Pt has TKA in 12/20, has been experiencing pain ever since. Underwent retinaculum repair 2 months ago and still having pain. Now surgeon brings pt back in for knee exploration using 27331 with the findings of sharp edge of bone/concrete where the implant was cemented. I'm having a horrible time finding ICD 10 codes that would work. Provider used superficial foreign body code, which obviously not correct. Is this a complication of the TKA so maybe a T code? He's out of global from his TKA but still in global from his retinacular repair but this is not related to that surgery, so would use 79 mod? Here's the OP note:
After failing conservative measures, I elected to explore the wound and remove potential sharp edges around the lateral aspect of the knee prosthesis that may be irritating tissue.
A laterally based 4 cm incision was placed in a curvilinear fashion over the center of the lateral femoral condyle. A sharp subcutaneous edge of bone or residual cement was palpable through skin. The retinaculum was opened laterally in a vertical fashion. The edge of the lateral femoral condyle was exposed. There was indeed a sharp edge of residual cement in this region that was the likely cause of lateral based crepitation and pain. An osteotome and rongeur were utilized to remove smooth the lateral prosthesis/bone interface. Digital palpation was utilized to confirm a smooth edge. The entirety of the lateral border of the femoral implant and tibial implant were inspected and no residual bone or cement was obviously remaining to cause further irritation.
After failing conservative measures, I elected to explore the wound and remove potential sharp edges around the lateral aspect of the knee prosthesis that may be irritating tissue.
A laterally based 4 cm incision was placed in a curvilinear fashion over the center of the lateral femoral condyle. A sharp subcutaneous edge of bone or residual cement was palpable through skin. The retinaculum was opened laterally in a vertical fashion. The edge of the lateral femoral condyle was exposed. There was indeed a sharp edge of residual cement in this region that was the likely cause of lateral based crepitation and pain. An osteotome and rongeur were utilized to remove smooth the lateral prosthesis/bone interface. Digital palpation was utilized to confirm a smooth edge. The entirety of the lateral border of the femoral implant and tibial implant were inspected and no residual bone or cement was obviously remaining to cause further irritation.