jdibble
True Blue
Good day!
Can someone please review this OP note and tell me what CPT code would be appropriate for the Tibial Tubercle osteotomy? I have seen at least 3 different answers to the correct code and I am not completely comfortable with the ones that I have seen.
Pre-op Diagnosis: Patellar chondromalacia and maltracking , right.
Post-op Diagnosis: Same as Preoperative Diagnosis.
Procedure: 1.Tibail tubercle osteotomy right , 2.Lateral Release right knee 3. Chondroplasty right patella 4. Chondroplasty of the right medial femoral condyle.
Indication: 39 yo with persistant anterior knee pain with high q angle and positive J sign. For tubercle osteotomy..
Surgeon(s):
Assistant(s)
Anesthesia: General.
Description of Procedure: After informed consent was obtained patient was taken to the OR and general anesthesia was introduced. The right leg was prepped and drapped in standard fashion., Standard portals were made and the knee was examined. The lateral compartments was found to be intact with no cartilage wear or meniscus injury. The medial compartment was examined. There was significant grade 2 and 3 chondromalacia of the medial femoral condyle with loose cartilage fragments. This was all debrided using the shaver back to stable cartilage. The meniscus was normal. The anterior compartment was examined and grade 2/3 wear was found on the the patella. This was debrided with shaver. Excessive tilt was found. A lateral release was performed with hook knife. Tilt improved. Scope was removed and incision made over the patellar tendon. Edges of the tendon were isolated and periosteom was opened along the line of the tendon medially. Tibialis anterior was removed from lateral cortex. A saw blade was then passed medially in a posterior direction at 45 degrees. A 5 cmm wedge was cut. The tubercle was elevated and translated medially about 2 cm. Two 4.5 mm screws were placed to hold it reduced. The tib ant was repaired. Skin closed. , Sterile dressing was placed and patient was awoken and taken to recovery room in good condition. Patient will go home today and FU 1-2 weeks..
Specimens: None.
Thank you so much for all of the help I can get!!
Thanks!!
Can someone please review this OP note and tell me what CPT code would be appropriate for the Tibial Tubercle osteotomy? I have seen at least 3 different answers to the correct code and I am not completely comfortable with the ones that I have seen.
Pre-op Diagnosis: Patellar chondromalacia and maltracking , right.
Post-op Diagnosis: Same as Preoperative Diagnosis.
Procedure: 1.Tibail tubercle osteotomy right , 2.Lateral Release right knee 3. Chondroplasty right patella 4. Chondroplasty of the right medial femoral condyle.
Indication: 39 yo with persistant anterior knee pain with high q angle and positive J sign. For tubercle osteotomy..
Surgeon(s):
Assistant(s)
Anesthesia: General.
Description of Procedure: After informed consent was obtained patient was taken to the OR and general anesthesia was introduced. The right leg was prepped and drapped in standard fashion., Standard portals were made and the knee was examined. The lateral compartments was found to be intact with no cartilage wear or meniscus injury. The medial compartment was examined. There was significant grade 2 and 3 chondromalacia of the medial femoral condyle with loose cartilage fragments. This was all debrided using the shaver back to stable cartilage. The meniscus was normal. The anterior compartment was examined and grade 2/3 wear was found on the the patella. This was debrided with shaver. Excessive tilt was found. A lateral release was performed with hook knife. Tilt improved. Scope was removed and incision made over the patellar tendon. Edges of the tendon were isolated and periosteom was opened along the line of the tendon medially. Tibialis anterior was removed from lateral cortex. A saw blade was then passed medially in a posterior direction at 45 degrees. A 5 cmm wedge was cut. The tubercle was elevated and translated medially about 2 cm. Two 4.5 mm screws were placed to hold it reduced. The tib ant was repaired. Skin closed. , Sterile dressing was placed and patient was awoken and taken to recovery room in good condition. Patient will go home today and FU 1-2 weeks..
Specimens: None.
Thank you so much for all of the help I can get!!
Thanks!!