Articia1
New
Hi Fellow Coders,
I'm a new coder and I'm having some trouble coding these ortho cases if someone can please read the op report attached below and explain to me how I would code this it would really help me out alot .
After reading over the case I came up with 29881-RT only but I think that is incorrect. Again thank you in advance.
SUBJECTIVE: This pleasant 48-year-old male presents to Anytown Hospital for a scheduled right knee
diagnostic and therapeutic arthroscopy with findings consistent with medial meniscus tear, documented
PCL rupture and chondromalacia. The entire procedure including all risks and complications have been
explained and informed written consent is signed and on the chart.
PREOPERATIVE DIAGNOSIS: Right knee medial meniscus tear with documented PCL rupture and
medial collateral ligament sprain.
POSTOPERATIVE DIAGNOSIS:
1. Right knee chondromalacia grade II to III at the medial femoral condyle, patellofemoral
articulation and lateral femoral condyle. Multiple small loose bodies
2. Suprapatellar plica and synovitis.
3. Right PCL rupture.
PROCEDURE PERFORMED:
1. Diagnostic and therapeutic arthroscopy right knee.
2. Partial medial femoral condyle chondroplasty.
3. Chondroplasty of the patellofemoral and lateral femoral condyle right knee.
4. Loose body removal.
5. Plica removal.
6. Debridement of synovitis.
7. Examination under anesthesia.
DESCRIPTION OF PROCEDURE: Prior to transport to the operative suite in stable condition the patient
was given 1 gram of IV piggyback Kefzol and once in the operative suite general endotracheal anesthesia
was initiated by the anesthesia department. Once adequate anesthesia was obtained examination under
anesthesia is done, revealing posterior cruciate ligament laxity, positive posterior Drawer test, negative
Lachman, negative instability of the lateral lower medial collateral ligaments. At this time a nonsterile
tourniquet was placed high on the right upper extremity and the extremity was placed into an appropriate
arthroscopic leg holder and then prepped and draped utilizing accepted sterile technique.
At this time the inferior lateral portal is identified and 60 cc's of saline was injected interarticularly. At this
time a blunt tipped trocar is placed into the interarticular environment without difficulty. The remaining
superior lateral and inferior medial portals were placed under direct visualization. Constant pressure
monitoring is done throughout the procedure and thorough interarticular examination of the knee reveals
findings consistent with significant chondromalacia grade II to III at the medial femoral condyle, LFC and
the patellofemoral articulations. There are multiple free-floating loose bodies, small extensive synovitis and
a suprapatellar medial plica. There is also what appears to be a past medial meniscus tear. However, this is
healed and stable at this time with no rough edges.
Utilizing a suction shaving device and punches, gentle chondroplasties were done at the above-noted areas
until stable cartilage is achieved. All interarticular loos
e bodies are removed and the plica is debrided and a
second thorough interarticular examination reveals no overt pathology. At this time all portals were
discontinued and single interrupted nylon sutures were placed at the portal sites and 20 cc's of 0.25%
Marcaine is injected interarticularly. A sterile nonadherent dressing is applied, along with bilateral thigh
high TED hose.
I'm a new coder and I'm having some trouble coding these ortho cases if someone can please read the op report attached below and explain to me how I would code this it would really help me out alot .
After reading over the case I came up with 29881-RT only but I think that is incorrect. Again thank you in advance.
SUBJECTIVE: This pleasant 48-year-old male presents to Anytown Hospital for a scheduled right knee
diagnostic and therapeutic arthroscopy with findings consistent with medial meniscus tear, documented
PCL rupture and chondromalacia. The entire procedure including all risks and complications have been
explained and informed written consent is signed and on the chart.
PREOPERATIVE DIAGNOSIS: Right knee medial meniscus tear with documented PCL rupture and
medial collateral ligament sprain.
POSTOPERATIVE DIAGNOSIS:
1. Right knee chondromalacia grade II to III at the medial femoral condyle, patellofemoral
articulation and lateral femoral condyle. Multiple small loose bodies
2. Suprapatellar plica and synovitis.
3. Right PCL rupture.
PROCEDURE PERFORMED:
1. Diagnostic and therapeutic arthroscopy right knee.
2. Partial medial femoral condyle chondroplasty.
3. Chondroplasty of the patellofemoral and lateral femoral condyle right knee.
4. Loose body removal.
5. Plica removal.
6. Debridement of synovitis.
7. Examination under anesthesia.
DESCRIPTION OF PROCEDURE: Prior to transport to the operative suite in stable condition the patient
was given 1 gram of IV piggyback Kefzol and once in the operative suite general endotracheal anesthesia
was initiated by the anesthesia department. Once adequate anesthesia was obtained examination under
anesthesia is done, revealing posterior cruciate ligament laxity, positive posterior Drawer test, negative
Lachman, negative instability of the lateral lower medial collateral ligaments. At this time a nonsterile
tourniquet was placed high on the right upper extremity and the extremity was placed into an appropriate
arthroscopic leg holder and then prepped and draped utilizing accepted sterile technique.
At this time the inferior lateral portal is identified and 60 cc's of saline was injected interarticularly. At this
time a blunt tipped trocar is placed into the interarticular environment without difficulty. The remaining
superior lateral and inferior medial portals were placed under direct visualization. Constant pressure
monitoring is done throughout the procedure and thorough interarticular examination of the knee reveals
findings consistent with significant chondromalacia grade II to III at the medial femoral condyle, LFC and
the patellofemoral articulations. There are multiple free-floating loose bodies, small extensive synovitis and
a suprapatellar medial plica. There is also what appears to be a past medial meniscus tear. However, this is
healed and stable at this time with no rough edges.
Utilizing a suction shaving device and punches, gentle chondroplasties were done at the above-noted areas
until stable cartilage is achieved. All interarticular loos
e bodies are removed and the plica is debrided and a second thorough interarticular examination reveals no overt pathology. At this time all portals were
discontinued and single interrupted nylon sutures were placed at the portal sites and 20 cc's of 0.25%
Marcaine is injected interarticularly. A sterile nonadherent dressing is applied, along with bilateral thigh
high TED hose.