I need some help here. Not sure if 29871, 29877 or both would apply here or 29999?
Findings
Multiple pictures were taken intraop and saved to the chart. The camera trocar was inserted into the knee and then the fluid was expressed through the trocar and collected in a sterile specimen cup. This was saved on the back table and then sent to the lab for cell count with differential, culture and Gram stain for aerobic, anaerobic, fungal, AFB. It was also sent for evaluation of glucose and protein. Crystal evaluation from the clinic aspiration was negative. Once the arthroscopic camera was inserted into the joint a diagnostic exam was performed and there were no significant areas or pockets consistent with sequestered bacteria or significant purulence. No significant change was noted of the underlying arthritis that was visualized on his knee scope 2 weeks ago. No acute meniscal tears or other acute findings were appreciated.
Specimen(s)
Synovial fluid for lab evaluation
Complications
None
Technique
Patient was seen in the preoperative holding area. The correct operative site was marked. Verbal and written consent was obtained. He was transferred to the operative suite and placed supine on the operating table. All bony prominences were well padded. He was given benefit of general anesthesia by anesthesia team. The right lower extremity was then prepped and draped in a normal sterile fashion. All those in attendance were in agreement with the correct operative site procedure performed after the time-out.
Using the previous portal incisions 11 blade scalpel used to incise skin both medial lateral and this was passed onto the "dirty" Mayo stand. The camera trocar was inserted in the fluid was expressed who trocar and kept on a sterile specimen container. The arthroscope was inserted and diagnostic exam was performed with findings as noted above. The arthroscopic shaver was then inserted into the joint and debridement of all 3 compartments of the knee was performed until fresh bleeding was visualized. The 3 compartment debridement did remove fibrous tissue with poor circulation. Once this was performed the knee was then irrigated with 9 L of sterile saline with outflow portal being utilized through the anteromedial portal. All fluid was suctioned from the joint on all instruments were removed. The portal incision skin edges were then debrided utilizing a clean curette. The skin was then reapproximated with a 3 0 Prolene in a simple inverted fashion. Incisions were covered with Xeroform, 4 x 4, Kerlix, and an Ace wrap. He is or from anesthesia and transferred to PACU in stable condition. All needle and scrubbed counts were correct in the case x2.
Findings
Multiple pictures were taken intraop and saved to the chart. The camera trocar was inserted into the knee and then the fluid was expressed through the trocar and collected in a sterile specimen cup. This was saved on the back table and then sent to the lab for cell count with differential, culture and Gram stain for aerobic, anaerobic, fungal, AFB. It was also sent for evaluation of glucose and protein. Crystal evaluation from the clinic aspiration was negative. Once the arthroscopic camera was inserted into the joint a diagnostic exam was performed and there were no significant areas or pockets consistent with sequestered bacteria or significant purulence. No significant change was noted of the underlying arthritis that was visualized on his knee scope 2 weeks ago. No acute meniscal tears or other acute findings were appreciated.
Specimen(s)
Synovial fluid for lab evaluation
Complications
None
Technique
Patient was seen in the preoperative holding area. The correct operative site was marked. Verbal and written consent was obtained. He was transferred to the operative suite and placed supine on the operating table. All bony prominences were well padded. He was given benefit of general anesthesia by anesthesia team. The right lower extremity was then prepped and draped in a normal sterile fashion. All those in attendance were in agreement with the correct operative site procedure performed after the time-out.
Using the previous portal incisions 11 blade scalpel used to incise skin both medial lateral and this was passed onto the "dirty" Mayo stand. The camera trocar was inserted in the fluid was expressed who trocar and kept on a sterile specimen container. The arthroscope was inserted and diagnostic exam was performed with findings as noted above. The arthroscopic shaver was then inserted into the joint and debridement of all 3 compartments of the knee was performed until fresh bleeding was visualized. The 3 compartment debridement did remove fibrous tissue with poor circulation. Once this was performed the knee was then irrigated with 9 L of sterile saline with outflow portal being utilized through the anteromedial portal. All fluid was suctioned from the joint on all instruments were removed. The portal incision skin edges were then debrided utilizing a clean curette. The skin was then reapproximated with a 3 0 Prolene in a simple inverted fashion. Incisions were covered with Xeroform, 4 x 4, Kerlix, and an Ace wrap. He is or from anesthesia and transferred to PACU in stable condition. All needle and scrubbed counts were correct in the case x2.