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Knee procedure

  1. #1
    Location
    North Carolina
    Posts
    3,126
    Question Knee procedure
    Medical Coding Books
    I'm feeling somewhat out of my comfort zone. Can you help me with this op note?

    Procedure-Arthroscopy left knee w/ partial lateral meniscectomy; debridement of inflamed fat pad and plica

    Inflow cannula was introduced through a superomedial portal and the irrigant contained epinephrine per protocol. The arthroscope was introduced through an anterolateral portal. The knee was scanned w/ the following finding:

    1-Suprapatellar pouch normal

    2-Patellofemoral joint demonstrated that the patella was well aligned and there were minimal degenerative changes in the patellofemoral joint. There was an inflamed medial plica.

    3-Medial compartment showed some hypertrophied synovium and fat pad anteromedially. There were minimal degenerative changes on the medial compartment, chondral surfaces, and the medial meniscus appeared to be intact

    4-the intercondylar notch showed that there was partially torn ligamentum mucosum attached to the femoral notch. The anterior and posterior cruciate ligaments appeared normal although there was some fraying of the posterolateral area of the ACL.

    5-Lateral compartment visualization showed large kissing lesions w/ eburnated bone on both the femoral and tibial side. There was degenerative tearing of the lateral meniscus.

    6-There were no loose bodies in the lateral gutter.

    A probe was introduced though an anteromedial portal and the medial meniscus was probed and found to be stable. The tear of the lateral meniscus was defined by probing and partial lateral meniscectomy back to a stable rim performed with punch, shaver, and electrocautery. I then debrided the partially torn tigamentum musosum as well as the inflamed medial plica and fat pad, such that at then end of the debridement there was no further impingement of any of these tissues in the 3 compartments of the knee.

    All advice is greatly appreciated!!

  2. #2
    Location
    ENGLEWOOD/DENVER
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    2,338
    Default
    29881 w/ 29875-59 is my two cents

    Mary, CPC, COSC

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    Mary,

    Thank you so much! I was on the right path but needed a confirmation. Do you have anything that simplifies knee surgeries? For some reason, I struggle with these from time to time.

  4. #4
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    If you promise not to laugh........

    I write on my op note P (patellofemoral) M (medial) L(lateral)

    as I am reading, I write dx codes and procedures under each compartment and then determine whats bundled (in same compartment) and whats not.

    Hope it helps
    Mary, CPC, COSC

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    Hey Mary...

    If that's your method...it's certainly working!

    Thanks, again!

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