help with knee scope tibial osteophytes and meniscus tear

Rvoigt

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Bellingham, WA
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Need to know the best way to code the following surgery. I am getting conflicting information. Help is greatly appreciated.
Surgeon wants
27630 LT
29874RT
29881 RT (bundled with 29874)
Surgery Center wants
29881
27635
27355
OP note
Postoperative Diagnosis:

1. Right knee loose bodies, arthritis, and lateral meniscus tear.
2. Severe left knee osteoarthritis with tibial and femoral osteophytes.

An examination under anesthesia revealed intact ACL, PCL, MCL, and LCL ligaments bilaterally. Starting on the right knee, the anteromedial portal was prepped with Betadine and the patient was given 20 cc of 0.25% Marcaine with epinephrine interarticularly. Both legs were then prepped and draped in the usual sterile fashion. The right knee lateral suprapatellar pouch portal was injected with local anesthetic and established with an 11-blade. The large inflow cannula was inserted. The effusion was drained. The knee was distended with saline. The anteromedial and anterolateral portals were injected with local anesthetic and established longitudinally with an 11-blade. The scope sheath with blunt trocar was passed in anterolaterally and on into the suprapatellar pouch with the knee in extension. The 30-degree scope, camera and light source were attached. Diagnostic arthroscopy was carried out systematically looking in the suprapatellar pouch, patellofemoral joint, medial and lateral gutters, the notch and the medial and lateral compartments. All of our findings were documented on still pictures. The findings revealed deep grade 3 and grade 4 chondral changes on the femoral trochlea and deep grade 3 changes on the retropatellar surface that were smoothed slightly with the shaver. There loose bodies in the anterior aspect of the knee just anterior to the ACL that were just slightly adherent to the synovium and these were easily removed with a shaver. There were no loose bodies in the suprapatellar pouch or anywhere else within the knee. The ACL was intact. The medial compartment revealed a normal meniscus and some partial-thickness grade 3 chondral loss on the femur. In the lateral compartment, there were grade 4 changes on the femur and tibia and the lateral meniscus was torn in a complex manner around the popliteus tendon. The basket forceps was used as well as the shaver to remove this shredded meniscus material.

Once completed, the arthroscopic equipment was withdrawn. The knee was drained. The three portals were closed with 4-0 Monocryl and half-inch Steri-strips. The knee was injected with 10 mg of morphine in 10 cc of 0.25% Marcaine with epinephrine. The wounds were covered with 4x4s, ABD pad, sterile Webril and a 6-inch ACE wrap was applied from the ankle to the thigh.
Next, attention was turned to the left knee. The leg was exsanguinated with a sterile 6-inch ACE wrap. The tourniquet was inflated to 250 mmHg. The previous incision that was horizontal over the lateral compartment was opened with a scalpel and I came down immediately to a large permanent suture knot that I removed with a knife. Then, palpating the joint, I went below the joint over the proximal tibia, and incised down to bone with electrocautery and went posteriorly, staying below the joint level. The joint fluid was evacuated and I was able to spread this incision to look into the joint. There was some calcified, hard meniscal tissue that I removed. Once the Cobb elevator could be passed posteriorly behind the tibia, I used the rongeur to trim osteophytes off the tibial surface from posterior to anterior. Through this arthrotomy, I could also see the distal femur and ensured that any small spurs that were present were trimmed off also. After I was assured that I had saucerized the tibia and femur adequately, I used #2 Tycron suture to close this arthrotomy with a running stitch. I flexed the knee to ensure the arthrotomy repair held. I next closed the subcu layer with interrupted 2-0 Vicryl and the skin with 4-0 Monocryl running subcuticular stitch and steri strips. I used 0.25% Marcaine with epinephrine to inject this incision deep and intraarticularly. The wound was covered with 4x4s, ABD pad, and sterile Webril and then a 6-inch ACE wrap was applied. The tourniquet was dropped at 27 minutes. The patient was then transported to recovery room in stable condition.
 
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