Orthopedic Coding Alert

Question: An orthopedic surgeon states in the operative report that he did both a medial and lateral arthroscopic meniscectomy. However, the MRI shows only medial meniscus tear and states that the lateral meniscus is intact, even though all supporting documentation in patient chart states medial and lateral meniscectomies were performed. Should I bill for both?

Alabama Subscriber

Answer: You must code 29880 (Arthroscopy, knee, surgical; with meniscectomy [medial AND lateral, including any meniscal shaving] including debridement/shaving of articular cartilage [chondroplasty], same or separate compartment[s], when performed). This code covers everything that the surgeon performed. When coding an operative report, the coder must base their diagnosis code on the diagnostic statement in the operative report, not the MRI findings.

Keep in mind that some abnormalities are not found on imaging. MRIs sometimes see the lateral meniscus as normal, but on further examination via the arthroscopy (which tends to dole out more targeted information) the orthopedic surgeon discovers previously unseen abnormalities.

However, the documentation you provided does seem to be conflicting. You claim the report says that the lateral meniscus is intact, but then proceeds to perform a partial lateral meniscectomy. This does seem to be a discrepancy.

Keep in mind: Surgeons are not infallible. Documentation errors can be made. The contradiction in the report would have to be addressed to describe and document the abnormalities of the lateral meniscus that warranted the partial lateral meniscectomy which was performed.

Takeaway: Bill for every procedure that was performed. However, it is acceptable to query the orthopedic surgeon if he or she did not include a postoperative diagnosis that would support the lateral side. Coding, after all, depends on that documentation to be correct if reports are going to survive the scrutiny of the auditors.