Hi list! 
Still a newbie to Ortho
I am gathering I would only code the menisectomy in this case since all of this was performed in same compartment of knee??
Any guidance is greatly appreciated!!
Knee Arthroscopy Procedure Note
Pre-operative Diagnosis:
right Knee:
Lateral meniscal tear
Knee arthritis
Post-operative Diagnosis:
Right Knee:
Lateral meniscus tear (very extensive extending from the posterior horn through to the anterior horn complete tear in front of the popliteus tendon)
Patellofemoral chondromalacia
Medial compartment chondromalacia
Lateral compartment chondromalacia
patellofemoral had grade 2 chondromalacia as did the medial compartment and fraying of the medial edge of the medial meniscus. Lateral compartment had some grade 3 chondromalacia as well as the extensive lateral meniscus tear.
Procedures Performed:
right Knee:
Partial Lateral Meniscectomy
Lateral Meniscus Repair
Lateral femoral condyle chondroplasty (not to bleeding bone)
Surgeon:
Anesthetic: General anesthetic without block
Total IV Fluids: Crystaloid
Tourniquet time: 35 min at 350 mm
Estimated Blood Loss: min
Antibiotic Given: Two grams of Cefazolin were given.
Drains: None
Implants: none
Indications: This patient is 70-year-old male who presented to my office over a month ago with right knee pain. He had signs and symptoms as well as x-ray evidence of some arthritis in the lateral compartment where his symptoms were located. We did an MRI scan which showed an extensive lateral meniscus tear and arthritis. He had a lot of signs and symptoms of mechanical dysfunction rather than pain from arthritis. He was offered arthroscopy for dressing mechanical problems. He came in knowing the risks including those of neurovascular compromise and infection in fact no guarantee can be given as to outcome of surgery. He knew that he could become worse with surgery. Also knows that I cannot get rid of his arthritic pain. Also is aware that there'll be one to 2 weeks of decreased activity postop.
Intraoperative findings:
Exam under anesthetic findings: stable lig exam for all lig, Full ROM
Arthroscopic findings:
Patellofemoral: Grade 2 chondromalacia with small area of grade 3 chondromalacia
Medial compartment: Grade 2 chondromalacia
Notch: ACL was frayed but functionally intact.
Lateral compartment: Extensive posterior horn body and anterior horn lateral meniscus tear necessitating nearly full lateral meniscectomy. Also grade 2 and 3 chondromalacia of the lateral femoral condyle and grade 2 medial tibial plateau.
Procedure Details
After the risks, benefits, and indications for the proposed procedure were discussed with the patient, the patient agreed to proceed. Consent form was reviewd, Questions were answered. The correct extremity was identified with permanent one-time use marker in preoperative hold and the patient was brought back to the operating room, where general anesthetic was administered. After I performed an examination under anesthetic of the affected knee (findings noted above), we prepped and draped the affected lower extremity over a thigh tourniquet. I began the case by utilizing esmarch for limb exsanguination, and then inflated the thigh tourniquet. I began by developing an anterolateral portal for arthroscopic visualization. Under direct arthroscopic visualization, I then developed an anteromedial arthroscopic portal just superior to the medial meniscus using needle localization. Please see arthroscopic findings section for details of the intraarticular findings. I utilized a combination of meniscal biter, arthroscopic shaver, and ArthroCare wand in order to perform the above-listed procedures. I closed the portals using 3-0 nylon for the skin and a sterile dressing covered with xeroform, 4x4 gauze, cast padding and Ace wrap. I let the tourniquet down, and distal vascular status immediately normalized. Instrument, sponge, and needle counts were correct prior to wound closure and at the conclusion of the case.
The patient awoke from general anesthetic without complication, was transferred to the recovery room in stable condition. It appeared that the patient tolerated the procedure well, as vital signs remained stable throughout. There were no complications.
Complications: None
Condition: Stable
Disposition: Recovery Room, then Same Day Surgery
Post-Operative Plan: The patient will be weight bearing as tolerated, with range of motion as tolerated. Crutches may be necessary for a couple days to a couple weeks, for comfort only. No physical therapy will be necessary
Still a newbie to Ortho
I am gathering I would only code the menisectomy in this case since all of this was performed in same compartment of knee??
