27415 with 29877 and 29875

I am new to Ortho coding and my boss says that I am to bill for 27415, 29877, and 29875 because the Dr does the chondroplasty and the synovectomy in different compartments. Encoder pro says you can't bill 29875 and 29877 together under any circumstances. Is there any way around this because my boss is very adamant about this and that the Dr puts in extra work to do these procedures. Can anyone help? This is the op note: DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and was given general anesthetic by Dr. . The knee was examined under anesthesia. There was crepitance with flexion and extension, no significant instability. An operative time out was taken and the operative site was verified and preoperative antibiotics were given.
 
I examined the left knee under anesthesia.  The patella tracked centrally.  There was crepitance with flexion and extension.  There is some clicking in the anterior medial joint line as well.  There was no gross instability or no obvious McMurray's.
 
A left thigh tourniquet was placed. The leg was placed in the leg holder and prepped and draped in a routine sterile fashion.  The left hip anterior crest was also prepped out for a bone marrow aspiration.
 
I then aligned ahead and prepared the bone marrow aspiration.  A 11 blade was used to make a small stab incision over the left hip iliac crest.  10 mL of ACD anticoagulant had been aspirated into a 60 mL syringe and 5 mL's of this was flushed through an 11-gauge Jamshidi needle to prevent clotting.  The Jamshidi needle was then placed against iliac crest and tapped through the outer table into the bone marrow between the inner and outer tables.  I then used a 60 mL syringe to aspirate 30 ML's of bone marrow aspirate and blood from the hip.  I then repositioned the needle to another splint location and aspirated an additional 30 ML's of bone marrow aspirate and blood to get a total of 55 ML's mixed with 5 mL of anticoagulant.  I then transferred this to the Biomet bone marrow aspirate reservoir and spun this in the centrifuge for 15 minutes at 3500 RPMs.
 
When this was finished 30 ML's of the platelet poor plasma was withdrawn this is placed in a 30 mL syringe.  Next, a 10 mL syringe was used to aspirate 7 ML's of the bone marrow concentrated aspirate which will be used for mixing with the bio cartilage and also injecting into the knee after surgery to promote healing.
 
I then turned my attention to arthroscopy of the left knee.
 
 
The leg had been in full extension with elevation and I finished exsanguinated the leg and raised the tourniquet to 300  millimeters mercury.  I made an inferolateral parapatellar incision.  The blunt trocar was introduced into the scope and a superomedial outflow portal was established. The suprapatellar pouch had some adhesions. There was chondromalacia under the patella centrally.  There was grade 3 chondromalacia. It was a moderate portion of the Central portion of the patella.  This was in the region of the previous CARTIFORM osteochondral allograft
 
The trochlea was fairly clean with just slight chondromalacia. The medial and lateral gutters were clean. I entered the medial compartment. The medial femur had a chondral lesion in the weightbearing portion of the medial femur.  It was about 20 mm wide and about 20 mm long.  The tibia was in good condition.   The medial meniscus appeared to be intact. I probed this. It was stable without tears.
 
I then checked the intercondylar notch. The anterior cruciate ligament and posterior cruciate ligament were intact. I debrided the ligamentum mucosum.
 
 
The knee was then brought into the figure-of-4 position and the lateral compartment was inspected. There was No chondromalacia on the lateral tibial plateau, or lateral femur. The lateral meniscus was intact and the lateral femur was in good condition with no chondromalacia . I used the shaver to just trim off some mild synovitis. I then brought the knee into full extended position and resected the suprapatellar adhesions through the inferomedial and superomedial portals. I then d brided some of the patella, and then as I inspected this, the cartilage appeared to have near full-thickness cartilage defect in the central aspect.
 
I then went to check patellar tracking.
Checked the tracking through the inferolateral portal and as the knee flexed the patella seemed to track centrally.  I did not do a formal check through the superior medial portal with the 70 degree arthroscope.
 
 
I then returned to the articular cartilage defects on the medial femur and the patella.  I used a ring curet to bear debrided this loose fibrillated articular cartilage and clean the calcified cartilage layer down to the bone area.
 
 
I then used the Arthrex arthroscopic bio cartilage delivery system and used the fat pad retractor in the knee and mixed 1 mL of bio cartilage cells in the delivery system with the 0.8 ML's of bone marrow aspirate concentrate.  Once this was a fairly firm placed I then dried and the medial compartment and the joint and under dry arthroscope inserted the inserter in fill the defect on the medial femoral condyle.
 
I used the specialists move this in the defect.  I then made sure there was dry and then used Tisseel fibrin glue to glue this closed.  I waited 5 minutes to let this a completely solid.  I then flexed the knee up and brought into full extension.
 
I then introduced the bio cartilage to the patellar chondral defect and placed some of the graft into the patellar defect.  I smoothed this over and then once this is hard used the fibrin glue to glue this defect  as well.
 
I then infiltrated the bone marrow aspiration site and the arthroscopy portal sites as well as a deep medial abductor canal block with a mixture of 40 ML's of half percent plain Marcaine and 20 ML's of Experal using a 22-gauge spinal needle.
 
I then took my remaining 6 ML's of bone marrow aspirate concentrate and injected into the left knee through the inferomedial and inferolateral and superomedial portals.  I then covered these with Polysporin and Xeroform 4 x 4's, ABD pads, sterile cast padding, and Ace wraps, toe-to-thigh. The patient was then
placed in a knee immobilizer. The blood loss was about 50 mL. She tolerated this well. She was then awakened, extubated, and taken to the recovery tom in stable condition.
 
The postoperative plan of care will be to keep the patient in a knee immobilizer for 5 days. She can do ankle pumps, straight-leg raises, abduction, but remain non- weight bearing. At that point, I planned to start passive range of motion with rolling chair or skateboard, 0-50
degrees for approximately 2 weeks, followed by increasing this to 0-70 degrees for an additional 2 weeks, And then allowing allowing her to increase to 50% weightbearing in full extension, locking in full extension for at least 4 weeks, touchdown weight bearing before advancing
to full weight bearing.   She will return in 3 days for dressing change and drain removal.  Suture removal will be in about 10 days.
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Comments

  • The NCCI Policy Manual, Chapter 4, Section E, Subsection 8 is very clear that 29875 can never be billed with another arthroscopic code when performed on the same knee. 

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