AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2026 Issue 2; Ask the Editor
Trochleoplasty
A patient with a history of chronic patellar subluxation presented for surgical intervention due to left patellar instability with a medial patellofemoral ligament tear, type D trochlear dysplasia and a loose body in the knee. During the procedure, a 5 cm long tibial tubercle osteotomy was performed and the trochlea was exposed. A trochleoplasty was performed using osteotomes, burr and Arthrex guided burrs to create a thin shell osteotomy. A pushlock anchor was placed in the central trochlea and then affixed to another pushlock anchor over the lateral trochleoplasty. Additional fixation was obtained by placing compression screws in the medial and lateral trochlear flaps. Following the trochleoplasty portion of the procedure, tibial tubercle fixation was performed with bone graft followed by reconstruction of the medial patella-femoral ligament using allograft tendon.Is the trochleoplasty inherent to the reconstruction procedure to repair the patellar instability or is it separately reported? If it is separately reported, what is the ICD-10-PCS code for trochleoplasty? ...
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Article Overview
This article reviews an orthopedic surgical scenario involving patellar instability, trochlear dysplasia, and related knee reconstruction procedures. It is relevant to surgeons, coders, and billing staff who need to understand how the operative components fit together and whether the trochleoplasty is treated as part of the overall reconstruction or as a separate procedure. The discussion is framed around procedure composition and coding considerations rather than clinical management.
Why This Topic Matters
Accurate procedure coding in complex knee stabilization cases depends on understanding which operative components are distinct and which may be considered integral to the primary repair. This article helps readers evaluate how the reported surgical steps fit together for coding and documentation review.
What You Will Learn
- How trochleoplasty is discussed in the context of complex patellar instability surgery
- How associated knee reconstruction procedures are presented in relation to the main operative repair
- What kinds of coding and billing questions arise when multiple surgical components are performed in one case
- How operative documentation can affect interpretation of procedure distinctness
Who Should Read This
- Orthopedic surgeons
- Medical coders
- Billing specialists
- Clinical documentation staff
- Revenue cycle professionals
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