# Knee arthroscopy



## tschrader (Aug 22, 2014)

The doctor has selected codes 29888, 29882, and 29881. When I reviewed the operative report the anterior horn had the meniscectomy done. The posterior horn had the repair done.

I feel that the 29881 is bundled into 29888 since you cannot separate out the anterior from the posterior. But of course I am also doubting myself and would like another opinion on this before I tell the doctor that this is. 

I would like some of your opinions on this. Thank you!



PRE-OPERATIVE DIAGNOSIS:   
Right knee ACL tear, right knee meniscal tear.  

POST-OPERATIVE DIAGNOSIS:   
Same.  

NAME OF PROCEDURE:   
1. Right knee ACL reconstruction, arthroscopic assisted.  
2. Right knee partial lateral meniscectomy.  
3. Arthroscopic lateral meniscal repair.  

ASSISTANT:  
NP assisted with patient positioning, exposure, retraction, graft preparation, leg manipulation, wound closure, brace application.  

ANESTHESIA:   
General.  

ESTIMATED BLOOD LOSS:  
Minimal.  

FLUIDS:  
Per Anesthesia.  

DRAINS:  
None.  

SPECIMEN:  
None.  

IMPLANTS:   
Mitek Rigidfix and Bio-Intrafix pins and screws, size 8-10 large sheath and one Omnispan Mitek meniscal repair device.  

COMPLICATIONS:   
None.  

DISPOSITION:  
Stable to PACU.  

BRIEF HISTORY OF THE PATIENT:  
A male patient has injured his right knee.  Clinical exam demonstrates the above noted pathology.  The risks and benefits of ACL 
reconstruction, meniscal repair versus meniscectomy were discussed.  These include, but are not limited to infection, blood clot, stiffness, loss of 
range of motion, continued pain, problems with anesthesia, the need for further surgery, the expected postoperative course including a week in a 
brace locked straight, a month total in a brace, 6 months until full return to activity.  He agreed to the procedure.  

DESCRIPTION OF PROCEDURE:  
Patient taken to the Operating Room after informed consent was obtained, placed supine on the operating room table.  General anesthesia was 
established.  The right leg was prepped and draped in the usual sterile fashion.  An examination under anesthesia showed full and equivalent range of motion with a 2+ Lachman.  Time-out was accomplished to the satisfaction of the operating room staff, the anesthesia team and the surgical team.  

An incision was made over the anteromedial edge of the tibia.  The skin and subcutaneous tissues were divided.  Hemostasis was achieved.  Blunt 
dissection was taken down.  The semitendinosus and gracilis tendons were harvested without incident, placed on the back table and formed into a quad 
stranded autograft in accordance with the manufacturer's instructions for our chosen implants.  It was approximately 8.5 mm in width and of 
appropriate length.  It was placed under tension.  An inferolateral viewing portal was created.  An arthroscopic examination of the knee commenced.  
Upon entering the patellofemoral joint, patellar and trochlear cartilage were intact.  We entered the medial compartment of the knee.  A medial 
working portal was created with the use of a spinal needle and outside-in technique.  Medial femoral condyle had some grade I changes.  Medial tibial 
plateau was intact.  Medial meniscus was checked with a probe and felt to be stable.  We entered the intercondylar notch.  The ACL was completely 
obliterated.  The stump was scarred into the PCL.  There was no evidence of fibers in continuity.  We entered the lateral compartment of the knee.  
The lateral femoral condyle was intact.  The lateral tibial plateau had some grade I changes.  The anterior horn of the lateral meniscus had evidence 
of a large flap tear.  Perhaps 30% of the meniscus was torn.  It appeared to be sticking straight into the lateral joint space.  The posterior horn 
of the lateral meniscus had a separate tear which was noted to be an avulsion off the posterior root.  The meniscus appeared to be partially fixed to the back capsule.  Decision was made to remove the anterior horn flap.  A series of shavers and biters were entered in the joint until the torn 
portion of the anterior horn of the lateral meniscus was resected.  Perhaps 30% of the anterior horn was removed.  We then turned our attention 
posteriorly.  Decision was made to repair the posterior horn through the rootlet.  An Omnispan meniscal repair device was deployed across the tear 
and from attaching the meniscus into the capsule.  A horizontal mattress configuration was used.  The device was tightened down and the repair was 
completed without incident.  At this point, the meniscus appeared to be stabilized.  We turned our attention to the intercondylar notch.  The shaver 
and the Mitek vapor wand were used to resect the remnants of the ACL until the tibial and femoral footprints were visualized.  The tibial guide was 
entered in the joint.  Bullet apparatus was passed through the medial tibial incision.  A guidepin was directed from the medial tibia up through the 
tibial footprint of the ACL.  It was checked under arthroscopic visualization.  A 9.5 mm reamer was passed over the top of the guide pin.  Tibial 
tunnel was created.  A shaver was entered in the joint.  Bony debris was removed.  An aiming device was used to direct a guide pin through the 
femoral footprint of the ACL.  It was taken out through the lateral femoral condyle.  An 8.5 mm reamer was passed over the top of it to a depth of 35 
mm creating our femoral socket.  The reamer and guidepin were removed.  The scope was passed up through the tibial tunnel.  The back wall of the 
femoral socket was visualized.  The scope was returned to the viewing portal.  The Rigidfix apparatus was deployed in the knee.  The Rigidfix pin 
tracts were inserted through a separate stab wound on the lateral side of the knee without incident.  The Rigidfix guide was removed.  The scope was 
passed up through the tibial tunnel.  The femoral socket was visualized.  Both pin tracts intersected with the femoral socket as checked with a 
nitinol guidewire.  A Beath pin was then placed through the tibial tunnel, through the femoral socket and out through the skin.  It was used to pull 
the graft into place under arthroscopic visualization.  The Rigidfix pins were deployed in the knee creating our femoral fixation.  The graft was 
cycled while being taken through a range of motion approximately 20 times while held under tension.  A large sheath and 8-10 screw were then placed 
into the tibia with the leg held in perhaps 5 degrees of flexion.  Once the tibial fixation had been deployed, a Lachman maneuver was checked.  It 
was negative.  The scope was returned to the joint.  The graft was visualized.  It was taken through a range of motion from 0 to 90 degrees with no evidence of impingement, good tension and good obliquity.  The excess graft was trimmed.  

