sukheshini
New
Please suggest me with appropriate CPT coding.
DX:
1. Left knee grade I chondromalacia of patella medial surface.
2. Left knee grade II and III chondromalacia of patellofemoral surfaces.
3. Left knee complex horizontal cleavage tear of the posterior horn of medial meniscus.
4. Left knee complete root tear of the posterior horn of medial meniscus.
5. Left knee synovitis with small plica.
Procedures:
1. Left knee arthroscopy with arthroscopic partial medial meniscectomy.
2. Left knee arthroscopy with arthroscopic medial meniscus root repair.
3. Left knee arthroscopy with arthroscopic plica excision and debridement and synovectomy.
4. Left knee percutaneous MCL release.
BRIEF DESCRIPTION OF OPERATIVE PROCEDURE: The patient was brought into the operating room, placed on table in supine position. After administration of appropriate anesthetic agents and monitoring devices, the left lower extremity was sterilely prepped and draped in standard orthopedic fashion with nonsterile tourniquet. Time-out was taken to ensure correct site for surgery and preoperative antibiotics were given. The leg was elevated, exsanguinated, and tourniquet inflated to 250 mmHg. Medial and lateral portals were made. Suprapatellar pouch was identified. We identified grade II and III chondromalacia of the patellofemoral surfaces. There was a medial plica that was incarcerated of this area. This was shaven. We then entered the medial joint. There was a complex degenerative cleavage tear of the posterior horn of the medial meniscus. We clipped and shaved it into smooth surface, removing approximately 60% of the meniscus. The root was completely torn and extruded as well. We then completed our percutaneous MCL release, opening the knee safely. We then used ACL drill guide to make the tibial tunnel exiting at the origin of the posterior root. We then reamed this with a 4.5 reamer. We then placed a PassPort and placed locking sutures around the meniscus root. We then pulled this meniscus root into the tunnel, fixated this distally in the tibia with an interference screw and tied the sutures over the interference screw. There was anatomic fixation of the meniscus root at the completion of repair without complications. We then resected some more fat pad anteriorly. We entered the lateral knee. The ACL was intact. The lateral joint was pristine. There was no evidence of meniscus tearing. We then closed the portals with nylon. A sterile dressing was applied. The patient was awakened from anesthesia and transferred to the recovery room in stable condition. All counts were correct.
DX:
1. Left knee grade I chondromalacia of patella medial surface.
2. Left knee grade II and III chondromalacia of patellofemoral surfaces.
3. Left knee complex horizontal cleavage tear of the posterior horn of medial meniscus.
4. Left knee complete root tear of the posterior horn of medial meniscus.
5. Left knee synovitis with small plica.
Procedures:
1. Left knee arthroscopy with arthroscopic partial medial meniscectomy.
2. Left knee arthroscopy with arthroscopic medial meniscus root repair.
3. Left knee arthroscopy with arthroscopic plica excision and debridement and synovectomy.
4. Left knee percutaneous MCL release.
BRIEF DESCRIPTION OF OPERATIVE PROCEDURE: The patient was brought into the operating room, placed on table in supine position. After administration of appropriate anesthetic agents and monitoring devices, the left lower extremity was sterilely prepped and draped in standard orthopedic fashion with nonsterile tourniquet. Time-out was taken to ensure correct site for surgery and preoperative antibiotics were given. The leg was elevated, exsanguinated, and tourniquet inflated to 250 mmHg. Medial and lateral portals were made. Suprapatellar pouch was identified. We identified grade II and III chondromalacia of the patellofemoral surfaces. There was a medial plica that was incarcerated of this area. This was shaven. We then entered the medial joint. There was a complex degenerative cleavage tear of the posterior horn of the medial meniscus. We clipped and shaved it into smooth surface, removing approximately 60% of the meniscus. The root was completely torn and extruded as well. We then completed our percutaneous MCL release, opening the knee safely. We then used ACL drill guide to make the tibial tunnel exiting at the origin of the posterior root. We then reamed this with a 4.5 reamer. We then placed a PassPort and placed locking sutures around the meniscus root. We then pulled this meniscus root into the tunnel, fixated this distally in the tibia with an interference screw and tied the sutures over the interference screw. There was anatomic fixation of the meniscus root at the completion of repair without complications. We then resected some more fat pad anteriorly. We entered the lateral knee. The ACL was intact. The lateral joint was pristine. There was no evidence of meniscus tearing. We then closed the portals with nylon. A sterile dressing was applied. The patient was awakened from anesthesia and transferred to the recovery room in stable condition. All counts were correct.