Take a look at the following operative note, and review our experts' coding recommendations.
Procedure overview: The surgeon performed reconstruction of the medial patellofemoral ligament using a semitendinosus graft. He also performed partial anterior synovectomy arthroscopically. Operative Note: Trace the Surgeon's Work The pertinent details from the operative report are as follows: The surgeon examined the patella through an arthroscope. He noted some anterior synovitis and performed a partial anterior synovectomy for visualization. He thought reconstruction of the soft-tissue restraints medially was appropriate.
Through a small oblique incision over the medial border of the proximal tibia metaphyseal area, the surgeon identified the semitendinosus tendon and, using an open-face tendon stripper, stripped the tendon away from the muscle belly.
The surgeon made a second 2-cm incision over the medial patellar retinaculum midway between the patellar and the medial epicondyle.
The surgeon drilled a 3-mm hole centrally in the medial patella. He dissected free the medial collateral ligament proximally and passed the semitendinosus tendon through a subcutaneous tunnel, through the posterior third of the MCL as close to the insertion on the medial epicondyle as practical, and passed it through the drill hole in the patella.
Then, using a Pulver-Taft weave, he sutured the tendon back upon itself with multiple sutures in a figure of eight with 4-0 Vicryl.
Medical Coding Advice : Follow These Simple Steps Step 1: Code the patellofemoral ligament reconstruction. Because the surgeon performed the reconstruction to stabilize a dislocating patella, the practice should report 27422 (Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release [e.g., Campbell, Goldwaite type procedure]) for the main procedure, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J.
Step 2: Code the graft, if documented. Practices that perform patellofemoral ligament reconstruction with graft may be able to report 20924 (Tendon graft, from a distance [e.g., palmaris, toe extensor, plantaris]), if the surgeon documents that he harvested the graft "from a distance." The report should note that the surgeon obtained the graft through either a separate skin incision or fascial exposure, says Bill Mallon, MD, medical director at Triangle Orthopaedic Associates in Durham, N.C.
The operative report in our case study above [...]