2-0 Vicryl and 3-0 Prolene were used to close the tibial wound.  3-0 Prolene was used to close the scope and Rigidfix portals.  Dry sterile dressing 
applied.  A brace applied.  All counts were correct.  The patient taken to the PACU in stable condition.


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## lekishabryant@rocketmail.com (Aug 22, 2014)

per AAOS 29881 is bundled into 29882 not unless it is on the other leg.


Lekisha Bryant, CPC,COSC


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## coderguy1939 (Aug 22, 2014)

In the AAOS GSD, under 29882 it states under Not Included Menisectomy both Other meniscus and Other leg.  AAOS GSD for 29881 under Not Included states 29882 Repair of meniscus, other meniscus.

It appears that you can do both a menisectomy and meniscus repair for the SAME knee as long as the repair is in one compartment AND the menisectomy in another (one in the lateral, the other in the medial).

The issue with your report is that the repair and menisectomy are being done in the same compartment.  In that circumstance, I believe you can only code the repair of the meniscus along with the ACL repair.

Review your AAOS GSD manual for 29881 and 29882 and take a look at the information under Not Included.

My opinion.


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## nyyankees (Aug 25, 2014)

coderguy1939 said:


> In the AAOS GSD, under 29882 it states under Not Included Menisectomy both Other meniscus and Other leg.  AAOS GSD for 29881 under Not Included states 29882 Repair of meniscus, other meniscus.
> 
> It appears that you can do both a menisectomy and meniscus repair for the SAME knee as long as the repair is in one compartment AND the menisectomy in another (one in the lateral, the other in the medial).
> 
> ...



I agree - add 59 mod for separate meniscus


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## lekishabryant@rocketmail.com (Aug 25, 2014)

Per AAOS it does say 29881 is not included but it says other leg (e.g. 29881) and based on what the sx note says I would not code it that way. I would code 29888 and 29882.  I dont see any other information or whether the medial of lateral meniscus is has any bearing on it to add 29881. Moreover, I haven't seen 29881 coded with 29882 not unless it is on the contralateral side.  Do you have something in writing to state that literally.

Lekisha Bryant, CPC, COSC



My thought on it


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## coderguy1939 (Aug 25, 2014)

If the Not Included section of 29882 states Other Meniscus Other Leg it appears that the instruction is the other meniscus of the same knee OR one of the menisci of the other knee.  If you have access to Margie Vaught at MedAssets you could pose the question to her or review her previous posts on the subject.

As I indicated in my previous post, the issue with the attached op report is that the repair and the menisectomy are performed in the same compartment in which case only the repair can be coded.

My suggestion to tschrader is that you not leave 29881 uncoded when performed in a separate compartment of the same knee until you've researched the question to your satisfaction.

Per CPT, certain procedures performed in separate compartments of the same knee can be coded with modifier 59.

If you come to the conclusion that both can be coded, modifier 59 is attached to 29882, not 29881.


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## nyyankees (Aug 26, 2014)

I think this may explain it better:

http://www.aaos.org/news/aaosnow/may12/managing1.asp


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## coderguy1939 (Aug 26, 2014)

Example number 3 in the attached AAOS article supports coding  both, but I've found that if you attach mod 59 to 29881 carriers will deny 29882 using the AAOS GSD Included guidelines for 29882.  Even on appeal.


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## lekishabryant@rocketmail.com (Aug 27, 2014)

I will use that going forward.  Thank you very much as you have made my day.


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## tschrader (Aug 27, 2014)

Thank you all for your help! This helps me alot.


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## coderguy1939 (Sep 9, 2014)

This is an addendum to my last post.  It appears that AAOS has updated the wording in their current online GSD manual and based on those changes, placing modifier 59 on 29881 when coded with 29882 should allow both procedures to be paid without appeal.


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