Question: I work for a Surgeon who performs percutaneous tenotomies and tendon lengthening procedure to the extremities as well as destruction by neurolytic to the nerves. Since there aren’t percutaneous cpt codes for these types of procedures how would you suggest billing? Would you suggest billing all unlisted codes or billing open codes with a modifier? Below is an example operative note for your reference.
Some (but not all) of the common open procedure he performs percutaneous are :
Orthopaedic Surgery Procedure Note
Preop Diag: Cerebral Palsy with contractures and spasticity of bilateral lower extremity
Postop Diag: same
Procedure:
Anesthesia: general
Dispo: PACU in good condition
Indications for procedure: Contractures discussed with parent goal of better walking
The following chart includes the preop, intraop, and postop joint ROM's that were checked.
In clinic With Anes Post op
Hip abduction in flexion R 10 15 20
L 20 15 25
Knee flexion contracture R 30 25 20
L 30 25 20
Popliteal angle R 115 80 70
L 115 85 75
Ankle Eq knee extended R 35 10 -10
L 20 10 -20
Ankle Eq knee flexed R 10 -10 -25
L 10 -20 -30
Max ankle Eq R -25 -15 -35
L -20 -25 -45
Operation in Detail:
Along with the faculty anesthesiologist, Dr.XXXXX performed a time-out procedure, with the patient's parent identifying the nature and location of their child's surgery. The patient was brought into the operating room and placed under general anesthesia.
After checking the patient's joint motion under anesthesia, the operative extremity/extremities were sterilely prepped and draped.
EtOH OBTURATOR
The bilateral obturator nerve was identified with a nerve stimulator inserted in the medial, proximal thigh in-between the adductor longus and brevis. It was initially set at 5mA, then 2mA, and finally 0.8mA to make sure that the catheter was in good position in relation to the nerve. 2mL of a 1:1 mixture ratio of 98% ethyl alchol and 0.9% saline was then injected (4 mL total). The needle entry sites were then cleaned and dried with dry gauze. Small clear adhesive dressings were placed over the groin needle entry sites.
GASTROCNEMIUS
The bilateral gastrocnemius and the overlying tight fascia was then identified and percutaneously released with a beaver blade to lengthen the gastrocnemius and achilles. This was done until the above documented degrees of dorsiflexion was achieved with the knee extended and flexed. The incisions were cleaned and dried. ~1cc of 0.25% marcaine with epinephrine was injected into each incision. A compression bandage was then fashioned from two raytecs. One folded into a small square and placed over the incisions, and the other wrapped around the distal leg to hold it in place, as a temporary dressing.
HAMSTRINGS
With the hip flexed to 90 degrees, the bilateral semitendinosus, semimembranosus and gracilis tendons were identified by flexing and extending the knee to tension the semitendinosus and semimembranosus and by abducting and adducting the leg to tension the gracilis. A percutaneous tenotomy was made in the semitendinosus with the beaver blade. A percutaneous tenotomy was then made in the semimembranosus with the beaver blade. Finally, a percutaneous lengthening was made in the gracilis with the beaver blade. All muscles were lengthened percutaneously by cutting the fascia over the muscle with the beaver blade. The incisions were cleaned and dried. ~1cc of 0.25% marcaine with epinephrine was injected into each incision. Afterwards, a compression bandage was fashioned from two raytecs. One was folded into a small square and placed over the small incisions, and the other wrapped around the leg to hold it in place, as a temporary dressing.
ADDUCTOR
The bilateral adductor longus was then identified by abducting and adducting the hip to place tension on the tendon. A small percutaneous tenotomy was made in the central portion of the proximal tendon (5mm lateral to the inguinal crease) and then expanded superiorly and inferiorly if/as deemed necessary until adequate hip abduction was achieved. The incisions were cleaned and dried. ~1cc of 0.25% marcaine with epinephrine was injected into each incision. Dry gauze was then temporarily applied to the incisions and gentle compression applied.
All incisions were ~3 mm in length. The incisions were cleaned and dried. All temporary dressings were removed and Surgicel with overlying gauze and tegaderms were subsequently applied to the incisions. With the ankle held in appropriate dorsiflexion, a well-padded short leg cast was applied to each operative extremity. A post-op shoe was finally placed over the cast once it was dry. A knee immobilizer was applied to each operative extremity (bilateral).
The patient was then awakened from anesthesia and transferred to the PACU in good condition. Patient tolerated the procedure well. Dr. XXXX was present for the entire procedure, including the time-out.
