Hi, I am having a lot of confusion about the op note below. I am questioning whether to code 29874 or 29877. A plica is mentioned, but I have not seen anything in the note regarding the plicectomy. Anyone have any feedback? Thanks!!
PRINCIPAL DIAGNOSIS: Synovitis with plica, anterior Hoffa fat pad, osteochondritis dissecans of medial femoral condyle.
PRINCIPAL PROCEDURE: Arthroscopic debridement.
PROCEDURE: The patient was site marked in the holding area. Time-out was done on patient's entry into the room. Ancef 2 g was given within 1 hour of the incision. All bony prominences were appropriately padded. Warm blankets and warm IV fluids were used throughout the procedure to maintain optimum normothermia. Lidocaine 1% with 1:200,000 epinephrine solution was instilled in the intra-articular portion of the joint. Medial and lateral parapatellar portals incised, inflow and scope inserted.
Patellofemoral joint was inspected and probed. She was noted to have some hypertrophic synovitis in the medial patellofemoral mechanism. She was noted to have a small OCD of the medial femoral condyle that was in the nonweightbearing portion of the bone, which we did debride. The medial meniscus was noted to be normal. She was noted to have anterior synovitis around the anterior aspect of the medial meniscus, which we did debride. ACL was normal. Lateral joint space was normal. We then spent a long time debriding out all the synovitis until we got back to good stable tissue. We did debride the OCD until we got back to good stable tissue.
We copiously irrigated, closed with Prolene, placed Naropin, Toradol, and Astramorph in the knee for postop analgesia. The patient tolerated the procedure well and was taken to the recovery room in good condition. Sponge and needle counts
PRINCIPAL DIAGNOSIS: Synovitis with plica, anterior Hoffa fat pad, osteochondritis dissecans of medial femoral condyle.
PRINCIPAL PROCEDURE: Arthroscopic debridement.
PROCEDURE: The patient was site marked in the holding area. Time-out was done on patient's entry into the room. Ancef 2 g was given within 1 hour of the incision. All bony prominences were appropriately padded. Warm blankets and warm IV fluids were used throughout the procedure to maintain optimum normothermia. Lidocaine 1% with 1:200,000 epinephrine solution was instilled in the intra-articular portion of the joint. Medial and lateral parapatellar portals incised, inflow and scope inserted.
Patellofemoral joint was inspected and probed. She was noted to have some hypertrophic synovitis in the medial patellofemoral mechanism. She was noted to have a small OCD of the medial femoral condyle that was in the nonweightbearing portion of the bone, which we did debride. The medial meniscus was noted to be normal. She was noted to have anterior synovitis around the anterior aspect of the medial meniscus, which we did debride. ACL was normal. Lateral joint space was normal. We then spent a long time debriding out all the synovitis until we got back to good stable tissue. We did debride the OCD until we got back to good stable tissue.
We copiously irrigated, closed with Prolene, placed Naropin, Toradol, and Astramorph in the knee for postop analgesia. The patient tolerated the procedure well and was taken to the recovery room in good condition. Sponge and needle counts