Wiki Arthroscopic Menisectomy

[coderguy1939]

I'm having trouble coding the above based on what the doctor is leaving out of the op report. Here is the operative findings and procedure in detail from the op report. I'd like some opinions on whether or not this can be coded or should be returned for additional information:

"Operative Findings: Intraarticular arthroscopic examination demonstrated fairly healthy patella with damage along the medial facet requiring debridement with the full-radius shaver. The suprapatellar pouch and medial and lateral gutters were healthy. The ACL and PCL were normal. The medial compartment demonstrated partial thickness loss with some unstable cartilage on the medial femoral condyle requiring debridement. There were no full-thickness lesions. There was an obvious degenerative tear in the posterior horn of the medial meniscus requiring partial medial menisectomy. The tibial surface demonstrated minor wearing out requiring debridement. The lateral compartment demonstrated a small tear in the posterior horn requiring shaving of the posterior horn of the lateral meniscus. The remainder of the lateral meniscus was healthy. There was softening without significant damage to the articular surfaces in the lateral compartment. A chondroplasty was needed of medial femoral condyle and patella but not the lateral compartment."

"Procedure in Detail: The knee was infiltrated through the intended arthroscopic incisions with lidocaine with epinephrine. An arthroscope was introduced through a standard anterolateral portal. An anteromedial portal was then created under direct visualization with an operating cannula. Sequential diagnostic examination was performed, with findings as above."

"Partial menisectomy was performed utilizing hand and motorized instruments, including banana blade for tapering, low profile Acufex instruments and pituitary rongueur to resect and remove all unstable meniscal tissue. A Dyonics shaver was used to smoothen the remaining meniscus and to remove any other loose articular cartilage. The meniscal remnant was probed and noted to be stable. Any additional chondroplasty was then performed and the knee thoroughly irrigated of all remaining debris."

This is the part of the op report I'm concerned with. Does indicating in the Findings that the doctor was in the lateral and medial compartments and that the meniscus in those compartments "requires" menisectomy and then stating "a partial menisectomy was performed" without indicating which compartments it was done in the procedure in detail provide enough information about the details of the surgery to code 29880?

Thanks.

 

[mbort]

I would let the surgeon know that he needs to tell you "where" he is at under the procedures performed. By only stating the medial and lateral compartments in the findings does not mean that he did both meniscectomies. Also he indicated that a chondroplasty was "needed" in both the medial and patellar compartments but not lateral. He does not tell you in the description of the procedure where the chondroplasty was performed. He only states "Any additional chondroplasty was then performed and the knee thoroughly irrigated of all remaining debris", again he does not tell you "where" therefore not really codeable.

My two cents
Mary

 

[coderguy1939]

I agree. Do you have direct access to your doctors or another method for resolving op report related issues?

 

[mbort]

in the ortho office I work in I have direct contact, however for the ASC's that I code for I send back to the administrator to query and obtain the additional information.

 

[coderguy1939]

Currently, the op reports are going back to the administrators but with varying degrees of success. They don't seem particularly comfortable with the role. I've suggested using another physician to do in-servicing on the issue but, so far, no success with that idea. Thanks for your help.