the above structures were
noted. Next, using a full-radius resector, the medial synovial fold was resected back to a
stable capsular rim.
Next, using a full-radius resector, a general chondral debridement of the grade 2
chondromalacia was performed down to a base which was further contoured and
stabilized using just whisping general motion with a Vulcan TAC-C chondral debrider.
Following this, the lesion was probed and was noted to be completely stable. There were
no high grade 3 or grade 4 lesions noted.
Next, all instruments were removed from the knee. The previous incision for the graft
harvest was incised only at its bottom approximately 3 cm. Preoperatively, the area of the
maximum pain was marked and with dissection transversely of the hamstring insertion
and pes anserinus bursa, the bioabsorbable screw and the part of the bone plug were
evaluated and noted to be moderately prominent. There was excellent healing of the bone
plug to the surrounding bone and then this and the biocomposite screws were burred
down completely flushed with the surrounding tibia. No further prominences or hardware
could be found. This wound was thoroughly irrigated with dilute Betadine solution. The
hamstring longitudinal release were sutured side to side with 2-0 Vicryl. Subcutaneous
tissue was closed with 2-0 Vicryl. Skin and all portals were closed with 4-0 nylon.
Approximately 15 cc of 5% ropivacine with epinephrine was instilled into the knee and
into the subcutaneous tissue. The sterile dressing was applied. The patient was awake in
the Operative Room and taken to the Recovery Room in stable condition.
TOURNIQUET TIME: 41 minutes.
COMPLICATIONS: None.
DISPOSITION: To the Recovery Room and home when stable.
