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My provider was reading something today that said in order to code Chronic Kidney Disease Level 2, you have to be able to show "injury"…so albumin level has to be high enough to support the Dx. Everything I read in regard to coding CKD levels is in relation to GFR levels.
Can anyone provide any insight and if possible references? I would be so appreciative!
Thanks!
"…The same bone void that was there previously was reassessed. The alignment was appropriate. I didn’t see any significant worsening of the soft tissue and felt overall he had a reasonably stable bed. I irrigated with 9 L of normal saline and debrided any tissue felt was tenuous area this included some skin and muscle and bone. I then turned my attention to the medial side. I assessed where the posterior medial aspect of the tibia was. I measured it to the anterior wound and had at least 7 cm but mostly 7-10 cm. Posteriorly was at least 12. I then performed a standard posterior medial approach. Became very evident that he hadn’t had a severe crush injury to his leg and the soft tissue was very contused. Any nonviable tissue was removed. I dissected directly down onto his posterior medial tibia. I did not think it is worth salvaging hamstrings in this particular situation and therefore cut through them. The footprint for the plate was made. Using a sharp reduction clamp I reduced the proximal fracture to the tibial shaft. The fracture had initially been extension and this realigned. I then chose an appropriate length plate to give me enough screws distal to the fracture itself but also proximal to the pin sites of the ex-fix. I then attached the plate to the distal bone with a single cortical screw. I checked the locking trajectory on the proximal screws and I did not like where it was directly and therefore opted to put in non-lockers proximally. I could skirt the subchondral bone. I inserted 4 proximal screws and 3 more distal screws all of them were non-lockers. Because of this I did not think that my construct was stable enough in isolation. I therefore opted to apply a short lateral plate with only a single screw distally. The benefit of this is that I could contain the bone cement between the 2 plates and the bone and I could use the cement to screw into 2 enhance my stability. Once the lateral plate was applied about 2 bags of tobramycin cement and added 6 g of vancomycin. It was hand mixed. When doughy I pressed it into the bone void. I did not push it far down the canal and simply filled in the proximal lateral tibia that I felt was deficient. Once in the appropriate position and hardened I drilled into the bone cement and inserted 2 cortical screws. Final fluoroscopy shots were taken demonstrated appropriate alignment and appropriate position of the bone cement with no leakage out of the bone into concerning laces…."
I will capture the ORIF RT Tibia, but I haven’t seen a staged Masquelet before.
Thanks for the help,
Aubrey
PREOPERATIVE DIAGNOSES:
1. Left knee anterior cruciate ligament graft tear
2. Left knee medial meniscal tear
POSTOPERATIVE DIAGNOSES:
1. Left knee anterior cruciate ligament graft tear.
2. Left knee medial meniscus degenerative tear
3. Left knee lateral meniscus posterior root tear
4. Medial femoral condyle and lateral tibial plateau grade 2/3 chondromalacia
PROCEDURES PERFORMED:
1. Left knee arthroscopic anterior cruciate ligament debridement and bone grafting
2. Left knee partial medial meniscectomy
3. Left knee medial femoral condyle and lateral tibial plateau chondroplasty
ANESTHESIA:General COMPLICATIONS:None. BLOOD LOSS:Minimal. TOURNIQUET TIME:Per Anesthesia.
FINDINGS: 1. Complete ACL rupture torn from the femoral side.2. Degenerative posterior horn medial meniscus tear but there is more than 25% of the posterior horn remaining3. Avulsion of the posterior root of the lateral meniscus4. Grade 3 chondromalacia of the medial femoral condyle which is diffuse as well as grade 3 diffuse chondromalacia of the lateral tibial plateau
INDICATIONS: is a male that 3 years ago underwent a left knee MCL and anterior cruciate ligament reconstruction surgery using allograft as well as partial medial meniscectomy. Patient states that since that surgery his knee has never felt stable. He has problems when doing sporting activities and he is very active. I order an MRI which showed a tear of the anterior cruciate ligament graft as well as a medial meniscus posterior horn tear. I explained to the patient that his physical exam was consistent with anterior cruciate ligament insufficiency and in order to improve that we’ll need to do a revision anterior cruciate ligament surgery. MRI as well as x-ray showed widening of the femoral and tibial tunnel therefore I told the patient that I will do this in a 2 stage procedure. The first stage will be diagnostic scope and anterior cruciate ligament debridement along with bone grafting of the tunnels. I also will perform partial medial meniscectomy the same procedure. He will come back 3 months later for the second stage will be anterior cruciate ligament reconstruction using patellar tendon autograft. Patient understands and agreed to sign surgical consent.
