SirCodesAlot07
Networker
I need help coding the following op report. The doctor wants to use 29882 and 29876. I don't agree with 29882 since the meniscus was only debrided, I don't see where he really repaired it. Also, he dictated a tear in the medial and lateral menisci. So 29882 wouldn't be correct anyway, right? Thank you in advance!
After informed consent was obtained, the patient was brought into the operative suite and placed in the supine position and given LMA. The left knee was examined under anesthesia. Range of motion was 0 to 140. ACL, PCL, MCL, and LCL were intact. Scope was introduced. The left leg was then placed in a non-sterile tourniquet and was exsanguinated with an Esmarch and placed in arthroscopic leg holder and then prepped and draped in a regular sterile fashion. The inferomedial and inferolateral arthroscopic portals were created. I started the arthroscopy in a suprapatellar joint. There were no loose bodies. The scope was then introduced into the medial joint. There was noted to be grade III and IV changes on the weightbearing portion of the medial femoral condyle and there was a tear in the posterior horn of the medial meniscus. I used a shaver to debride this tear to a stable rim. I then performed a medial synovectomy. I put the scope into the notch. The ACL and PCL were intact. There was noted to be a 1 x 1 cm full-thickness chondral loss lesion of the trochlea and I debrided this with a shaver. I performed chondroplasty of this chondral lesion. I then placed the scope into the lateral compartment. There was noted to be a tear in the lateral meniscus. This was debrided with a shaver and arthroscopic biter to a stable rim. The chondral surfaces were intact. Then, I performed a lateral synovectomy as well. I removed the arthroscopic equipment. I closed the portals with 4-0 nylon. I injected the portals with Marcaine, dressed with Xeroform, 4x4s, cast padding, and an Ace wrap.
After informed consent was obtained, the patient was brought into the operative suite and placed in the supine position and given LMA. The left knee was examined under anesthesia. Range of motion was 0 to 140. ACL, PCL, MCL, and LCL were intact. Scope was introduced. The left leg was then placed in a non-sterile tourniquet and was exsanguinated with an Esmarch and placed in arthroscopic leg holder and then prepped and draped in a regular sterile fashion. The inferomedial and inferolateral arthroscopic portals were created. I started the arthroscopy in a suprapatellar joint. There were no loose bodies. The scope was then introduced into the medial joint. There was noted to be grade III and IV changes on the weightbearing portion of the medial femoral condyle and there was a tear in the posterior horn of the medial meniscus. I used a shaver to debride this tear to a stable rim. I then performed a medial synovectomy. I put the scope into the notch. The ACL and PCL were intact. There was noted to be a 1 x 1 cm full-thickness chondral loss lesion of the trochlea and I debrided this with a shaver. I performed chondroplasty of this chondral lesion. I then placed the scope into the lateral compartment. There was noted to be a tear in the lateral meniscus. This was debrided with a shaver and arthroscopic biter to a stable rim. The chondral surfaces were intact. Then, I performed a lateral synovectomy as well. I removed the arthroscopic equipment. I closed the portals with 4-0 nylon. I injected the portals with Marcaine, dressed with Xeroform, 4x4s, cast padding, and an Ace wrap.