tschrader
Networker
The doctor has selected codes 29888, 29882, and 29881. When I reviewed the operative report the anterior horn had the meniscectomy done. The posterior horn had the repair done.
I feel that the 29881 is bundled into 29888 since you cannot separate out the anterior from the posterior. But of course I am also doubting myself and would like another opinion on this before I tell the doctor that this is.
I would like some of your opinions on this. Thank you!
PRE-OPERATIVE DIAGNOSIS:
Right knee ACL tear, right knee meniscal tear.
POST-OPERATIVE DIAGNOSIS:
Same.
NAME OF PROCEDURE:
1. Right knee ACL reconstruction, arthroscopic assisted.
2. Right knee partial lateral meniscectomy.
3. Arthroscopic lateral meniscal repair.
ASSISTANT:
NP assisted with patient positioning, exposure, retraction, graft preparation, leg manipulation, wound closure, brace application.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
Minimal.
FLUIDS:
Per Anesthesia.
DRAINS:
None.
SPECIMEN:
None.
IMPLANTS:
Mitek Rigidfix and Bio-Intrafix pins and screws, size 8-10 large sheath and one Omnispan Mitek meniscal repair device.
COMPLICATIONS:
None.
DISPOSITION:
Stable to PACU.
BRIEF HISTORY OF THE PATIENT:
A male patient has injured his right knee. Clinical exam demonstrates the above noted pathology. The risks and benefits of ACL
reconstruction, meniscal repair versus meniscectomy were discussed. These include, but are not limited to infection, blood clot, stiffness, loss of
range of motion, continued pain, problems with anesthesia, the need for further surgery, the expected postoperative course including a week in a
brace locked straight, a month total in a brace, 6 months until full return to activity. He agreed to the procedure.
DESCRIPTION OF PROCEDURE:
Patient taken to the Operating Room after informed consent was obtained, placed supine on the operating room table. General anesthesia was
established. The right leg was prepped and draped in the usual sterile fashion. An examination under anesthesia showed full and equivalent range of motion with a 2+ Lachman. Time-out was accomplished to the satisfaction of the operating room staff, the anesthesia team and the surgical team.
An incision was made over the anteromedial edge of the tibia. The skin and subcutaneous tissues were divided. Hemostasis was achieved. Blunt
dissection was taken down. The semitendinosus and gracilis tendons were harvested without incident, placed on the back table and formed into a quad
stranded autograft in accordance with the manufacturer's instructions for our chosen implants. It was approximately 8.5 mm in width and of
appropriate length. It was placed under tension. An inferolateral viewing portal was created. An arthroscopic examination of the knee commenced.
Upon entering the patellofemoral joint, patellar and trochlear cartilage were intact. We entered the medial compartment of the knee. A medial
working portal was created with the use of a spinal needle and outside-in technique. Medial femoral condyle had some grade I changes. Medial tibial
plateau was intact. Medial meniscus was checked with a probe and felt to be stable. We entered the intercondylar notch. The ACL was completely
obliterated. The stump was scarred into the PCL. There was no evidence of fibers in continuity. We entered the lateral compartment of the knee.
