dyoungberg
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I am lost on this one.............The doctor attempted irrigation of both knees without arthroscopy. The arthroscopic code would be 29871, but what would I code this done without arthroscopy?
Here is the Op Note:
PROCEDURE: 1. ATTEMPTED IRRIGATION OF BOTH KNEES
2. INJECTION OF STEROID BOTH KNEES (40 MG OF
KENALOG AND 9 CC OF 0.25% MARCAINE)
TECHNIQUE: The patient was brought to the operating room and placed supine on the operating room table. She was sedated with Versed. A skin wheal was raised over the lateral joint line on the right knee after a sterile prep. An #18 gauge large bore needle was then inserted. The saline flowed freely but I really was not able to get any saline back. I believe there were some adhesions causing problems. The mixture of Kenalog and Marcaine was then injected. The needle was withdrawn and a sterile dressing was applied. Similarly on the left side the knee was prepped. A skin wheal was raised with local anesthesia and a large bore needle inserted into the joint. A few drops of synovial fluid came back. I attempted to irrigate the joint with normal saline; however, again the saline entered easily but I could not withdraw it. For this reason I went ahead and stopped the attempted irrigation and simply injected the steroid/Marcaine mixture. A sterile dressing was then applied. She was allowed to awaken and was then sent to the recovery room to be dismissed.
Thanks very much!
Debbie
Here is the Op Note:
PROCEDURE: 1. ATTEMPTED IRRIGATION OF BOTH KNEES
2. INJECTION OF STEROID BOTH KNEES (40 MG OF
KENALOG AND 9 CC OF 0.25% MARCAINE)
TECHNIQUE: The patient was brought to the operating room and placed supine on the operating room table. She was sedated with Versed. A skin wheal was raised over the lateral joint line on the right knee after a sterile prep. An #18 gauge large bore needle was then inserted. The saline flowed freely but I really was not able to get any saline back. I believe there were some adhesions causing problems. The mixture of Kenalog and Marcaine was then injected. The needle was withdrawn and a sterile dressing was applied. Similarly on the left side the knee was prepped. A skin wheal was raised with local anesthesia and a large bore needle inserted into the joint. A few drops of synovial fluid came back. I attempted to irrigate the joint with normal saline; however, again the saline entered easily but I could not withdraw it. For this reason I went ahead and stopped the attempted irrigation and simply injected the steroid/Marcaine mixture. A sterile dressing was then applied. She was allowed to awaken and was then sent to the recovery room to be dismissed.
Thanks very much!
Debbie