DESCRIPTION OF PROCEDURE:After informed consent was obtained, the patient was identified in the preop holding room. The left leg was marked and then the patient was administered a Dr. canal nerve block by Anesthesia, taken to theoperating room, laid supine on the operating table and placed under general anesthesia. The left lower extremity was then examined. The patient had the above findings on the exam under anesthesia. Patient was then prepped and draped in a normal sterile fashion. Time-out was initiated. The correct patient and procedures were identified. We then exsanguinated the leg and inflated the tourniquet. I then made anterolateral and anteromedial portals. Arthroscope was placed in the knee. The patellofemoral articular cartilage was probed and it was found to have the above-mentioned findings. Looking in the medial compartment the meniscus and articular cartilage was examined and probed. The patient had the above-mentioned findings. With the help of arthroscopic baskets and shaver I treated for portion of the posterior horn of the medial meniscus. After this was done the reminder of the meniscus was probed and found to be stable. I also performed a chondroplasty using arthroscopic shaver of the iliofemoral condyle. Undermining of the cartilage rim was probed and found to be stable. In the intercondylar notch the patient had an obvious ACL tear and the stump which was identified and probed. I then went to the lateral compartment and the meniscus and articular cartilage was examined and probed. The patient had avulsion of the posterior root of the lateral meniscus. This was debrided but left intact and I will perform good repair procedure on the second stage. I performed chondroplasty of the lateral tibial plateau with the help of arthroscopic shaver. I then debrided the remnants of the ACL of the femur as well as the tibia. Then I took a radiofrequency ablator to clean off the soft tissue from the lateral femoral condyle wall as well as the ACL footprint on the tibia. After removing all the soft tissues on the lateral femoral wall and performing another notch plasty with the help of arthroscopic bur I debrided the soft tissue from inside the tunnel under visualization of the previews guidepin hole was seen on the back wall. I inserted a guide pain and retrieve it outside of the lateral knee. Then overreaming with a low-profile reaming was done until a size 12 reamer was inserted. Total length of the tunnel was measured to be 25 mm. The total diameter of the femoral tunnel measured about 20 mm in diameter. After cleaning out all the soft tissue from inside the tunnel with the arthroscopic shaver I performed microfracture along the femoral tunnel using chondral picks. Then I removed the scope from the joint and went to the back table where I made 2 bone graft bone proximal from of femoral head allograft. The 2 bone plugs measured 12 mm and 9 mm in diameter. Then I went back into the joint and retrieve the 12 mm plug in the femoral tunnel with a bone tamp and then a side-to-side 9 mm plug was inserted and again impacted with a bone tamp until adequate filling of the femoral tunnel was achieved. The remaining of the bone plugs were resected using arthroscopic shaver. Adequate femoral tunnel coverage was obtained. Then I removed the scope out of the joint and I went to the medial proximal tibia where I perform a 3 cm incision along the previously marked tibial tunnel. The tunnel was identified and removal of previews of the bone stitches was done. Then I inserted a guide pin through the tibial tunnel. I placed the scope back in the joint and with the knee flexed at 90° and the guide pin clamp with a hemostat I performed overreaming of the tibial tunnel until an 11 mm barrel reamer was inserted. After this perform a use an arthroscopic shaver to remove all soft tissue from inside the tunnel. I performed microfracture of the tibial tunnel using a chondral pick. Then I made an 11 mm bone plug and inserted in the tibia and compressed it using a bone tamp. After this perform a put some bone wax outside of the tibial tunnel. Removed the scope from inside the joint. The 2 portals were closed using a 3-0 nylon. The medial tibial incision was closed using 0 Vicryl, 2-0 Vicryl and 3-0 nylon. Sterile dressings were applied. The tourniquet was let down. The patient was placed in an IROM knee immobilizer and awoken and taken to the recovery room. He will be following the chondroplasty rehabilitation protocol.
Thank you
Gayathri Subramanian
All eligible hospitals, critical access hospitals (CAHs), and dual-eligible hospitals seeking to demonstrate meaningful use of certified electronic health record technology (CEHRT) for the first time in 2017 must attest to Modified Stage 2 or Stage 3 objectives and measures. The EHR reporting period is a minimum of any continuous 90 days between Jan. 1, […]
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