AHA Coding Clinic® for HCPCS - 2020 Quarter 3; Ask the Editor
Bone grafting of femur and tibial tunnels
A patient with a left knee anterior cruciate ligament tear, torn lateral meniscus and retained hardware from a previous anterior cruciate ligament reconstruction presented for a left knee arthroscopic anterior cruciate ligament repair, open removal of retained hardware and bone grafting of the distal femur and tibial tunnels. Following the arthroscopic anterior cruciate ligament repair, a tibial incision was made through subcutaneous tissue to access the tibial tunnel in order to remove the deep hardware. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. What code(s) would be reported for the open removal of retained deep hardware, along with placement of bone graft to the femur and tibial tunnels? Is it appropriate to assign codes for both the arthroscopic and open portions of the procedure? ...
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Article Overview
This premium article explains how to approach CPT reporting for a knee operative encounter that includes arthroscopic and open components, hardware removal, and bone grafting related to prior reconstruction tunnels. It is intended for coders, auditors, and clinical documentation staff who need to understand the scope of the encounter and the types of coding considerations addressed in the article.
Why This Topic Matters
Complex knee cases often combine multiple procedures across different approaches, and accurate CPT reporting depends on understanding how the operative services relate to one another. This article helps readers evaluate whether the arthroscopic and open portions of the encounter are separately reportable and what coding topics are involved.
What You Will Learn
- How the article frames CPT reporting for a combined arthroscopic and open knee procedure
- What coding topics are involved when hardware removal and tunnel bone grafting occur in the same operative encounter
- How the article addresses the relationship between the arthroscopic and open portions of the case
- What kinds of documentation details are relevant to reporting prior reconstruction tunnel work
Who Should Read This
- Medical coders
- Coding auditors
- Orthopedic billing staff
- Clinical documentation specialists
Codes Discussed
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