Hi list! I was hoping someone could please give me their thoughts on how they would code this. I had thought about 29876 & 29879
Even G0289 & 29876, but it says G0289 has to be used with a primary code and it doesn't like 29876 per my Encoder. ") Please bear with me I am still learning this Ortho coding.
Thanks in advance,
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSES:
Right knee pain, synovitis and chondromalacia.
POSTOPERATIVE DIAGNOSES:
right knee pain, synovitis and chondromalacia of the medial
femoral condyle and patellofemoral area with multiple
cartilaginous loose bodies and disruption of ligamentum
mucosum.
PROCEDURES:
Arthroscopic examination with synovectomy, loose body removal
and abrasion chondroplasty of the right knee.
SURGEON:
ANESTHESIA:
General endotracheal.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 39-year-old female with history of persistent pain
and soreness of her right knee for the last several months.
She has had continued trouble despite conservative care and
options of continued conservative care versus surgery were
discussed at length. She requested surgical treatment.
DESCRIPTION OF PROCEDURE:
After obtaining informed consent, the patient was brought to
the operating room and placed on the operating room table in
supine position. After administration of general endotracheal
anesthesia, time-out was performed. The patient was
identified, appropriate body site had been marked and she
received appropriate antibiotics. Next, a tourniquet was
placed on the right proximal thigh and the skin was prepped
and 0.5% lidocaine with epinephrine was placed in the knee
joint. Next, the right leg was sterilely prepped and draped
in a routine manner. An anterolateral arthroscopy portal was
then made and arthroscopic examination of the joint was
performed. Examination of the joint showed some small
cartilaginous loose bodies in the suprapatellar area and mild
inflammation of the synovium. The patellofemoral joint showed
some grade II chondromalacial changes and thinning. The
medial gutter showed thickened and inflamed plica and some
inflammation along the edge of the condyle. The lateral joint
was examined and the lateral meniscus was noted to be intact
and articular surface was normal in appearance. The notch
area was examined and the ACL and PCL were intact. There was
disruption of the ligamentum mucosum and synovial impingement
noted along the joint and the notch area. Next, the lateral
compartment was examined and there articular cartilage injury
was noted and this was debrided with a shaver back to stable
edges and loose bodies removed here also. Thorough
debridement of the joint was performed. The remaining portion
of the exam was otherwise unremarkable. Next, the arthroscopy
equipment was removed from the knee joint. Steri-Strips were
used to approximate the skin edges and the portals and joint were infiltrated with
1% lidocaine. A sterile dressing was applied and the patient
was transferred to recovery room in stable condition.
Even G0289 & 29876, but it says G0289 has to be used with a primary code and it doesn't like 29876 per my Encoder. ") Please bear with me I am still learning this Ortho coding.
Thanks in advance,
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSES:
Right knee pain, synovitis and chondromalacia.
POSTOPERATIVE DIAGNOSES:
right knee pain, synovitis and chondromalacia of the medial
femoral condyle and patellofemoral area with multiple
cartilaginous loose bodies and disruption of ligamentum
mucosum.
PROCEDURES:
Arthroscopic examination with synovectomy, loose body removal
and abrasion chondroplasty of the right knee.
SURGEON:
ANESTHESIA:
General endotracheal.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 39-year-old female with history of persistent pain
and soreness of her right knee for the last several months.
She has had continued trouble despite conservative care and
options of continued conservative care versus surgery were
discussed at length. She requested surgical treatment.
DESCRIPTION OF PROCEDURE:
After obtaining informed consent, the patient was brought to
the operating room and placed on the operating room table in
supine position. After administration of general endotracheal
anesthesia, time-out was performed. The patient was
identified, appropriate body site had been marked and she
received appropriate antibiotics. Next, a tourniquet was
placed on the right proximal thigh and the skin was prepped
and 0.5% lidocaine with epinephrine was placed in the knee
joint. Next, the right leg was sterilely prepped and draped
in a routine manner. An anterolateral arthroscopy portal was
then made and arthroscopic examination of the joint was
performed. Examination of the joint showed some small
cartilaginous loose bodies in the suprapatellar area and mild
inflammation of the synovium. The patellofemoral joint showed
some grade II chondromalacial changes and thinning. The
medial gutter showed thickened and inflamed plica and some
inflammation along the edge of the condyle. The lateral joint
was examined and the lateral meniscus was noted to be intact
and articular surface was normal in appearance. The notch
area was examined and the ACL and PCL were intact. There was
disruption of the ligamentum mucosum and synovial impingement
noted along the joint and the notch area. Next, the lateral
compartment was examined and there articular cartilage injury
was noted and this was debrided with a shaver back to stable
edges and loose bodies removed here also. Thorough
debridement of the joint was performed. The remaining portion
of the exam was otherwise unremarkable. Next, the arthroscopy
equipment was removed from the knee joint. Steri-Strips were
used to approximate the skin edges and the portals and joint were infiltrated with
1% lidocaine. A sterile dressing was applied and the patient
was transferred to recovery room in stable condition.