1. LT Knee Chondromalacia of patella type 2 to 3
2. Extensive Synovitits
3. Posterior third medical meniscal with type 3 to 4 chondromalacia on the medical femoral condyle
4. Loose Body
1. Complete Synovectomy of the superior patella pouch, inferior patella pouch, medial gutters and lateral gutters, and posteromedial aspects of the knee
2. Partial Medial Menisectomy
3. Complete synovectomy
4. Chondroplasty of the patella
5. Loose body removal
6. Chondroplasty of the medical femoral condyle
The patient was idenitifed in the holding area. The proper extremity was identified and marked. The patient was taken back to the operative suite where general endotracheal anesthesia was induced without complication. The left lower extremity was then prepped and draped in sterile fashion. Standard inferomedial and inferolateral portals were obtained. Standard arthroscopic examination revealed the aforementioned findings. The patient then had a complete synovectomy of the superior patella pouch, inferior patella pouch, medial gutters and lateral gutters, and posteromedial aspects of the knee. The medial meniscus was then visualized. The medial meniscus was absolutely torn into the meniscal capsular margin with radial type tear. The sucker shaving device and straight biter was utilized to remove the posterior third of this medial meniscus. The medial femoral condyle had a type 3/4 lesion throughout the weight bearing portion of the medical femoral condyle. The lateral compartment was very clean. There is no issue what so ever so the chondroplasty was performed on the underneath surface of the kneecap which was type 2 chondromalacia in the medial femoral condyle which was type 3 to 4 chondromalacia. All loose fibrillated cartilage was removed and stable cartilage was retained. The patient then had a loose body the was visualized in the posterior third of the joint. A straight grasper was utilized to pull this out of the medial aspect of the joint. The patient then had copious irrigation of all the wounds, 4-0 nylon utilized to close the portal sites and the patient returned to recovery room in stable condition.
I am thinking that this should be coded as 29881 with M23.222; M22.42; M23.42 and 29875-59 with M65.862. Any feedback is appreciated. Thanks
2. Extensive Synovitits
3. Posterior third medical meniscal with type 3 to 4 chondromalacia on the medical femoral condyle
4. Loose Body
1. Complete Synovectomy of the superior patella pouch, inferior patella pouch, medial gutters and lateral gutters, and posteromedial aspects of the knee
2. Partial Medial Menisectomy
3. Complete synovectomy
4. Chondroplasty of the patella
5. Loose body removal
6. Chondroplasty of the medical femoral condyle
The patient was idenitifed in the holding area. The proper extremity was identified and marked. The patient was taken back to the operative suite where general endotracheal anesthesia was induced without complication. The left lower extremity was then prepped and draped in sterile fashion. Standard inferomedial and inferolateral portals were obtained. Standard arthroscopic examination revealed the aforementioned findings. The patient then had a complete synovectomy of the superior patella pouch, inferior patella pouch, medial gutters and lateral gutters, and posteromedial aspects of the knee. The medial meniscus was then visualized. The medial meniscus was absolutely torn into the meniscal capsular margin with radial type tear. The sucker shaving device and straight biter was utilized to remove the posterior third of this medial meniscus. The medial femoral condyle had a type 3/4 lesion throughout the weight bearing portion of the medical femoral condyle. The lateral compartment was very clean. There is no issue what so ever so the chondroplasty was performed on the underneath surface of the kneecap which was type 2 chondromalacia in the medial femoral condyle which was type 3 to 4 chondromalacia. All loose fibrillated cartilage was removed and stable cartilage was retained. The patient then had a loose body the was visualized in the posterior third of the joint. A straight grasper was utilized to pull this out of the medial aspect of the joint. The patient then had copious irrigation of all the wounds, 4-0 nylon utilized to close the portal sites and the patient returned to recovery room in stable condition.
I am thinking that this should be coded as 29881 with M23.222; M22.42; M23.42 and 29875-59 with M65.862. Any feedback is appreciated. Thanks