Wiki Day #5 Winner - 02/06/15

alex.mckinley@aapc.com

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Congratulations to Annie J. for winning day #5 of our Coding Challenge contest. Case #6 is now live: http://bit.ly/1EM7wEz

FYI: Regarding case #2, thoracic spine pain can be of muscular or spinal origin. Within the body of the record, the provider states it is right-sided thoracic paraspinal musculature.

Pain/Thoracic Spine codes to 724.1
Pain/muscle or Pain/musculoskeletal codes to 729.1

The question then becomes which is more specific. Is the location (thoracic) or the fact that it is the muscle more specific?

Both 724.1 and 729.1 will be given credit. Points will be distributed accordingly within the next 48 hours.
 
Case # 5 clinical added to Answer key & Rationale

Case # 5 clinical added to Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing clinical info.



Answer Key:

CPT: 29881-LT

ICD-9-CM: 717.2, 715.36, 717.7


Hint: The 5th case in the Coding Challenge is about a patient whose left knee was examined under anesthesia.


Case# 5

PREOPERATIVE DIAGNOSIS:

1. Degenerative tear of posterior horn medial meniscus, left knee.

POSTOPERATIVE DIAGNOSES:

1. Degenerative tear of posterior horn and portion mid third medial meniscus, left knee - multi-cleavage, non-repairable.

2. Chondrosis, grade 3, medial femoral condyle - medial compartment osteoarthritis.
3. Chondrosis, grade 3, central zone undersurface of the patella - chondromalacia patella.

OPERATION PERFORMED:

1. Examination under anesthesia, left knee.

2. Diagnostic arthroscopy of left knee.

3. Arthroscopic partial medial meniscectomy (the patient retains approximately 50% of medial meniscus)

4. Arthroscopic chondroplasty of chondromalacia patella - patellar chondrosis, grades. 5. Arthroscopic chondroplasty of medial femoral condyle.



ANESTHESIA: General


OPERATION: The patient was taken to the Operating Room and placed supine on the operating table. The patient was then placed under general anesthesia by the anesthesia staff without problem. A time out took place prior to the start of the procedure.

The patient's left knee was then examined under anesthesia. On clinical laxity testing ACL, PCL, MCL, and LCL were stable, left knee.

A pneumatic tourniquet was then placed about the left proximal thigh and the left lower extremity was positioned in the leg holder and then sterilely prepped and draped.

Medial and lateral parapatellar tendon arthroscopic portals were made and the arthroscope was introduced through the anterolateral portal, the probe through the anteromedial portal and diagnostic arthroscopy of the left knee was carried out.

The suprapatellar pouch was without lesions. At the patellofemoral joint the undersurface of the patella demonstrated grade 3 chondrosis - chondromalacia patella involving the central zone of the patella, as

seen in photographs #1 and #2. The femoral trochlea itself was relatively smooth, as seen in photograph #3.




Within the medial gutter there were no loose bodies or abnormalities. The medial meniscus margin as seen from the medial gutter was intact, as seen in photograph #4. In the lateral gutter the popliteal hiatus and the popliteal tendon were intact, as seen in photograph #5. The lateral meniscal margin as seen from the lateral gutter was intact, as seen in photograph #6. There were some small chondral bodies that are seen in photographs #7 and #8 in the anterior compartment of the knee.

In the lateral compartment the chondral surface of the lateral femoral condyle and lateral tibial plateau were was relatively smooth and intact, as seen in photographs #9 and #10. The posterior horn, mid third and anterior horn of the lateral meniscus were intact, as seen in photographs #9 and #10.

Within the medial compartment there was chondrosis, grade 3, of the weightbearing surface of the medial femoral condyle with unstable hanging articular cartilage, as seen in photographs #11 and #13. The other areas of the medial femoral condyle were relatively smooth, as seen in photograph #12. This area of chondrosis was approximately 1.5 x 2.0 cm.

The anterior horn of the medial meniscus was intact, as seen in photograph #13. At the junction of the mid third and posterior horn there was an unstable degenerative complex multi-cleavage tear of the meniscus with unstable meniscus tissue in the gutter adjacent to the meniscotibial coronary ligament, as seen in photographs #14 and #15. With a probe this tissue could be brought up from the gutter area, as seen in photographs #19 and #20. At this point, it was noted that the medial tibial plateau was relatively smooth, as seen in photographs #14 and #15.

At this point, diagnostic arthroscopy was completed.

Surgical arthroscopy was begun. Straight baskets, up biting baskets were used to morselize the degenerative tear of the medial meniscus to a stable margin, as seen in photographs #21, #22, #23, #24, #25 and #26. Once this was completed, a chondroplasty of the medial femoral condyle was carried out using the suction shaver. All meniscal debris was removed from the medial compartment.

Attention was then turned to the patellofemoral joint where a chondroplasty of the patella was carried out using the suction shaver, as seen in photographs #28 and #29. Once this was completed, the suction shaver was used to move any further meniscal or chondral debris from the suprapatellar pouch area and from the medial compartment, as seen in photograph #30.

The arthroscopic instruments were then removed. The two portals were closed with 3-0 nylon vertical mattress sutures and Steri-Strips. A compressive dressing applied followed by a knee wrap for knee cooling. The patient was then awakened from general anesthesia and brought to the Recovery Room in satisfactory condition.

https://www.aapc.com/code/aapc-coding-challenge/cases.aspx
 
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