L2270 - HCPCS Code for Varus/valgus strap padded/li

Hello! I am a 25 y/o medical student who broke bilateral radial heads in a high-impact FOOSH biking accident early last spring. In the last 3 months, I have since had new-onset and worsening crepitation, pain, and stiffness in passive and active ROM of my L elbow, most prominent with forearm supination during elbow flexion. This is in the context of a relatively benign MRI, so I don't know what could be causing it and am looking for answers here!
Hx: I got x-rays at the time of the accident showing bilaterally minimally-displaced intra-articular radial head fractures, and given low concern for possible displacement, I went almost immediately back to usual life, barring heavy lifting. I also did aggressive home physical therapy and recovered all ROM and then some, maybe suggesting some instability. 6 weeks later, I had a follow-up with a hand and elbow orthopedist who was pleased with my progress as I was almost 100% back to normal. I went back to biking and using my arms heavily. In October, I noticed loud cracking sounds in my L elbow combined with feeling of resistance with certain elbow motions, some intermittent swelling, and occasional pain localizing over the radial head, so I went back for an MRI. It was read as unremarkable, with a small effusion and osteochondral defect to be expected given the initial injury. Ortho's exam was significant for some bilaterally symmetric varus and valgus instability, which could have been there prior to injury given my baseline hyperflexibility. Otherwise normal with full symmetric ROM and strength. (Though since then, I have lost some strength mostly in elbow extension that is likely due to pain/under-use.) The source of the loud cracking remained a mystery, but ortho felt confident it would improve with time. I felt less confident given it was a new-onset issue that happened after I had made a full recovery. Since November, it's only gotten worse with louder crepitation present throughout flexion and forearm supination, loud cracks on full extension, and sharp pain on the lateral elbow with full extension and flexion.
I'm very grateful that my R (dominant) arm has healed 100% and stayed that way, but my L arm is really bothering me. Prior to the MRI, I was most worried about post-traumatic osteoarthritis, but I think the MRI would have shown more dramatic changes. I guess there's the possibility that there's a small free body in there that wasn't picked up on the MRI. What do you think is most likely the issue, and what do you think I should be doing to help improve the function of my elbow?
Thank you in advance for your input!

Overview of LCL Pathology
In patients who have a complete lateral or fibular collateral ligament (LCL) tear and noticeable side-to-side instability with activities, a lateral collateral ligament surgery is recommended. The term fibular collateral ligament (FCL) is more anatomically correct, but is more commonly referred to as lateral collateral ligament (LCL).
LCL surgery is very effective in restoring side-to-side stability to the knee and preventing varus gapping. During a clinical exam and varus stress radiographs, we will be able to confirm whether or not there is a complete LCL tear. It is important to note that an MRI scan can be inaccurate – especially in cases of a chronic situation where the LCL heals improperly – that is why it is important to properly analyze the pathology.
Treatment for LCL Injury
The severity of the LCL injury will determine the treatment method. In less severe cases, a remedy of rest, ice, compression, and elevation (RICE) along with the use of anti-inflammatory medications (NSAIDs) and pain relievers can alleviate discomfort and help diminish swelling. Increasing strength and range-of-motion can be achieved through physical therapy, and ultimately restore the knee back to a healthy state.
Typically, patients who have a complete LCL tear will require surgical treatment. This surgical procedure is typically done as an open procedure in conjunct with arthroscopy. Dr. Miten Sheth from The Knee Clinic will replace the torn lateral collateral ligament with a tissue graft. The graft is passed through the bone tunnels and attached to the femur and fibula bone using screws.
We prefer an anatomic technique for surgical reconstruction. With this technique, we use either autograft hamstring tendon to reconstruct the lateral collateral ligament between its native course. First, a tunnel is reamed at the femoral attachment site, slightly proximal and posterior to the lateral epicondyle. We then secure the graft at this location with an interference screw in the prepared tunnel. The graft is then passed under the superficial layer of the iliotibial band and the lateral aponeurosis of the long head of the biceps femoris. Next, a tunnel is reamed through the fibular head, starting laterally at the exact attachment site of the LCL on the fibular head, and exits on the medial aspect of the fibular styloid just distal to the popliteofibular ligament. The graft is then passed through this. The graft is placed under tension, the knee is flexed to 20 degrees and a valgus reduction force is applied. A screw is then used to attach the graft in the fibular head. Once one confirms on exam under anesthesia that the varus gapping is eliminated, the procedure can then be ended.
Are you a candidate for LCL Reconstruction?
There are two ways to initiate a consultation with Dr. Sheth:
1. You can provide X-rays and/or MRIs for a clinical case review with Dr. Sheth.
2. You can schedule an OPD consultation.
REQUEST CASE REVIEW OR OPD CONSULTATION
(Please keep reading below for more information on this treatment.)
Post-Operative Protocol for LCL Surgery
Rehabilitation for LCL surgery involves early range of motion of the knee, starting at a minimum of 0 to 90 degrees the first day, and then after 2 weeks progressing further. Isolated hamstring exercises should be avoided for the first 4 months post-operatively. Patients should not place weight on the injured leg for 6 weeks and then may progress to crutches and start the use of a stationary bike starting at week 6. They should avoid side-to-side activities, or step-up activities, until varus stress X-rays are obtained at 5 months post-operatively verify that there is sufficient healing of the reconstruction graft to allow further activities. For athletes, we usually recommend the use of a secure brace to allow them to initiate these activities and request that they wear it through the first year after surgery to maximize graft healing.

