Desperate Denise
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Fellow coders:
Can you please look at this opnote and tell me what you think?
I coded 29881, 29824-59 G0289 (Blue Shield of Massachusetts).
Also, can someone clarify which compartment the notch is in and which compartment the trochlea is in? I always get confused especially with thee types of procedures when he is in and out of all sorts of compartments.
Thank you soooooo much!!
Denise
PREOPERATIVE DIAGNOSIS: Left knee osteoarthritis with medial meniscal
tear.
POSTOPERATIVE DIAGNOSIS: Left knee osteoarthritis with medial meniscal
tear. Loose body/fragments > 5mm. Chondromalacia patella.
OPERATION PERFORMED: Left knee arthroscopy. Partial synovectomy. Removal of loose body. Partial medial meniscectomy. Chondroplasty, patellofemoral joint and medial compartment.
INDICATIONS FOR PROCEDURE: The patient is a 61-year-old male who has been having left knee pain with mechanical symptoms refractory to nonoperative intervention. X-rays revealed moderate degenerative changes. MRI revealed meniscus tear. The patient had mechanical symptoms. Therefore, he is indicated for surgery. The patient was aware of the limits of surgery, given the fact that he has osteoarthritis.
DESCRIPTION OF PROCEDURE: The patient was taken to the OR and the left knee was identified as the correct operative site by the patient and
signed by the surgeon. The left knee was shaved in the holding area. The
patient was placed supine on the OR table. One gram of Ancef was given
preoperatively within one hour of incision. The patient was administered
local anesthetic with half of 1% Xylocaine with epinephrine and half of
0.25% Marcaine with epinephrine. 50 cc were injected intra-articularly and
20 cc were injected, split between the anterior medial and anterior
lateral portal sites. The left knee was prepped and draped in the standard
surgical fashion using a standard anterior lateral and anterior medial
portal. These portal sites were made. Arthroscope was inserted. Diagnostic
arthroscopy was started. There were noted to be end-stage degenerative
changes in the trochlea in the middle and the medial aspect, there was
noted to be grade 3-4 chondromalacia in the patella. Using a 4.5 curved
incisor, synovectomy was performed and the chondroplasty was performed.
Also, using ArthroCare wand on a low setting, chondroplasty was performed.
Attention was directed towards the medial compartment. There were noted to be end-stage degenerative changes of the medial compartment. There was noted to be fraying of the remnant of the posterior horn and the anterior
horn of the medial meniscus. This was debrided with a 4.5 curved incisor,
as well as ArthroCare wand. The chondroplasty also performed, deriding the
loose cartilage with the 4.5 curved incisor and ArthroCare wand. The notch
was visualized. There was noted to be synovitis within the notch. It was
debrided with the 4.5 curved incisor and ArthroCare wand. There was noted
to be a very small loose body at the origin of the PCL. This was just
excised with a 4.5 curved incisor. Lateral compartment was visualized. The
ACL and PCL were noted to be intact. Stable lateral compartment was
visualized with only mild grade 2 chondromalacia. In the lateral tibial
plateau, noticed a lateral meniscal tearing. The knee was copiously
irrigated. Excess fluid was suctioned out. Portal sites were closed with
#4-0 nylon suture in a simple fashion. Sterile Xeroform dressing was
placed on the left knee. The patient tolerated the procedure well an was
taken to the recovery room in good and stable condition.
Can you please look at this opnote and tell me what you think?
I coded 29881, 29824-59 G0289 (Blue Shield of Massachusetts).
Also, can someone clarify which compartment the notch is in and which compartment the trochlea is in? I always get confused especially with thee types of procedures when he is in and out of all sorts of compartments.
Thank you soooooo much!!
Denise
PREOPERATIVE DIAGNOSIS: Left knee osteoarthritis with medial meniscal
tear.
POSTOPERATIVE DIAGNOSIS: Left knee osteoarthritis with medial meniscal
tear. Loose body/fragments > 5mm. Chondromalacia patella.
OPERATION PERFORMED: Left knee arthroscopy. Partial synovectomy. Removal of loose body. Partial medial meniscectomy. Chondroplasty, patellofemoral joint and medial compartment.
INDICATIONS FOR PROCEDURE: The patient is a 61-year-old male who has been having left knee pain with mechanical symptoms refractory to nonoperative intervention. X-rays revealed moderate degenerative changes. MRI revealed meniscus tear. The patient had mechanical symptoms. Therefore, he is indicated for surgery. The patient was aware of the limits of surgery, given the fact that he has osteoarthritis.
DESCRIPTION OF PROCEDURE: The patient was taken to the OR and the left knee was identified as the correct operative site by the patient and
signed by the surgeon. The left knee was shaved in the holding area. The
patient was placed supine on the OR table. One gram of Ancef was given
preoperatively within one hour of incision. The patient was administered
local anesthetic with half of 1% Xylocaine with epinephrine and half of
0.25% Marcaine with epinephrine. 50 cc were injected intra-articularly and
20 cc were injected, split between the anterior medial and anterior
lateral portal sites. The left knee was prepped and draped in the standard
surgical fashion using a standard anterior lateral and anterior medial
portal. These portal sites were made. Arthroscope was inserted. Diagnostic
arthroscopy was started. There were noted to be end-stage degenerative
changes in the trochlea in the middle and the medial aspect, there was
noted to be grade 3-4 chondromalacia in the patella. Using a 4.5 curved
incisor, synovectomy was performed and the chondroplasty was performed.
Also, using ArthroCare wand on a low setting, chondroplasty was performed.
Attention was directed towards the medial compartment. There were noted to be end-stage degenerative changes of the medial compartment. There was noted to be fraying of the remnant of the posterior horn and the anterior
horn of the medial meniscus. This was debrided with a 4.5 curved incisor,
as well as ArthroCare wand. The chondroplasty also performed, deriding the
loose cartilage with the 4.5 curved incisor and ArthroCare wand. The notch
was visualized. There was noted to be synovitis within the notch. It was
debrided with the 4.5 curved incisor and ArthroCare wand. There was noted
to be a very small loose body at the origin of the PCL. This was just
excised with a 4.5 curved incisor. Lateral compartment was visualized. The
ACL and PCL were noted to be intact. Stable lateral compartment was
visualized with only mild grade 2 chondromalacia. In the lateral tibial
plateau, noticed a lateral meniscal tearing. The knee was copiously
irrigated. Excess fluid was suctioned out. Portal sites were closed with
#4-0 nylon suture in a simple fashion. Sterile Xeroform dressing was
placed on the left knee. The patient tolerated the procedure well an was
taken to the recovery room in good and stable condition.