Here is another example - - how would you code the DX??
Thank you
PREOPERATIVE DIAGNOSES: Torn right medial and lateral menisci.
POSTOPERATIVE DIAGNOSES: Torn right medial and lateral menisci and medial hypertrophic plica.
OPERATIONS PERFORMED:
1. Arthroscopy, right knee.
2. Partial medial meniscectomy.
3. Partial lateral meniscectomy.
4. Excision of hypertrophic plica.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: The patient was seen in the holding area where the right knee was marked as the correct knee. He was taken to OR and placed in the supine position on the operating table. General anesthesia was induced. He was given Ancef 2 g IV for infection prophylaxis. His right lower extremity was prepped using isopropyl alcohol and a towel. He was then prepped and draped in usual sterile fashion using ChloraPrep solution. Standard arthroscopic portal incisions were made to the knee and the knee joint was examined. He had grade III chondromalacia in the intercondylar groove, grade II chondromalacia on both the medial and lateral facets of the patella. The grade III was debrided using 4.5 mm full-radius shaver. Camera was then placed in the notch. The anterior and posterior cruciate ligaments were intact. The medial and lateral gutters were examined and found to be free of loose bodies. The medial joint line was examined. He had a posterior horn tear of the medial meniscus that extended into the central body, this was photographed and excised using meniscal biters and a shaver. The chondral surfaces medially had grade II and III chondromalacia. Chondromalacia was debrided back to stable base using the shaver. Camera was then placed in lateral joint line with the knee in figure four position. He had a complex central body and posterior horn lateral meniscal tear, this was photographed and had horizontal and vertical components. The tear was excised using meniscal biters and shaver was used to shave the remaining meniscus. The knee was then irrigated with 2 liters of normal saline. All excess floating cartilaginous and soft tissue debris was suctioned lavaged from the knee. He had a hypertrophic medial parapatellar plica that was photographed and excised with shaver. Portal sites were then closed with 3-0 nylon and injected with 0.5% Marcaine with epinephrine for postop control of pain and bleeding. A dry sterile lightly compression dressing was applied and the patient was taken to the recovery room, breathing unassisted. There were no complications.
Thank you
PREOPERATIVE DIAGNOSES: Torn right medial and lateral menisci.
POSTOPERATIVE DIAGNOSES: Torn right medial and lateral menisci and medial hypertrophic plica.
OPERATIONS PERFORMED:
1. Arthroscopy, right knee.
2. Partial medial meniscectomy.
3. Partial lateral meniscectomy.
4. Excision of hypertrophic plica.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: The patient was seen in the holding area where the right knee was marked as the correct knee. He was taken to OR and placed in the supine position on the operating table. General anesthesia was induced. He was given Ancef 2 g IV for infection prophylaxis. His right lower extremity was prepped using isopropyl alcohol and a towel. He was then prepped and draped in usual sterile fashion using ChloraPrep solution. Standard arthroscopic portal incisions were made to the knee and the knee joint was examined. He had grade III chondromalacia in the intercondylar groove, grade II chondromalacia on both the medial and lateral facets of the patella. The grade III was debrided using 4.5 mm full-radius shaver. Camera was then placed in the notch. The anterior and posterior cruciate ligaments were intact. The medial and lateral gutters were examined and found to be free of loose bodies. The medial joint line was examined. He had a posterior horn tear of the medial meniscus that extended into the central body, this was photographed and excised using meniscal biters and a shaver. The chondral surfaces medially had grade II and III chondromalacia. Chondromalacia was debrided back to stable base using the shaver. Camera was then placed in lateral joint line with the knee in figure four position. He had a complex central body and posterior horn lateral meniscal tear, this was photographed and had horizontal and vertical components. The tear was excised using meniscal biters and shaver was used to shave the remaining meniscus. The knee was then irrigated with 2 liters of normal saline. All excess floating cartilaginous and soft tissue debris was suctioned lavaged from the knee. He had a hypertrophic medial parapatellar plica that was photographed and excised with shaver. Portal sites were then closed with 3-0 nylon and injected with 0.5% Marcaine with epinephrine for postop control of pain and bleeding. A dry sterile lightly compression dressing was applied and the patient was taken to the recovery room, breathing unassisted. There were no complications.
