Forum - Questions & Answers
Knee Arthroscopy
Can someone please take a look at this…our billing dept has billed 29877, 29874-51. I understand the more appropriate modifier would be -59 in this instance I just need to an unbiased insight to decipher if I am missing something here – I have reviewed the below as well.
Intraoperative services not included in the global service package:
1. supplies and medication (eg, code 99070, HCPCS Level II
codes)
2. insertion, removal, or exchange of nonbiodegradable drug
delivery implants (eg, 11981–11983)
3. arthroscopic removal of loose or foreign bodies greater than
5 mm or through a separate incision (e.g., 29874)
4. arthroscopic abrasion arthroplasty, multiple drilling or
microfracture, separate compartment (e.g., 29879)
5. arthroscopic meniscectomy or meniscal repair (e.g., 29880–
29883)
A commercial carrier has denied this as 29874 as not billable with a major procedure. Any insight given would be much appreciated. Thank you in advance for your time.
MJ
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PREOPERATIVE DIAGNOSIS:
Left knee loose body.
POSTOPERATIVE DIAGNOSIS:
Left knee large osteochondral defect, medial femoral condyle.
PROCEDURES:
1. Left arthroscopic removal of loose body.
2. Left knee arthroscopic chondroplasty of medial femoral condyle.
ANESTHESIA: General.
EBL: Minimal.
TOURNIQUET TIME: 50 minutes.
DRAINS: None.
IMPLANTS: Mini Acutrak screws x3, removed.
INDICATIONS
This is a 44-year-old female who sustained an acute work-related injury when her knee sustained a direct blow. Since that time she has had mechanical symptoms including catching and locking. Plain radiographs showed what appeared to be a loose body. She elected to proceed with arthroscopic removal. Risks and benefits have been discussed with the patient and informed consent was obtained.
TECHNIQUE IN DETAIL
The patient is brought to the operating room. She is given 2 grams of Ancef as well as general anesthesia. Exam under anesthesia is performed demonstrating full flexion but with mechanical clicking on her range of motion and a stable ligamentous exam. At this point a well-padded tourniquet is placed high on the thigh and the left lower extremity was prepped and draped in the usual sterile manner. A time-out is performed. The knee is insufflated with 60 cc of normal saline and standard arthroscopic portals are established. Diagnostic arthroscopy is performed with the following findings:
1. Normal articular surface of the patella.
2. Normal articular surface of the trochlea.
3. Normal suprapatellar pouch.
4. Normal medial and lateral gutters.
5. Intact ACL.
6. Normal lateral compartment including articular cartilage with a normal meniscus.
7. Large full-thickness osteochondral defect of the medial femoral condyle, acute, with intact medial meniscus and a preserved articular surface of the tibial plateau.
At this point this injury is recognized as not a complete loose body. The osteochondral piece is large and there is still soft tissue attachment. There is a large bony bed and a defect on the medial femoral condyle. The corresponding osteochondral piece has fragmented articular cartilage, but there is bone on the back side of the articular piece. After careful inspection, the decision is made to attempt a repair. It is fairly easily reducible with a probe via the inferomedial portal. Before this is performed, however, a curet is used to remove any fibrous tissue from the bed of the osteochondral defect as well as from the osteoarticular piece. Once it is debrided and fresh bony surfaces are obtained, the piece is then reduced. At this point multiple small percutaneous incisions are made for guide pins for the Acutrak mini screws. These are placed in a triangular configuration securing the piece to its bony bed. Each wire is then sequentially drilled under arthroscopic visualization and 3 separate mini Acutrak screws are placed. Please note that the most posterior one is done with the knee in deep flexion. Excellent fixation is attained; however, once the knee is brought in through a range of motion there is noted to be instability. The probe is used to inspect the repair site and it is found to have marked comminution of the osteochondral piece. It is deemed to be irreparable and it is felt that the residual surface would produce mechanical symptoms. The decision was made to perform a chondroplasty and removal. At this point careful removal of the Acutrak screws was performed arthroscopically. The comminuted piece which is now loose is removed. Multiple osteochondral pieces are excised. The bed of the defect is then abraded with a 4.5 mm shaver to stimulate some healing. Please note that the length and width of the defect is 34 mm x 28 mm. The knee is inspected for residual retained pathology and there is none. All loose bodies are removed. The portals are then closed, bulky sterile dressings applied. The patient is awakened from anesthesia.