Any guidance is greatly appreciated!!
Knee Arthroscopy Procedure Note
Pre-operative Diagnosis:
right Knee:
Lateral meniscal tear
Knee arthritis
Post-operative Diagnosis:
Right Knee:
Lateral meniscus tear (very extensive extending from the posterior horn through to the anterior horn complete tear in front of the popliteus tendon)
Patellofemoral chondromalacia
Medial compartment chondromalacia
Lateral compartment chondromalacia
patellofemoral had grade 2 chondromalacia as did the medial compartment and fraying of the medial edge of the medial meniscus. Lateral compartment had some grade 3 chondromalacia as well as the extensive lateral meniscus tear.
Procedures Performed:
right Knee:
Partial Lateral Meniscectomy
Lateral Meniscus Repair
Lateral femoral condyle chondroplasty (not to bleeding bone)
Surgeon:
Anesthetic: General anesthetic without block
Total IV Fluids: Crystaloid
Tourniquet time: 35 min at 350 mm
Estimated Blood Loss: min
Antibiotic Given: Two grams of Cefazolin were given.
Drains: None
Implants: none
Indications: This patient is 70-year-old male who presented to my office over a month ago with right knee pain. He had signs and symptoms as well as x-ray evidence of some arthritis in the lateral compartment where his symptoms were located. We did an MRI scan which showed an extensive lateral meniscus tear and arthritis. He had a lot of signs and symptoms of mechanical dysfunction rather than pain from arthritis. He was offered arthroscopy for dressing mechanical problems. He came in knowing the risks including those of neurovascular compromise and infection in fact no guarantee can be given as to outcome of surgery. He knew that he could become worse with surgery. Also knows that I cannot get rid of his arthritic pain. Also is aware that there'll be one to 2 weeks of decreased activity postop.
Intraoperative findings:
Exam under anesthetic findings: stable lig exam for all lig, Full ROM
Arthroscopic findings:
Patellofemoral: Grade 2 chondromalacia with small area of grade 3 chondromalacia
Medial compartment: Grade 2 chondromalacia
Notch: ACL was frayed but functionally intact.
Lateral compartment: Extensive posterior horn body and anterior horn lateral meniscus tear necessitating nearly full lateral meniscectomy. Also grade 2 and 3 chondromalacia of the lateral femoral condyle and grade 2 medial tibial plateau.
Procedure Details
After the risks, benefits, and indications for the proposed procedure were discussed with the patient, the patient agreed to proceed. Consent form was reviewd, Questions were answered. The correct extremity was identified with permanent one-time use marker in preoperative hold and the patient was brought back to the operating room, where general anesthetic was administered. After I performed an examination under anesthetic of the affected knee (findings noted above), we prepped and draped the affected lower extremity over a thigh tourniquet. I began the case by utilizing esmarch for limb exsanguination, and then inflated the thigh tourniquet. I began by developing an anterolateral portal for arthroscopic visualization. Under direct arthroscopic visualization, I then developed an anteromedial arthroscopic portal just superior to the medial meniscus using needle localization. Please see arthroscopic findings section for details of the intraarticular findings. I utilized a combination of meniscal biter, arthroscopic shaver, and ArthroCare wand in order to perform the above-listed procedures. I closed the portals using 3-0 nylon for the skin and a sterile dressing covered with xeroform, 4x4 gauze, cast padding and Ace wrap. I let the tourniquet down, and distal vascular status immediately normalized. Instrument, sponge, and needle counts were correct prior to wound closure and at the conclusion of the case.
The patient awoke from general anesthetic without complication, was transferred to the recovery room in stable condition. It appeared that the patient tolerated the procedure well, as vital signs remained stable throughout. There were no complications.
Complications: None
Condition: Stable
Disposition: Recovery Room, then Same Day Surgery
Post-Operative Plan: The patient will be weight bearing as tolerated, with range of motion as tolerated. Crutches may be necessary for a couple days to a couple weeks, for comfort only. No physical therapy will be necessary