Coding relating to diagnosis:
- patellar dislocation – S83.0
- recurrent patella dislocation – M22.0
- patellar instability – Category M22 includes other patella disorders as shown below:
M22.1 Recurrent subluxation of patella
M22.2 Patellofemoral disorders
M22.3 Other derangements of patella
M22.4 Chondromalacia patellae
M22.8 Other disorders of patella
M22.9 Disorder of patella, unspecified
Coding relating to treatment – It should be noted that none of these code combinations are specific to the procedure (OPCS does not have specific procedure codes for these procedures and each case would be coded individually based on the documentation and if stabilisation was mentioned then could be coded at W77 or O27).
- Lateral release – W78.3, Y76.7 (If arthroscopic) and Z94.-.
- Trochleoplasty – W81.8, Y26.2 and Z76.5 (may be coded as Z84.4 depending on documentation). If arthroscopic - W84.8, Y26.2 and Z76.5 (may be coded as Z84.4 depending on documentation)(prior to April 2019). Should be W85.8, Y26.2 and Z76.5 (may be coded as Z84.4 depending on documentation)(Post-April 2019) unless stated to be for stabilisation.
- Tibial tubercle osteotomy including Elmslie Trillat / Maquet – Maquet should be coded as T70.3 and Z57.3. Elmslie Trillat is a slightly different procedure.
- Proximal realignment – this is a group of procedures. Would be one of the following procedures:
• lateral release – see above
• lateral retinacular lengthening – W81.8, Y76.7 (If arthroscopic), Y18.8 and Z84.4 (Patellofemoral joint) or Z84.6 (Knee joint unspecified).
• medial reefing or medial plication – W81.6, Y76.7 (If arthroscopic) and Z84.4 (Patellofemoral joint) or Z84.6 (Knee joint unspecified).
• Galleazzi procedure (hamstrings tenodesis) – T64.5, Z57.7.
- Medial patello-femoral ligament (MPFL) reconstruction – W74.3 (O27.1 if documented as for stabilisation) and Z84.4.
-Allograft (at the time of MPFL reconstruction) – Secondary codes to be used with reconstruction codes would include:
Y01.4 Alloreplacement of organ from cadaver heart beating NOC
Y01.5 Alloreplacement of organ from cadaver heart non-beating NOC
Y01.6 Alloreplacement of organ from cadaver NOC
