Seit dem 1. Juli 2020 gibt es eine neue Q-Beurteilungs-Richtlinie für alle niedergelassenen Ärzte. Ab sofort müssen aus den vorgelegten Unterlagen die OP-Indikation und das ausgewählte OP-Verfahren nachvollziehbar dokumentiert sein.
Hier finden Sie eine Liste mit möglichen Indikations-Begründungen aller gängigen arthroskopischen Eingriffe an Knie und Schulter. Die Inhalte könne in die jeweilige Praxis-Software eingepflegt werden. Eine Anpassung der Liste auf die individuelle Situation ist unbedingt notwendig. Die Auswahl des Eingriffes sollte so dokumentiert sein, dass sie sich dem fachkundigen Kollegen in der KV-Kommission erschließt. Bei Abweichungen vom medizinischen Standard sollten Erläuterungen zum Verfahren dokumentiert werden.
Beispiele
Die Indikation zur arthroskopischen Operation ergibt sich in diesem individuellen Fall aufgrund:
von persistierenden Schmerzen | |
der Erfolglosigkeit der bisherigen Behandlung | |
des langen Beschwerdezeitraumes | |
fehlender nicht operativer Behandlungsoptionen mit gleicher Ergebniswahrscheinlichkeit | |
des Verletzungsmusters | |
des kombinierten Verletzungsmusters | |
der subjektiven Instabilität | |
der objektiven Instabilität | |
der komplexen Instabilität | |
der Bewegungseinschränkung | |
der Blockade(n) | |
der Gelenkschwellung(en) | |
der Arbeitsunfähigkeit | |
der Sportunfähigkeit | |
des Aktivitätsanspruches | |
des sportlichen Anspruches | |
der beruflichen Anforderungen | |
des hohen Leidensdruckes | |
des expliziten Patientenwunsches | |
der Notwendigkeit zu einer weiterführenden intraartikulären Diagnostik (staging OP) bei komplexem Schadensmuster |
spezifische OP-Indikation Schulter
Aufgrund der subakromialen Enge droht ohne Operation eine zunehmende Sehnenschädigung. | |
Aufgrund der Form der Sehnenruptur ist ohne Sehnenrekonstruktion eine Größenprogredienz, ggf. mit klinischer Verschlechterung und ggf. zukünftiger Unmöglichkeit der Rekonstruktion zu erwarten. | |
Aufgrund des Instabilitätsmusters ist ohne operative Stabilisierung mit einer rezidivierenden Schulterinstabilität und/oder zunehmenden Gewebeschäden zu rechnen. | |
Trotz Omarthrose ist durch eine arthroskopische Operation eine Verbesserung der Beschwerden zu erwarten |
spezifische OP-Indikation Knie
Trotz der isolierten Kreuzbandverletzung ist aufgrund des Alters und des sportlichen und des beruflichen Anspruches eine Kreuzbandplastik indiziert. | |
Aufgrund der Meniskusrissform droht ohne Operation eine zunehmende Knorpelschädigung. | |
Es sind die Ausnahmetatbestände des GBA-Beschlusses zur Arthroskopie bei Gonarthrose (Blockaden, freier Gelenkkörper) erfüllt. |
spezifische OP-Indikation Patientenwunsch
Der Pat. wünscht explizit ein arthroskopisches Vorgehen. | |
Der Pat. wünscht explizit ein operatives Vorgehen unter Verzicht auf (weitere) nicht operative Behandlungen.
Der Pat. wünscht explizit ein minimal-invasives Vorgehen. |
|
Der Pat. wünscht explizit keine Endoprothese. | |
Der Pat. wünscht explizit keine Umstellungsosteotomie. | |
Der Pat. wünscht explizit einen Rekonstruktionsversuch. | |
Der Pat. wünscht explizit keine knöcherne Schulterstabilisation. | |
Der Pat. wünscht explizit eine nochmalige Operation. |
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