Minimally invasive percutaneous procedures were done using the Selective Percutaneous Myofascial Lengthening (SPML) techniques. Compared to open techniques, these techniques result in less postoperative pain and faster recovery, including faster return to walking. This is a particular issue for children with cerebral palsy, who have increased challenges in the use of their legs. These techniques require special skills and additional training. It was the parent’s/patient’s choice to avoid open surgery and to have these minimally invasive techniques used instead. The results of these techniques have been presented at peer reviewed national meetings:
Some (but not all) of the common open procedure he performs percutaneous are :
- 23405- Tenotomy, shoulder area; single tendon
- 24305- Tendon lengthening, upper arm or elbow, each tendon
- 25280- Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon
- 27005- Tenotomy, hip flexor(s), open (separate procedure)
- 27006- Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure)
- 27393- Lengthening of hamstring tendon; single tendon
- 27394- Lengthening of hamstring tendon; multiple tendons, 1 leg
- 27395- Lengthening of hamstring tendon; multiple tendons, bilateral
- 27430- Quadricepsplasty (eg, Bennett or Thompson type)
- 27685- Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)
- 27686- Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each
- 27687- Gastrocnemius recession (eg, Strayer procedure
Orthopaedic Surgery Procedure Note
Preop Diag: Cerebral Palsy with contractures and spasticity of bilateral lower extremity
Postop Diag: same
Procedure:
- Gastroc recession soleus level
- Semitendinosus percutaneous tendon tenotomy
- Myofascial lengthening multiple hamstring at knee- gracilis and semimembranous
- Alcohol block obturator nerve
Anesthesia: general
Dispo: PACU in good condition
Indications for procedure: Contractures discussed with parent goal of better walking
The following chart includes the preop, intraop, and postop joint ROM's that were checked.
In clinic With Anes Post op
Hip abduction in flexion R 10 15 20
L 20 15 25
Knee flexion contracture R 30 25 20
L 30 25 20
Popliteal angle R 115 80 70
L 115 85 75
Ankle Eq knee extended R 35 10 -10
L 20 10 -20
Ankle Eq knee flexed R 10 -10 -25
L 10 -20 -30
Max ankle Eq R -25 -15 -35
L -20 -25 -45
Operation in Detail:
Along with the faculty anesthesiologist, Dr.XXXXX performed a time-out procedure, with the patient's parent identifying the nature and location of their child's surgery. The patient was brought into the operating room and placed under general anesthesia.
After checking the patient's joint motion under anesthesia, the operative extremity/extremities were sterilely prepped and draped.
EtOH OBTURATOR
The bilateral obturator nerve was identified with a nerve stimulator inserted in the medial, proximal thigh in-between the adductor longus and brevis. It was initially set at 5mA, then 2mA, and finally 0.8mA to make sure that the catheter was in good position in relation to the nerve. 2mL of a 1:1 mixture ratio of 98% ethyl alchol and 0.9% saline was then injected (4 mL total). The needle entry sites were then cleaned and dried with dry gauze. Small clear adhesive dressings were placed over the groin needle entry sites.
GASTROCNEMIUS
The bilateral gastrocnemius and the overlying tight fascia was then identified and percutaneously released with a beaver blade to lengthen the gastrocnemius and achilles. This was done until the above documented degrees of dorsiflexion was achieved with the knee extended and flexed. The incisions were cleaned and dried. ~1cc of 0.25% marcaine with epinephrine was injected into each incision. A compression bandage was then fashioned from two raytecs. One folded into a small square and placed over the incisions, and the other wrapped around the distal leg to hold it in place, as a temporary dressing.
HAMSTRINGS
With the hip flexed to 90 degrees, the bilateral semitendinosus, semimembranosus and gracilis tendons were identified by flexing and extending the knee to tension the semitendinosus and semimembranosus and by abducting and adducting the leg to tension the gracilis. A percutaneous tenotomy was made in the semitendinosus with the beaver blade. A percutaneous tenotomy was then made in the semimembranosus with the beaver blade. Finally, a percutaneous lengthening was made in the gracilis with the beaver blade. All muscles were lengthened percutaneously by cutting the fascia over the muscle with the beaver blade. The incisions were cleaned and dried. ~1cc of 0.25% marcaine with epinephrine was injected into each incision. Afterwards, a compression bandage was fashioned from two raytecs. One was folded into a small square and placed over the small incisions, and the other wrapped around the leg to hold it in place, as a temporary dressing.
ADDUCTOR
The bilateral adductor longus was then identified by abducting and adducting the hip to place tension on the tendon. A small percutaneous tenotomy was made in the central portion of the proximal tendon (5mm lateral to the inguinal crease) and then expanded superiorly and inferiorly if/as deemed necessary until adequate hip abduction was achieved. The incisions were cleaned and dried. ~1cc of 0.25% marcaine with epinephrine was injected into each incision. Dry gauze was then temporarily applied to the incisions and gentle compression applied.
All incisions were ~3 mm in length. The incisions were cleaned and dried. All temporary dressings were removed and Surgicel with overlying gauze and tegaderms were subsequently applied to the incisions. With the ankle held in appropriate dorsiflexion, a well-padded short leg cast was applied to each operative extremity. A post-op shoe was finally placed over the cast once it was dry. A knee immobilizer was applied to each operative extremity (bilateral).
The patient was then awakened from anesthesia and transferred to the PACU in good condition. Patient tolerated the procedure well. Dr. XXXX was present for the entire procedure, including the time-out.
Minimally invasive percutaneous procedures were done using the Selective Percutaneous Myofascial Lengthening (SPML) techniques. Compared to open techniques, these techniques result in less postoperative pain and faster recovery, including faster return to walking. This is a particular issue for children with cerebral palsy, who have increased challenges in the use of their legs. These techniques require special skills and additional training. It was the parent’s/patient’s choice to avoid open surgery and to have these minimally invasive techniques used instead. The results of these techniques have been presented at peer reviewed national meetings: