AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2026 Issue 3; Ask the Editor

Proximal Realignment Lateral Retinacular Release and Imbrication for Instability Status Post Total Knee Replacement

A patient had a computed tomography (CT) of the right knee which demonstrated a lateral dislocation of a prosthetic patellar component. The provider diagnosed recurrent instability status post right total knee replacement due to scar tissue from the previous surgery. The patient underwent a proximal realignment lateral retinacular release and imbrication of the right knee. During the procedure, a medial parapatellar arthrotomy was made, and the patella was everted. The provider performed an inside-out lateral release and subsequently raised a subcutaneous flap through the anterior incision and formalized the lateral release by connecting it with an outside-in technique. Following this, proximal realignment was done by imbricating the medial soft tissue off the patella and medial aspect of the quadriceps through a pants-over-vest technique using sutures. What is the correct code assignment for a retinacular release and imbrication of the patellar component of a total knee replacement? ...

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