ACL Reconstruction

CPT 29888
Approach Arthroscopic
Add-on / Variant CPTs
  • 29882 — Arthroscopy, knee, with meniscus repair
  • 29881 — Arthroscopy, knee, with meniscectomy
Preoperative Diagnosis:

Right [left] anterior cruciate ligament tear, [acute / chronic], confirmed on MRI

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] arthroscopic ACL reconstruction with [bone-patellar tendon-bone / hamstring (gracilis/semitendinosus) / quadriceps tendon] autograft

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal [/ spinal] with adductor canal block

Indications:

The patient is a [age]-year-old [male/female] who sustained a right [left] ACL tear [X months] ago. The patient presents with [instability / giving way / inability to return to sport] and desires surgical reconstruction. MRI confirmed complete ACL disruption [with associated meniscal / chondral pathology]. The risks, benefits, and alternatives including conservative management were discussed and informed consent was obtained.

Findings:

Arthroscopic examination confirmed complete ACL disruption. The [medial / lateral] meniscus was [intact / had a [posterior horn / bucket-handle] tear requiring [repair / partial meniscectomy]]. Articular cartilage was [intact / had Grade [I–IV] chondral injury at the [medial femoral condyle / lateral femoral condyle / trochlea]]. The PCL and collateral ligaments were intact. Graft: [BPTB / hamstring] autograft, [X] mm diameter.

Description of Procedure:

The patient was positioned supine with the operative knee in a leg holder. A thigh tourniquet was applied. Standard anteromedial and anterolateral arthroscopic portals were established. A diagnostic arthroscopy was performed.

[GRAFT HARVEST: BPTB]
A [3]-cm anterior longitudinal incision was made overlying the patellar tendon. The central third ([10] mm) of the patellar tendon was harvested with [25] × [10]-mm bone plugs from the patella and tibial tubercle. The harvest defect was filled with bone graft. The graft was prepared on the back table to [X] mm diameter.

[GRAFT HARVEST: HAMSTRING]
The gracilis and semitendinosus tendons were harvested through a [3]-cm anteromedial tibial incision using a closed tendon stripper. The tendons were prepared as a [quadrupled] graft to [X] mm diameter.

Notch preparation and debridement were performed. The ACL tibial guide was set to [55°] and the tibial tunnel was drilled at the anatomic ACL tibial footprint. The femoral tunnel was drilled [via accessory medial portal / transtibially] at the anatomic femoral footprint [10:30 / 1:30 o'clock position], to a depth of [30] mm.

The graft was passed through the tibial tunnel and into the femoral tunnel. [Femoral fixation: [Endobutton / interference screw] at [X°] of knee flexion.] The graft was tensioned at [20–30 lbs]. [Tibial fixation: [X]-mm × [X]-mm interference screw with the knee at [10–20°] flexion.] Final arthroscopic inspection confirmed anatomic graft position and full range of motion without impingement.

[Concomitant meniscal repair / partial meniscectomy was performed as described.]

Portals were closed with [3-0 Monocryl]. A sterile dressing and knee immobilizer were applied.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient was taken to the PACU in stable condition. Weight-bearing as tolerated with crutches was permitted. A postoperative rehabilitation protocol was provided. Follow-up in [2 weeks].

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left ACL tear, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left ACL reconstruction, *** autograft
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General + adductor canal block

INDICATIONS: .PTAGE-year-old .PTSEX with ACL tear *** months, instability. MRI confirmed. Consent obtained.

FINDINGS: ACL completely disrupted. Menisci: ***. Cartilage: ***. PCL/collaterals intact. Graft: *** autograft *** mm.

PROCEDURE:
Supine, leg holder. Tourniquet. AM/AL portals. Diagnostic scope: findings above. Graft harvest: ***. Graft *** mm prepared. Notch debridement. Tibial tunnel at 55°, anatomic footprint. Femoral tunnel via ***, 10:30/1:30, 30 mm. Graft passed. Femoral fixation ***. Tensioned. Tibial fixation *** × *** mm interference screw. Scope confirmed anatomic position, full ROM, no impingement. [Meniscal ***]. Closed.

EBL: Minimal
COMPLICATIONS: None
DISPOSITION: WBAT with crutches. Rehab protocol provided.

Signed: .ME, .MYDEGREE
.TODAY
Variants

ACL Reconstruction: Allograft

Given [patient age > 40 / prior harvest site morbidity / revision ACL surgery / patient preference], an allograft was selected. A [BPTB / Achilles / anterior tibialis] allograft processed by [tissue bank] was used. The graft was thawed and prepared to [X] mm. Fixation proceeded as described. Allografts have higher re-tear rates in young active patients and slower biological incorporation; they are preferred in older lower-demand patients and revision settings to avoid additional donor site morbidity.

Lateral Extra-Articular Tenodesis (LET): Augmentation

Given [high-grade pivot shift / revision ACL / anterolateral ligament injury / young athlete returning to pivoting sport], lateral extra-articular tenodesis was performed to augment rotational stability. The iliotibial band was harvested as a [modified Lemaire / MacIntosh] strip, left attached distally, and tunneled under the fibular collateral ligament to a bone tunnel in the lateral femoral condyle. The graft was tensioned at 30° flexion with the knee in neutral rotation and fixed with a [6.5-mm] screw. LET reduces the pivot-shift and improves return-to-sport rates in high-risk patients.

Charting Tips
  • Document graft diameter. ACL graft diameter <8 mm (hamstring) is associated with significantly higher re-tear rates. Document the measured graft size and if the diameter was suboptimal, document the decision rationale.
  • Document tunnel positions using anatomic landmarks (footprint, clock face). 'Isometric' tunnel placement is no longer the standard; anatomic placement at the native ACL footprint is. Documentation of the anatomic position justifies the technique and defends against claims of nonanatomic reconstruction if the patient re-tears.
  • Document concomitant meniscal pathology and treatment. Untreated meniscal tears at the time of ACL reconstruction accelerate articular cartilage degeneration. Document what was found, what was done, and why (repair vs. resection).
Billing Tips
  • Bill 27407 for primary ACL repair (10.58 wRVU, 90-day global). Bill 27409 for combined ACL and collateral ligament repair at the same setting (13.37 wRVU). Document which ligaments were addressed.
  • Arthroscopic ACL reconstruction (the standard approach) uses 29888 (27.44 wRVU, 90-day global), not 27407. 27407 is for open repair. Most modern ACL cases should be billed as 29888.
  • Concomitant meniscectomy (29880/29881) or chondroplasty (29877) at the same setting may be separately billable. Confirm with your billing team, as some payers bundle these with ACL reconstruction.
  • Graft type (patellar tendon, hamstring, allograft) does not change the CPT code. Allograft material may be separately billed as a supply by the facility.
  • 90-day global period: physical therapy coordination, brace management, and routine follow-up are bundled. Formal PT sessions are billed by the therapist independently.