coders_rock!
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can anyone assist me in coding this report? So far I have 29880
FINDINGS:
1. Posterior horn medial meniscal tear.
2. Grade 4 medial chondromalacia.
3. Posterior horn lateral meniscal tear.
4. Grade 2 lateral chondromalacia.
5. Synovitis, medial and lateral gutter.
6. Grade 4 patellofemoral, chondromalacia.
7. Synovitis, patellofemoral joint.
PROCEDURE: Excessive synovium noted in the medial, lateral, and patellofemoral and notch area was removed up by an upbiter, shaver, and Bovie cautery. This was found to bring in inflammatory tissue into the joint surface, a source of joint pain and dysfunction. Probing of the medial and lateral meniscus found tears, as described in the findings. These were removed with the upbiter, shaver, and taken back to the stable rim. Grade 2 to 3 degenerative changes were treated with a chondroplasty, removing all flaking surfaces with low setting Bovie along the periphery to prevent further flaking. Grade 4 changes, as noted, were treated with abrasionplasty, creating a bleeding surface at the bone-cartilage interface.
Thanks!
FINDINGS:
1. Posterior horn medial meniscal tear.
2. Grade 4 medial chondromalacia.
3. Posterior horn lateral meniscal tear.
4. Grade 2 lateral chondromalacia.
5. Synovitis, medial and lateral gutter.
6. Grade 4 patellofemoral, chondromalacia.
7. Synovitis, patellofemoral joint.
PROCEDURE: Excessive synovium noted in the medial, lateral, and patellofemoral and notch area was removed up by an upbiter, shaver, and Bovie cautery. This was found to bring in inflammatory tissue into the joint surface, a source of joint pain and dysfunction. Probing of the medial and lateral meniscus found tears, as described in the findings. These were removed with the upbiter, shaver, and taken back to the stable rim. Grade 2 to 3 degenerative changes were treated with a chondroplasty, removing all flaking surfaces with low setting Bovie along the periphery to prevent further flaking. Grade 4 changes, as noted, were treated with abrasionplasty, creating a bleeding surface at the bone-cartilage interface.
Thanks!