Can someone with a lot of experience in C&P exams help me out this and tell me based on the notes what my rating would be? Thanks, I greatly appreciate it!
Indicate method used to obtain medical information to complete this document:

 [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information 

on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.

 [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using 

the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.

 [ ] Examination via approved video telehealth [X] In-person examination 

a. Evidence review

 Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment 

records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other:
b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No

1. Diagnosis

   a. List the claimed condition(s) that pertain to this DBQ: bilateral patellofemoral pain syndrome
   b. Select diagnoses associated with the claimed condition(s) (Check all that apply):
   [X] Patellofemoral pain syndrome Side affected: [ ] Right [ ] Left [X] Both ICD Code: M22.2x1 and M22.2x2 Date of diagnosis: Right 2012 Date of diagnosis: Left 2012
   c. Comments (if any): No response provided
   d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A
   

2. Medical history

   a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Bilateral patellofemoral pain syndrome diagonsed in the Marines following a fall from a height when he landed on his knees. He has continued to have pain in both anterior kneessince then. He has not had care for his knees since discharge in 2013.
   b. Does the Veteran report flare-ups of the knee and/or lower leg? [ ] Yes [X] No
   c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [X] Yes [ ] No
   

    If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: Pain with walking, climbing or decending stairs, and with prolonged standing. He has pain with pressure on the anterior knees, so he 

   cannot kneel down.
   

3. Range of motion (ROM) and functional limitation

   a. Initial range of motion
   Right Knee
   [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
   

    Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking. 

   Description of pain (select best response): Pain noted on exam and causes functional loss
   If noted on exam, which ROM exhibited pain (select all that apply)? Flexion
   Is there evidence of pain with weight bearing? [X] Yes [ ] No
   Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
   

   If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line. 

   Is there objective evidence of crepitus? [ ] Yes [X] No
   Left Knee
   [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
   

    Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking. 

   Description of pain (select best response): Pain noted on exam and causes functional loss
   If noted on exam, which ROM exhibited pain (select all that apply)? Flexion
   Is there evidence of pain with weight bearing? [X] Yes [ ] No
   Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
   

   If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line. 

   Is there objective evidence of crepitus? [ ] Yes [X] No
   b. Observed repetitive use
   Right Knee
   Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No
   Left Knee
   Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No
   c. Repeated use over time
   Right Knee
   Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No
   Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
   

    Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing. 

   Left Knee
   Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No
   Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
   

    Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing. 

   d. Flare-ups No response provided
   e. Additional factors contributing to disability
   Right Knee
   In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None
   Left Knee
   In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None
   

4. Muscle strength testing

   a. Muscle strength - Rate strength according to the following scale:
   0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength
   Right Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No
   Left Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No
   b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
   c. Comments, if any: No response provided
   

5. Ankylosis

   Complete this section if the Veteran has ankylosis of the knee and/or lower leg.
   a. Indicate severity of ankylosis and side affected (check all that apply):
   Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis
   Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis
   b. Indicate angle of ankylosis in degrees: No response provided
   c. Comments, if any: No response provided
   

6. Joint stability tests

   a. Is there a history of recurrent subluxation?
   Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
   Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
   b. Is there a history of lateral instability?
   Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
   Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
   c. Is there a history of recurrent effusion?
   [ ] Yes [X] No
   d. Performance of joint stability testing
   Right Knee:
   

   Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) 

   Left Knee:
   

   Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) 

   e. Comments, if any: No response provided
   

7. Additional conditions

   a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No
   b. Comments, if any: No response provided
   

8. Meniscal conditions

   a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No
   b. For all checked boxes above, describe: No response provided
   

9. Surgical procedures

   No response provided
   
10. Other pertinent physical findings, complications, conditions, signs,
    

    symptoms and scars

    a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No
    b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No
    c. Comments, if any: No response provided
    

11. Assistive devices

    a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No
    b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided
    

12. Remaining effective function of the extremities

    Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
    [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No
    

13. Diagnostic testing

    a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No
    

     If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No 

    b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No
    c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided
    

14. Functional impact

    Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No
    If yes, describe the functional impact of each condition, providing one or more examples: The Veteran has significant pain in both knees with walking, standing and kneeling so that he would have a difficult time perorming duties which would require those actions.
    

15. Remarks, if any:

    No response provided