I have a physician that did a surgery and I am needing some assistance in coding what he did... I am still pretty new at this.
Procedures Performed:
1. Arthroscopy with debridement of medial compartment
2. Removal of loose body from the lateral compartment and patellofemoral compartment.
3. Remova of Baker's Cyst
Description of Procedure: The patient was taken to the operating room and placed on the operating room table in the supine position where general anesthesia with intubation was induced. Once adequate anesthesia had been achieved a pneumatic tourniquet was applied to the proximal right leg. The right leg was prepped and draped in the ususal fashion with the tourniquet distally. Examination of the suprapatellar puch revealed no abnormality. There were some loose pieces of what I found musht be hyaline cartilage. This was lightly suctioned. There was debirs on the medial facet of the patella with some bone exposed. There was not much in the way of disease of the trochlear groove. There was a loose fragment of maybe an old plica on the medial side and this was lightly debrided. On the notch side of the medial meniscus she had grade 3-4 wear on the medial femoral condyle in its entirety through the entire sagittal plane. There appears to have been an old lateral posterior horn meniscal tear that had to be a flap tear.
It is rounded and a piece is missing. On the lateral side both articular surface were normal, femur and tibia. There was fibrous tissue hanging from the underside of the lateral meniscus. The popliteus was intact and the meniscus is intact with its fibers being that when I suctioned it throug, which was maybe 4 mm and circular, I found it to be hard. The acl and pcl were intact. Having debrided all three compartments actually we then closed the two portals wiht 4-0prolene, put Opsite over the closures and then placed the patient in the lateral decubitus poisition re prepping. She had a tourniquet at the level of the arthroscopic leg holder which at this point after prepping the leg we inflated and ths was up for about five minutes. We made a hockey stick incision on the popliteal fossa on the medial side. Sharp dissection was taken down through the skin. There were multiple veins which were ligated. There was a very thin bakers cyst coming from the gastroc semitendinosus and juntion of the posterior capsule. We found the neck but I was unable to take the cyst out in one piece. I did send what I thought was to be the lining and then closed the neck of this with 0 vicryl. I then released the tourniquet and used Bovie electrocautery on the coagulation current to maintain hemostasis. We closed the subcu with 2-0 vicryl and the skin with horizontal mattress sutures of 3-0 prolene. We applied a sterile compressive dressing and took the patient to the postoperative recovery room in excellent condition.
Any suggetions??
Procedures Performed:
1. Arthroscopy with debridement of medial compartment
2. Removal of loose body from the lateral compartment and patellofemoral compartment.
3. Remova of Baker's Cyst
Description of Procedure: The patient was taken to the operating room and placed on the operating room table in the supine position where general anesthesia with intubation was induced. Once adequate anesthesia had been achieved a pneumatic tourniquet was applied to the proximal right leg. The right leg was prepped and draped in the ususal fashion with the tourniquet distally. Examination of the suprapatellar puch revealed no abnormality. There were some loose pieces of what I found musht be hyaline cartilage. This was lightly suctioned. There was debirs on the medial facet of the patella with some bone exposed. There was not much in the way of disease of the trochlear groove. There was a loose fragment of maybe an old plica on the medial side and this was lightly debrided. On the notch side of the medial meniscus she had grade 3-4 wear on the medial femoral condyle in its entirety through the entire sagittal plane. There appears to have been an old lateral posterior horn meniscal tear that had to be a flap tear.
It is rounded and a piece is missing. On the lateral side both articular surface were normal, femur and tibia. There was fibrous tissue hanging from the underside of the lateral meniscus. The popliteus was intact and the meniscus is intact with its fibers being that when I suctioned it throug, which was maybe 4 mm and circular, I found it to be hard. The acl and pcl were intact. Having debrided all three compartments actually we then closed the two portals wiht 4-0prolene, put Opsite over the closures and then placed the patient in the lateral decubitus poisition re prepping. She had a tourniquet at the level of the arthroscopic leg holder which at this point after prepping the leg we inflated and ths was up for about five minutes. We made a hockey stick incision on the popliteal fossa on the medial side. Sharp dissection was taken down through the skin. There were multiple veins which were ligated. There was a very thin bakers cyst coming from the gastroc semitendinosus and juntion of the posterior capsule. We found the neck but I was unable to take the cyst out in one piece. I did send what I thought was to be the lining and then closed the neck of this with 0 vicryl. I then released the tourniquet and used Bovie electrocautery on the coagulation current to maintain hemostasis. We closed the subcu with 2-0 vicryl and the skin with horizontal mattress sutures of 3-0 prolene. We applied a sterile compressive dressing and took the patient to the postoperative recovery room in excellent condition.
Any suggetions??
