# arthroscopic chondroplasty/synovectomy (help!)



## laurabee (May 20, 2009)

Can't code 29877 & 29876 together! How can I code so that we get reimbursed correct amt?


PREOPERATIVE DIAGNOSIS:	Internal derangement of the right knee.

POSTOPERATIVE DIAGNOSES:	1.	Grade III to IV chondromalacia of the superior half of the patella, patchy grade III to IV chondromalacia of the trochlea of the distal femur.
	2.	Grade III to IV chondromalacia of the medial femoral condyle and lateral femoral condyles and tricompartmental synovitis.

PROCEDURES PERFORMED:	1.	Arthroscopy of the right knee with tricompartmental chondroplasties.
	2.	Tricompartmental synovectomy.

ANESTHESIA:	General.

ESTIMATED BLOOD LOSS:	Minimal.

TOURNIQUET TIME:	None.

IMPLANTS:	None.

DISPOSITION:	The patient tolerated the procedure well without intraoperative problems or complications.  He was transferred to the PACU in the stable condition.

INDICATIONS:  Patient is a 67-year-old male who now presented to my office with a chief complaint of knee pain.  He was seen and we felt that he had potentially internal derangement of his knee and we were also concerned that the symptoms were not getting better despite conservative treatment.  So, eventually we came to the decision to perform a knee arthroscopy for him.  Prior to this procedure, we discussed the risks and complications associated with the operation and we discussed the treatments should those occur.  We answered the patient's questions to the best of my ability and to his satisfaction and he signed the informed consent in the preoperative holding area.

PROCEDURE:  The patient was taken to the operative suite and placed supine on the operating table.  He was placed under general anesthesia.  His vital signs were thoroughly monitored throughout the procedure.  The right lower extremity was fitted with a proximal thigh tourniquet and then placed into a padded leg holder.   The foot of the table was then dropped and the right lower extremity was thoroughly prepped and draped in the usual sterile fashion.  We began the procedure with a lateral portal incision at the joint line through which we inserted the blunt trocar with the arthroscopic cannula into the suprapatellar pouch with the knee extended.  We removed the blunt trocar and there was an immediate effluent emanating from the portal consisting of clear to slightly straw-colored synovial fluid.  This did not appear to be infected and appeared to be inflammatory in origin.  We then inserted the 30-degree arthroscope into the joint and began the process of evaluating all of the compartments.  Visualization was difficult due to hypertrophic, hyperemic synovitis throughout all three compartments of his knee.  In general, the synovium was extremely inflamed and very “angry” in appearance and this was in keeping with the significant joint effusion that we noted at the beginning of the case.  The superior half of his patella was involved with grade III to IV chondromalacia with the exposed bone.  The cartilage of the trochlea of the distal femur was also quite involved with cartilage damage.  There was patchy grade III to IV chondromalacia throughout the entire trochlea and this was very uneven and very osteoarthritic in appearance.  We then went down to medial gutter of the knee and went into the medial tibial femoral joint.  It was noted that full visualization was very difficult due to the synovitis.  So, we obtained a medial portal, then we inserted an ArthroCare wand in the joint and proceeded to use tissue ablation and coagulation, I also tried to remove some of this tissue.  This also necessitated the use of an arthroscopic shaver.  We also did this in the medial and lateral compartments.  We then inserted a probe into the joint and thoroughly probed the medial and lateral menisci and we noted no evidence of a meniscus tear.  However, there was grade IV chondromalacia of the weightbearing surface of this medial femoral condyle.  There was also grade IV chondromalacia and essential small area of his lateral femoral condyle.  The articular cartilage looked best in the lateral compartment and the medial side was the most involved.  As stated above, we thoroughly probed both menisci and the cruciate ligaments and we were satisfied that there was no meniscal tear or ligament rupture.  The main problem was severe chondromalacia in the medial and patellofemoral compartments, but there was also significant cartilage damage in the lateral femoral condyle.  The lateral lesion was about 1.5-cm in diameter, but extended all the way to the cartilage down to bone.  This was debrided as well.  So, at the end of this procedure we performed tricompartmental chondroplasty and tricompartmental synovectomy.  We irrigated the knee with copious amounts of sterile saline, occluded the inflow cannula and aspirated the joint of exsanguinous fluid.  We came out of the knee with the instruments and closed the two portals with nylon suture.  We then injected 80 mg of Depo-Medrol with lidocaine into the joint for postoperative pain control and to diminish swelling.  Sterile dressings were applied to the knee and the patient was brought out of the OR to the PACU in the stable condition.  The patient will be allowed to go home today with instructions to keep the dressings clean and dry, and he may remove the dressing to shower on Friday, and we would like to see him in our office in 10 days.


----------



## martnel (May 20, 2009)

I am thinking you CAN do 29877 and 29876, just not 29875, which is limited synovectomy.


----------



## Bella Cullen (May 20, 2009)

I would code 29876 only. 29877 is bundled into 29876.


----------



## martnel (May 20, 2009)

ILuvRock, that's right for medicare/CCI edits! 

I got this from CodeX:
CPT Code: 29876

Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (eg, medial or lateral) 

Intraoperative services *not included *in the global service package, when indicated

	1.	supplies and medication (eg, codes 99070, HCPCS Level II codes)
	2.	complex wound closure (eg, application of wound vacuum device to open wound, (eg, 97605-97606)) or closure requiring local or distant flap coverage and/or skin graft, when appropriate (eg, 13100-13160, 14000-14350, 15000-15400, 15570-15776)
	3.	insertion, removal, or exchange of nonbiodegradable drug delivery implants (eg, 11981-11983)
	4.	arthroscopic removal of loose or foreign bodies greater than 5 mm and/or through a separate incision (eg, 29874)
	5.	arthroscopic chondroplasty (eg, 29877)


----------



## Bella Cullen (May 21, 2009)

I say it's bundled because for extensive synovectomy up to six portal incisions may be made to access all of the involved comparments of the knee and while the doctor is already in there he does the chondroplasty. He doesn't make more separate incisions for the chondroplasty.
Also, I say to myself, if this surgery was to be denied how can I argue my case to say these are both payable together. Because that is my job also. I code the surgeries and deal with the insurance companies when it denies. And in this specific case I don't think these codes are billable together. And yes, Medicare CCI edits says 29877 is not billable with 29876 and I agree.


----------



## mitchellde (May 21, 2009)

This one is difficult I tink it was more of chondroplasty thay synovectomy.  Ordinarily we would use the G0289 ( I think this is the right code someone borrowed my book!) with the 29876  even for commercial carriers and they will pay for both , however I am not certain this scenario is appropriate for this, anyone else have an opinion here?  I might do the 29877 with a 22 modifier though.


----------



## Bella Cullen (May 21, 2009)

The G0289 you can bill for each compartment since this is considered an add on code, whereas 29877 you can only bill that once and usually isn't billable with anything else. 
Yes, the commercial carriers are paying for G0289 when billed with another arthroscopic procedure, at least where I am. 
I will agree on billing 29876, G0289, G0289-59, G0289-59. And that is my final answer. 
Any other opinions?


----------



## mbort (May 21, 2009)

are you billing for the surgeon?  is this a commercial payor?  if the answer is yes to both of those questions, then I would code 29876, 29877-59.  

The ONLY reason I would allow for the 29876 in this scenario is because he clearly states that this is hypotrophic, angry, synovitis.  He did not do the synovectomy for visualization.

my two cents
Mary, CPC, COSC


----------

