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?? 29880

  1. #1
    Default ?? 29880
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    Dx 836.1

    CPT 29880
    I feel like I am missing something can somoeone look this over??
    Thank you

    1. Degenerative complex tear, posterior horn, medial meniscus.
    2. Degenerative mid-substance tear, lateral meniscus, with
    3. Diffuse grade 2 and early grade 3 chondrosis of medial femoral
    4. Diffuse undersurface patella and proximal trochlea grade 2
    chondrosis, patellofemoral axis.
    5. Distal femoral notch stenosis with distal femoral bone
    overgrowth, and concomitant knee flexion contracture.
    6. Extensive hypertrophic synovial scar resection.

    1. Partial medial meniscectomy.
    2. Partial lateral meniscectomy.
    3. Limited chondroplasty of medial femoral condyle.
    4. Limited chondroplasty of undersurface of the patella and distal
    5. Distal femoral notch resection with concomitant notchplasty,
    removal of scar tissue and acquisition of full extension.
    6. Extensive hypertrophic synovial scar resection.
    7. Injection to the portal sites with 1% Xylocaine.


    ANESTHESIA: General anesthesia with local.


    DRAINS: None.


    FLUIDS GIVEN: 600 mL of LR.

    INDICATIONS FOR SURGERY: This is a middle-aged male who describes
    progression of mechanical left knee symptoms. At this time, he has
    failed initial conservative measures and has clinical and
    radiographic findings consistent with meniscal pathology. At this
    time, the benefits and risks of surgery were advised. We will
    proceed with surgery as per protocol.

    TECHNIQUE: The patient was brought to the operating room and was put
    to sleep using endotracheal anesthesia. The left lower extremity was
    placed into a leg holder. A tourniquet was applied; the tourniquet
    was never elevated. Standard prep and drape was provided to the
    patient's left lower extremity. Arthroscopic portals were made
    proximal and medial and also 2 distal working portals were made.
    Small nicks were made into the skin to allow blunt entrance technique
    to visualize the joint proper. Upon assessment and evaluation at the
    patellofemoral access, there was an extensive amount of scar tissue
    which was resected. The undersurface of the patella did have some
    diffuse chondrosis (grade 2). A limited chondroplasty was performed
    to contour the surface as a small distal patellar spur was removed.
    The proximal trochlea was with some chondrosis as well. A limited
    chondroplasty was performed. This was grade 2. Both medial and
    lateral gutters had no evidence of meniscal or chondral loose flaps.
    The medial compartment did have a generative tear involving the
    posterior horn of the medial meniscus. A partial medial meniscectomy
    was performed. The medial femoral condyle did have some surface
    delamination of the cartilage, which was a grade 2 lesion, and a
    diffuse early grade 3 lesion. Diffuse limited chondroplasty was
    performed to contour the surfaces and remove any loose cartilaginous
    debris. The central notch was stenotic. The anterior cruciate
    ligament (ACL) was intact. The posterior cruciate ligament (PCL) was
    intact. There was a notch contracture with limitation of full
    extension. A distal femoral notch resection was performed. This
    allowed for full extension as the base of the ACL was dbrided. The
    lateral compartment did have a mid-substance lateral meniscus tear
    with calcification. A partial meniscectomy was performed. At this
    time, the knee joint was arthroscopically lavaged using an
    antimicrobial solution. Each of the portals was sequentially closed
    using simple sutures. An injection of Xylocaine 1% was infused into
    each of the portal sites.

    PLAN: At this time, the patient will be touch-down weightbearing
    status. Thigh-high TEDs, icing modalities, activity restrictions,
    and analgesic medications. I would like to see this patient back
    within the next 24 hours for postoperative assessment, wound
    evaluation and dressing changes.

  2. #2
    I don't know what insurance the patient has, but you could bill G0289 for the chondroplasty/debridement of the patellar compartment.
    With the diagnosis the physician refers to the meniscal tears as degenerative, I would use just 717.XX codes for the tears.
    Last edited by bethh05; 12-09-2010 at 01:25 PM.

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