# Arthroscopic Excavation of Parameniscal Cyst



## MI_CODER (Nov 18, 2017)

Hello,

How would you code the following?

The area was prepped and draped in a sterile fashion. Time-out was performed prior to making an incision. This is an arthroscopic surgery. Medial and lateral arthrotomies were performed. The patient was found to have C3, C4 chondromalacia of the patellofemoral joint. Chondroplasty of the patellofemoral joint was performed. Medial gutter was then swept. No evidence of any loose bodies. Medial joint space was then entered. The patient was found to have a parameniscal cyst. Excavation of parameniscal cyst was performed. No evidence of any meniscal pathology. The patient did have C1, C2 chondromalacia of the medial femoral condyle, medial tibial plateau. The ACL was partially torn and debridement of ACL was performed. Lateral joint  space was entered. The patient was found to have C1, C2 chondromalacia of the lateral femoral condyle, lateral tibial plateau. Chondroplasty of the lateral femoral condyle, lateral tibial plateau was performed. Lateral gutter was then swept. No evidence of any loose bodies. The patient tolerated the procedure well.

I came up with 29877 for the chondroplasty and ACL debridement but would this include the excavation of the parameniscal cyst or would this get coded with an unlisted code (29999)?

Thank you in advance.


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## AlanPechacek (Nov 24, 2017)

"Deja-vu" all over again, but with a new twist, a Parameniscal Cyst in addition to the partially torn ACL.  I don't know whether the "Op Note" as you present it in your query is the actual one done by your physician or is your "edited down" version of his report.  If it is fact your surgeon's, then it is easy to see why you have trouble coding his procedures.  He is a lousy documenter.  As presented, you are correct in that the vast majority of the procedure was a Multi-compartmental Chondroplasty, 29877, for an arthritic joint.  Since there was no docmentation of meniscal lesions requiring treatment, the Chondroplasties of the medial and lateral compartments would not have been included/folded/bundled into meniscectomies (29880 or 29881).
     The "partially torn" ACL, for which there was some "debridement," I would handle in the same manner as I/we discussed previously, i.e. as an "incidental finding" with "incidental treatment."  You may have to check the NCCI Edits regarding 29877: Chondroplasty, to see what is "included/bundled" into it.  If they include "limited synovectomy &/or debridement" of other lesions, then you probably couldn't add a separate charge or procedural code for its treatment, particularly since it appears to be an "incidental" finding and procedure.  If this is not "bundled" into 29877, then you could possibly get by with a separate/additional procedure.  I would still probably go with 29875: Limited Synovectomy as I think it is a better choice than 29999: Unlisted Procedure.  Again, you would have to add a Modifier, probably 51.  Also, however, the ACL Tear (even though "partial") would need to be included in the Postoperative Diagnosis list.  Since this is a "Chronic" Disorder of the Ligaments, then M24.26 _ would apply for Old ACL Tear.
     As for the "Parameniscal Cyst" (M23.0 _), this is a difficult situation.  Again his documentation fails us.  I believe that among most Orthopedic Surgeons, a "true" Paramedical Cyst is considered to be the result of meniscal pathology, i.e. the cyst evolves/develops from a damaged/diseased meniscus, usually from chronic meniscal degeneration.  A true cyst of this type is a chronic lesion, not acute.  Your surgeon says the was no meniscal pathology, which makes me wonder if this wasn't an intra-articular ganglion cyst (M67.46 _) in stead.  In order to address it as a "treatable lesion" of the joint, it would also have to be included in the Postoperative Diagnosis list, and as for a procedural code, I would still tend to use 29875 as the lesion/cyst is a "synovial lesion."  However, again the NCCI Edits may include/bundle treatment of synovial lesions, i.e. synovectomy &/or debridement, and as such, since this also appears to be an "incidental finding" and an "incidental procedure," then you may not be able to separately charge for it.
     If you do try to separately charge for the ACL debridement and the Cyst "Evacuation," I would probably "bundle" them together as one under 29875, plus the Modifier.

Again, I hope this is sufficiently clear and helpful to you.  It is tricky. 

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


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## MI_CODER (Dec 9, 2017)

Thank you very much for taking the time to write such a detailed explanation. This does help me out a lot.


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## TCrabtree CPC CASCC  (Nov 18, 2020)

AlanPechacek said:


> "Deja-vu" all over again, but with a new twist, a Parameniscal Cyst in addition to the partially torn ACL.  I don't know whether the "Op Note" as you present it in your query is the actual one done by your physician or is your "edited down" version of his report.  If it is fact your surgeon's, then it is easy to see why you have trouble coding his procedures.  He is a lousy documenter.  As presented, you are correct in that the vast majority of the procedure was a Multi-compartmental Chondroplasty, 29877, for an arthritic joint.  Since there was no docmentation of meniscal lesions requiring treatment, the Chondroplasties of the medial and lateral compartments would not have been included/folded/bundled into meniscectomies (29880 or 29881).
> The "partially torn" ACL, for which there was some "debridement," I would handle in the same manner as I/we discussed previously, i.e. as an "incidental finding" with "incidental treatment."  You may have to check the NCCI Edits regarding 29877: Chondroplasty, to see what is "included/bundled" into it.  If they include "limited synovectomy &/or debridement" of other lesions, then you probably couldn't add a separate charge or procedural code for its treatment, particularly since it appears to be an "incidental" finding and procedure.  If this is not "bundled" into 29877, then you could possibly get by with a separate/additional procedure.  I would still probably go with 29875: Limited Synovectomy as I think it is a better choice than 29999: Unlisted Procedure.  Again, you would have to add a Modifier, probably 51.  Also, however, the ACL Tear (even though "partial") would need to be included in the Postoperative Diagnosis list.  Since this is a "Chronic" Disorder of the Ligaments, then M24.26 _ would apply for Old ACL Tear.
> As for the "Parameniscal Cyst" (M23.0 _), this is a difficult situation.  Again his documentation fails us.  I believe that among most Orthopedic Surgeons, a "true" Paramedical Cyst is considered to be the result of meniscal pathology, i.e. the cyst evolves/develops from a damaged/diseased meniscus, usually from chronic meniscal degeneration.  A true cyst of this type is a chronic lesion, not acute.  Your surgeon says the was no meniscal pathology, which makes me wonder if this wasn't an intra-articular ganglion cyst (M67.46 _) in stead.  In order to address it as a "treatable lesion" of the joint, it would also have to be included in the Postoperative Diagnosis list, and as for a procedural code, I would still tend to use 29875 as the lesion/cyst is a "synovial lesion."  However, again the NCCI Edits may include/bundle treatment of synovial lesions, i.e. synovectomy &/or debridement, and as such, since this also appears to be an "incidental finding" and an "incidental procedure," then you may not be able to separately charge for it.
> If you do try to separately charge for the ACL debridement and the Cyst "Evacuation," I would probably "bundle" them together as one under 29875, plus the Modifier.
> ...


You are always so helpful! I would loved to have had you as an instructor.


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