The lateral femoral condyle was intact. The lateral tibial plateau had some grade I changes. The anterior horn of the lateral meniscus had evidence
of a large flap tear. Perhaps 30% of the meniscus was torn. It appeared to be sticking straight into the lateral joint space. The posterior horn
of the lateral meniscus had a separate tear which was noted to be an avulsion off the posterior root. The meniscus appeared to be partially fixed to the back capsule. Decision was made to remove the anterior horn flap. A series of shavers and biters were entered in the joint until the torn
portion of the anterior horn of the lateral meniscus was resected. Perhaps 30% of the anterior horn was removed. We then turned our attention
posteriorly. Decision was made to repair the posterior horn through the rootlet. An Omnispan meniscal repair device was deployed across the tear
and from attaching the meniscus into the capsule. A horizontal mattress configuration was used. The device was tightened down and the repair was
completed without incident. At this point, the meniscus appeared to be stabilized. We turned our attention to the intercondylar notch. The shaver
and the Mitek vapor wand were used to resect the remnants of the ACL until the tibial and femoral footprints were visualized. The tibial guide was
entered in the joint. Bullet apparatus was passed through the medial tibial incision. A guidepin was directed from the medial tibia up through the
tibial footprint of the ACL. It was checked under arthroscopic visualization. A 9.5 mm reamer was passed over the top of the guide pin. Tibial
tunnel was created. A shaver was entered in the joint. Bony debris was removed. An aiming device was used to direct a guide pin through the
femoral footprint of the ACL. It was taken out through the lateral femoral condyle. An 8.5 mm reamer was passed over the top of it to a depth of 35
mm creating our femoral socket. The reamer and guidepin were removed. The scope was passed up through the tibial tunnel. The back wall of the
femoral socket was visualized. The scope was returned to the viewing portal. The Rigidfix apparatus was deployed in the knee. The Rigidfix pin
tracts were inserted through a separate stab wound on the lateral side of the knee without incident. The Rigidfix guide was removed. The scope was
passed up through the tibial tunnel. The femoral socket was visualized. Both pin tracts intersected with the femoral socket as checked with a
nitinol guidewire. A Beath pin was then placed through the tibial tunnel, through the femoral socket and out through the skin. It was used to pull
the graft into place under arthroscopic visualization. The Rigidfix pins were deployed in the knee creating our femoral fixation. The graft was
cycled while being taken through a range of motion approximately 20 times while held under tension. A large sheath and 8-10 screw were then placed
into the tibia with the leg held in perhaps 5 degrees of flexion. Once the tibial fixation had been deployed, a Lachman maneuver was checked. It
was negative. The scope was returned to the joint. The graft was visualized. It was taken through a range of motion from 0 to 90 degrees with no evidence of impingement, good tension and good obliquity. The excess graft was trimmed.
2-0 Vicryl and 3-0 Prolene were used to close the tibial wound. 3-0 Prolene was used to close the scope and Rigidfix portals. Dry sterile dressing
applied. A brace applied. All counts were correct. The patient taken to the PACU in stable condition.
I feel that the 29881 is bundled into 29888 since you cannot separate out the anterior from the posterior. But of course I am also doubting myself and would like another opinion on this before I tell the doctor that this is.
I would like some of your opinions on this. Thank you!
PRE-OPERATIVE DIAGNOSIS:
Right knee ACL tear, right knee meniscal tear.
POST-OPERATIVE DIAGNOSIS:
Same.
NAME OF PROCEDURE:
1. Right knee ACL reconstruction, arthroscopic assisted.
2. Right knee partial lateral meniscectomy.
3. Arthroscopic lateral meniscal repair.
ASSISTANT:
NP assisted with patient positioning, exposure, retraction, graft preparation, leg manipulation, wound closure, brace application.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
Minimal.
FLUIDS:
Per Anesthesia.
DRAINS:
None.
SPECIMEN:
None.
IMPLANTS:
Mitek Rigidfix and Bio-Intrafix pins and screws, size 8-10 large sheath and one Omnispan Mitek meniscal repair device.
COMPLICATIONS:
None.
DISPOSITION:
Stable to PACU.
BRIEF HISTORY OF THE PATIENT:
A male patient has injured his right knee. Clinical exam demonstrates the above noted pathology. The risks and benefits of ACL
reconstruction, meniscal repair versus meniscectomy were discussed. These include, but are not limited to infection, blood clot, stiffness, loss of
range of motion, continued pain, problems with anesthesia, the need for further surgery, the expected postoperative course including a week in a
brace locked straight, a month total in a brace, 6 months until full return to activity. He agreed to the procedure.
DESCRIPTION OF PROCEDURE:
Patient taken to the Operating Room after informed consent was obtained, placed supine on the operating room table. General anesthesia was
established. The right leg was prepped and draped in the usual sterile fashion. An examination under anesthesia showed full and equivalent range of motion with a 2+ Lachman. Time-out was accomplished to the satisfaction of the operating room staff, the anesthesia team and the surgical team.
