# Incising  bony bumps after Menisectomy



## ASC CODER (Nov 19, 2009)

I am having trouble finding a code for :
DESCRIPTION OF PROCEDURE:
The patient was taken back to the operating room suite and placed supine on the operating table. All downward bony prominences were well-padded. Once general inhalation was started and the tube secured in place, we began preparations on the left knee. We took a time out to confirm that the left knee was the correct knee and the antibiotics were fully instead and read the procedure out loud. 

We put a tourniquet high on the left upper thigh. We were able to put the lateral leg holder on the table to hold the distal portion of the thigh to allow us to manipulate the knee during the procedure. We shaved the procedure, as well as scrubbed as well as scrubbed the knee with a Hibiclens scrub brush prior to doing a routine ChloraPrep. At this point we draped the left knee out in a sterile fashion using arthroscopy draping. 

We began with the inferior lateral portal with a small, less than 1 cm longitudinal incisional just above the joint line and lateral to the patellar tendon. We were able to make this incision with a #11 blade and then use the blunt trocar to enter the knee joint. With the knee extended we were able to go into the suprapatellar pouch region. We removed the trocar and inserted the camera into the cannula and began the diagnostic arthroscopy. We went down to the medial compartment immediately and triangulated using an 18-gauge needle to help start our second vertical portal on the inferior medial side as well. We were able to insert a probe into this area that there was a posterior horn medial meniscus tear, as well as grade 3 chondral changes noted of the medial femoral condyle, lateral femoral condyle, medial and lateral plateaus, as well as patella and trochlear groove, with cartilage and cartilaginous crystals throughout the joint consistent with his clinic history of gout. These crystals were prevalent throughout the joint and in the synovial tissue with reddened synovium. We were able to debride the chondral surfaces of all three compartments where there were small flaps of cartilage noted, as well as crystals prominent throughout the knee. We noted that the ACL and PCL were both reddened. The ACL had a partial-thickness tear, which was débrided back to a stable rim. It looks like one of the bundles was still intact. The PCL did also appear to be partially ruptured on the posterior medial aspect of the notch. We did do some debridement not only of the cruciate, but we also did some debridement of the chondral surfaces in all three compartments with complete loss of cartilage surfaces noted in all three compartments down to pure bony surfaces. The posterior horn of the medial meniscus and anterior lateral horn of the lateral meniscus were shaved back to a stable peripheral rim using a combination of shavers and biters. These were probed for integrity on the peripheral rim and noted to be intact. 

We then turned out attention to the two small bony bumps noted on the anterior aspect of the tibial tubercle area. Immediately on incising these areas through the skin with a longitudinal 3 cm incision, we noted that there was cheesy material consistent with gouty tophi. This was cleaned out of the tendon and the tendon repair with an 0 Vicryl stitch into the defect where the tendon has been eroded from this tophi. Both of these areas were débrided back to stable tendon. There was no evidence of a complete rupture appreciated. We were able to sew up the skin with 4-0 Monocryl and the scope portals with a 4-0 nylon. We put a sterile dressing on the knee, as well as Webril, ACE wrap and ABD in a sterile fashion. 

The table was returned back to its natural position. The patient was extubated and taken over to recovery on the cart. No complications occurred during this procedure. The patient tolerated this procedure as well as we expected. We have specific postoperative instructions that are written out for the patient as well. 

I have 
29883 717.2 ( he did not mention Derangement of posterior horn of lateral meniscus) but he mentioned partial lateral meniscectomy!!!

then 29877 59 because it was in a different compartment
then 29999 due to ACL debridement
 now I am stuck on the incising of the skin for gouty tophi????
cant find a code for that?
This is a workmans comp

can someone help


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## ASC CODER (Nov 19, 2009)

*I need help quick!!!!!!!!!!!!!*

Hey if anyone can help with this quick I would appreciate it!!!


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## coderguy1939 (Nov 19, 2009)

I would not use 29883--the doctor did not repair the meniscus, he did a menisectomy of the medial posterior horn and the lateral anterior horn--medial and lateral which would be 29880.  The chondroplasty of the patella could be coded with 29877-59 and the debridment of the ACL/PCL as 29999.

He went to an open procedure for the gouty tophi, so I would look for an open produre for that part fo the surgery.

My opinion regarding the posted op rpt.  Anyone else?


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## nyyankees (Nov 19, 2009)

Since ACL is in patellafemoral compartment wouldn't 29999 ACL/PCL debridement be inclusive with 29877 (patella chondroplasty)?


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## ASC CODER (Nov 19, 2009)

your right 29880

I am reading far to much into this one. 

ok 29999 yes acl is in the patellafemoral compartment

still cant decide on the incision and removal of tophi???


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## ASC CODER (Nov 19, 2009)

ok 

27328 due to the fact that it had eroded the tendon.....


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## coderguy1939 (Nov 19, 2009)

I understand what you're saying about the ACL/PCL debridment inclusive to 29877.  However, I've seen it coded both ways.


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## ASC CODER (Nov 19, 2009)

coderguy

do you agree with 27238?


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## coderguy1939 (Nov 19, 2009)

Well, the surgeon doesn't say specfically that he is subfascial or intramuscular.  The report says that immediately upon incision he encountered material consistent with gouty tophi.  He debrides this off the tendon so you may want to look at debridement codes.


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## ASC CODER (Nov 19, 2009)

I feel good with 11042 

so it will be

29880 lt 712.2
29999 717.83 717.84
11042 274.03 ( new icd-9  code for 2009)


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## coderguy1939 (Nov 19, 2009)

You're going to need a DX code for the lateral meniscus.


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## ASC CODER (Nov 19, 2009)

I know I am going to query the surgeon in order to get my dx. He did not mention the lateral meniscus..... but he did the lateral menisectomy so he should have a reason why he did that.. wouldn't you think?

Thanks so much. sometimes you just need to take a step back.

Tks


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## coderguy1939 (Nov 19, 2009)

You probably should give some more thought to coding the chondroplasty of the patella.  What NYYankees was saying is that because the ACL and PCL are accessed through the Patellofemoral compartment the debridement could be considered inclusive by the carrier.  Recently I've been seeing both the chondroplasty, 29877, and the ACL debridement, 29999, coded together and I think it's partially based on the information coders are accessing here:

www.aaos.org/news/aaosnow/mar09/managing3.asp.

Based on the op note you posted, the surgeon did a chondroplasty of the patellofemoral compartment which I would code along with 29880.


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## ASC CODER (Nov 20, 2009)

thanks I will 

I always like documentation...

Thanks again...


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