Here is the op report that I need some help with....I think doctors come up with their own verbage sometimes.
PREOPERATIVE DIAGNOSIS:
Left anterior knee ganglion cyst.
POSTOPERATIVE DIAGNOSES:
1. Left knee anterior ganglion cyst.
2. Lateral gutter fibrous band.
3. Grade II chondrosis of medial patellar facet and medial femoral condyle.
PROCEDURES PERFORMED:
1. Left knee arthroscopy with synovectomy and débridement of the anterior cyst fat pad and lateral gutter.
2. Chondroplasty of the medial femoral condyle and patella.
ANESTHESIA:
General.
COMPLICATIONS:
None.
BLOOD LOSS:
Minimal.
TOURNIQUET:
None.
INDICATIONS:
Takima is a 30-year-old woman with a several month history of left anterior knee pain and tightness and an MRI showing a ganglion cyst in the anterior fat pad. She was indicated for excision.
FINDINGS:
Exam under anesthesia revealed no significant effusion on full range of motion. Ligamentous exam was stable.
Arthroscopic examination of the suprapatellar pouch and medial and lateral gutters revealed a prominent fibrous band in the lateral gutter. Examination of the patella revealed some grade II chondrosis with loose flaps on the medial patellar facet. The trochlea was unremarkable. Examination of the notch revealed the cruciate ligaments to be intact. There was a fullness of the fat pad consistent with a cyst and one cyst was débrided and the cyst was entered. Examination of the lateral compartment was unremarkable. Examination of the medial compartment showed no evidence of meniscal tears. There was a chondral flap on the medial edge of the medial femoral condyle.
PROCEDURE IN DETAIL:
Following induction of general anesthesia, the left thigh tourniquet and thigh holder were applied. The right leg was placed in a well-leg holder. Under sterile conditions, the left knee was injected with 30 cc of 0.25% Marcaine with epinephrine in a standard fashion. The left lower extremity was then prepped and draped in the usual fashion.
Standard anterolateral and anteromedial portals with superolateral outflow were established and diagnostic arthroscopy was performed with the findings as above. The shaver was used to debride the anterior fat pad and this entered and confirmed the location of the cyst. The intermeniscal ligament was identified and preserved. The cyst was excised including its stalk, which extended inferiorly anterior to the inner meniscal ligament. Hemostasis was achieved with a Vulcan. A thorough débridement of the fat pad was done. Next, a shaver was used to resect the fibrous band from the lateral gutter and this was cauterized with a Vulcan. Next, the shaver was used to debride the chondral flap on the edge of the medial femoral condyle. Finally, the shaver was used to debride the fibrillated articular cartilage on the medial patellar facet.
The arthroscope was withdrawn. The portals were closed with nylon sutures and 30 cc of 0.25% Marcaine with epinephrine was instilled into the joint. A sterile dressing was applied followed by a TED hose and a knee immobilizer. The patient was awakened and extubated in the operating room and transferred to the recovery room in stable condition.
Can anyone help me with what you think ICD-9 & CPT codes would be for this case? It's a commercial payer and I work at an ASC. Any suggestions would be appreciated!
Susan
PREOPERATIVE DIAGNOSIS:
Left anterior knee ganglion cyst.
POSTOPERATIVE DIAGNOSES:
1. Left knee anterior ganglion cyst.
2. Lateral gutter fibrous band.
3. Grade II chondrosis of medial patellar facet and medial femoral condyle.
PROCEDURES PERFORMED:
1. Left knee arthroscopy with synovectomy and débridement of the anterior cyst fat pad and lateral gutter.
2. Chondroplasty of the medial femoral condyle and patella.
ANESTHESIA:
General.
COMPLICATIONS:
None.
BLOOD LOSS:
Minimal.
TOURNIQUET:
None.
INDICATIONS:
Takima is a 30-year-old woman with a several month history of left anterior knee pain and tightness and an MRI showing a ganglion cyst in the anterior fat pad. She was indicated for excision.
FINDINGS:
Exam under anesthesia revealed no significant effusion on full range of motion. Ligamentous exam was stable.
Arthroscopic examination of the suprapatellar pouch and medial and lateral gutters revealed a prominent fibrous band in the lateral gutter. Examination of the patella revealed some grade II chondrosis with loose flaps on the medial patellar facet. The trochlea was unremarkable. Examination of the notch revealed the cruciate ligaments to be intact. There was a fullness of the fat pad consistent with a cyst and one cyst was débrided and the cyst was entered. Examination of the lateral compartment was unremarkable. Examination of the medial compartment showed no evidence of meniscal tears. There was a chondral flap on the medial edge of the medial femoral condyle.
PROCEDURE IN DETAIL:
Following induction of general anesthesia, the left thigh tourniquet and thigh holder were applied. The right leg was placed in a well-leg holder. Under sterile conditions, the left knee was injected with 30 cc of 0.25% Marcaine with epinephrine in a standard fashion. The left lower extremity was then prepped and draped in the usual fashion.
Standard anterolateral and anteromedial portals with superolateral outflow were established and diagnostic arthroscopy was performed with the findings as above. The shaver was used to debride the anterior fat pad and this entered and confirmed the location of the cyst. The intermeniscal ligament was identified and preserved. The cyst was excised including its stalk, which extended inferiorly anterior to the inner meniscal ligament. Hemostasis was achieved with a Vulcan. A thorough débridement of the fat pad was done. Next, a shaver was used to resect the fibrous band from the lateral gutter and this was cauterized with a Vulcan. Next, the shaver was used to debride the chondral flap on the edge of the medial femoral condyle. Finally, the shaver was used to debride the fibrillated articular cartilage on the medial patellar facet.
The arthroscope was withdrawn. The portals were closed with nylon sutures and 30 cc of 0.25% Marcaine with epinephrine was instilled into the joint. A sterile dressing was applied followed by a TED hose and a knee immobilizer. The patient was awakened and extubated in the operating room and transferred to the recovery room in stable condition.
Can anyone help me with what you think ICD-9 & CPT codes would be for this case? It's a commercial payer and I work at an ASC. Any suggestions would be appreciated!
Susan