An incision was made over the anteromedial edge of the tibia. The skin and subcutaneous tissues were divided. Hemostasis was achieved. Blunt
dissection was taken down. The semitendinosus and gracilis tendons were harvested without incident, placed on the back table and formed into a quad
stranded autograft in accordance with the manufacturer's instructions for our chosen implants. It was approximately 8.5 mm in width and of
appropriate length. It was placed under tension. An inferolateral viewing portal was created. An arthroscopic examination of the knee commenced.
Upon entering the patellofemoral joint, patellar and trochlear cartilage were intact. We entered the medial compartment of the knee. A medial
working portal was created with the use of a spinal needle and outside-in technique. Medial femoral condyle had some grade I changes. Medial tibial
plateau was intact. Medial meniscus was checked with a probe and felt to be stable. We entered the intercondylar notch. The ACL was completely
obliterated. The stump was scarred into the PCL. There was no evidence of fibers in continuity. We entered the lateral compartment of the knee.
The lateral femoral condyle was intact. The lateral tibial plateau had some grade I changes. The anterior horn of the lateral meniscus had evidence
of a large flap tear. Perhaps 30% of the meniscus was torn. It appeared to be sticking straight into the lateral joint space. The posterior horn
of the lateral meniscus had a separate tear which was noted to be an avulsion off the posterior root. The meniscus appeared to be partially fixed to the back capsule. Decision was made to remove the anterior horn flap. A series of shavers and biters were entered in the joint until the torn
portion of the anterior horn of the lateral meniscus was resected. Perhaps 30% of the anterior horn was removed. We then turned our attention
posteriorly. Decision was made to repair the posterior horn through the rootlet. An Omnispan meniscal repair device was deployed across the tear
and from attaching the meniscus into the capsule. A horizontal mattress configuration was used. The device was tightened down and the repair was
completed without incident. At this point, the meniscus appeared to be stabilized. We turned our attention to the intercondylar notch. The shaver
and the Mitek vapor wand were used to resect the remnants of the ACL until the tibial and femoral footprints were visualized. The tibial guide was
entered in the joint. Bullet apparatus was passed through the medial tibial incision. A guidepin was directed from the medial tibia up through the
tibial footprint of the ACL. It was checked under arthroscopic visualization. A 9.5 mm reamer was passed over the top of the guide pin. Tibial
tunnel was created. A shaver was entered in the joint. Bony debris was removed. An aiming device was used to direct a guide pin through the
femoral footprint of the ACL. It was taken out through the lateral femoral condyle. An 8.5 mm reamer was passed over the top of it to a depth of 35
mm creating our femoral socket. The reamer and guidepin were removed. The scope was passed up through the tibial tunnel. The back wall of the
femoral socket was visualized. The scope was returned to the viewing portal. The Rigidfix apparatus was deployed in the knee. The Rigidfix pin
tracts were inserted through a separate stab wound on the lateral side of the knee without incident. The Rigidfix guide was removed. The scope was
passed up through the tibial tunnel. The femoral socket was visualized. Both pin tracts intersected with the femoral socket as checked with a
nitinol guidewire. A Beath pin was then placed through the tibial tunnel, through the femoral socket and out through the skin. It was used to pull
the graft into place under arthroscopic visualization. The Rigidfix pins were deployed in the knee creating our femoral fixation. The graft was
cycled while being taken through a range of motion approximately 20 times while held under tension. A large sheath and 8-10 screw were then placed
into the tibia with the leg held in perhaps 5 degrees of flexion. Once the tibial fixation had been deployed, a Lachman maneuver was checked. It
was negative. The scope was returned to the joint. The graft was visualized. It was taken through a range of motion from 0 to 90 degrees with no evidence of impingement, good tension and good obliquity. The excess graft was trimmed.
2-0 Vicryl and 3-0 Prolene were used to close the tibial wound. 3-0 Prolene was used to close the scope and Rigidfix portals. Dry sterile dressing
applied. A brace applied. All counts were correct. The patient taken to the PACU in stable condition.
