Documentation Dissection

PREOPERATIVE DIAGNOSIS:
1. Medial meniscal tear, left knee

POST OPERATIVE DIAGNOSIS:

1. Medical meniscal tear, left knee |1|

2. Chondral defect, medial femoral condyle |2|

OPERATIONS PERFORMED:
1. Arthroscopy with partial medial meniscectomy |3|

2. Chondroplasty and mircofracture technique, medial femoral condyle |4|

ANESTHESIA: General

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the operating table in supine
position. After induction of general anesthesia, the left thigh, knee and leg were prepped with ChloraPrep and draped into a sterile
field with sterile sheets and towels. A stab wound for a superolateral portal |5| was made, and a cannula for inflow irrigation was
introduced into the knee using a blunt trocar. The trocar was removed. The cannula was connected to the inflow irrigation. The
knee joint was distended. A stab wound for an anterior portal |6| was made just lateral to the patellar tendon, and the cannula for
the arthroscope was introduced in the knee in a similar manner. Blunt trocar was removed. The arthroscope was inserted |7| into
the trocar and was connected to the light source, video equipment, and suction. Careful examination of the knee was undertaken.
Suprapatellar recess showed no evidence of loose bodies or joint pathology. The posterior surface of the patella was in reasonable
good condition. Some minimal chondromalacia changes |8| on the trochlea of the femur particularly. As we extended inferiorly
towards the knee joint, the patient had an area of grade III-IV chondromalacia changes in the medial compartment |9|. There was
also some substantial cartilage fragmentation and delamination over the weight bearing surface of the medial femoral condyle
|10|. Tibial plateau was in reasonably good condition. The posterior horn of the medial meniscus showed a complex tear |11|. Major

component of this represented a horizontal cleavage-type tear, but at the very far posterior attachment, there was flap component
to the tear |12|. Using basket forceps and a full-radius resector, we debrided these tears back to a healthy peripheral rim |13|. The
intercondylar notch showed normal cruciate structures. The lateral compartment showed normal articular cartilage on the femoral
condyle and the tibial plateau. The lateral meniscus was intact without evidence of tears.

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|1| |2| The postoperative diagnosis is used for coding unless further detail is found in the body of the op report.
|3| |4| This indicates the procedures performed. The procedures should be supported by the body of the op report.
|5| Stab wound made for insertion of portal indicate an arthroscopic procedure.
|6| Stab wound made for insertion of portal indicate an arthroscopic procedure.
|7| This is an arthroscopic procedure.
|8| The provider noted chondromalacia changes.
|9| Grade and location of chondromalacia changes are identified.
|10| Supports the medical necessity for the abrasion arthroplasty.
|11| A complex tear is identified in the posterior horn of the medial meniscus.
|12| Supports the complex tear.
|13| Documentation to support meniscal tear diagnosis and meniscectomy.
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Attention was redirected to the medial compartment. Again using a full-radius resector, we debrided some of the fragmented and
delaminating cartilage on the weight bearing surface of the medial femoral condyle |14|. The patient had a small area of exposed
subchondral bone, and an awl was used to perform a microfracture technique in the base of this defect to hopefully stimulate
fibrocartilage formation |15| in this area. Once this was completed, a careful reexamination of the knee was undertaken. No
additional joint pathology was identified. The fluid was suctioned from the knee and the instrumentation was removed. The knee
was injected with 20 mL of 0.25% Marcaine including 2 mg of morphine sulfate. The puncture wounds were closed with Steri-
Strips and covered with sterile 4X4’s. The knee was wrapped with a 6 inch Ace wrap. The patient was awakened, transferred to the
gurney, and returned to the recovery room in satisfactory condition. He tolerated the procedure well.

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|14| Debridement performed – this is included in the meniscectomy.
|15| Abrasion arthroplasty.

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What are the CPT® and ICD-10-CM codes reported?

CPT® Codes: 29881-LT, 29879-51-LT

ICD-10-CM Codes: S83.232A, M94.262

Rationales:
CPT®: In the CPT Index look for Arthroscopy /Surgical /knee referring you to 29871-29889. The code for a menisectomy (medial
OR latera)l , including meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate
compartments is 29881. The chondral defect (chondromalcia) was treated by abrasion arthroplasty using microfracture technique.
This is found in the same code range and is 29879. Modifier 51 is used on the second procedure code. Modifier LT can also be
appended to indicate the left knee was performed on.

ICD-10-CM: In ICD-10-CM Alphabetic Index look for Tear/meniscus/medial/complex referring you to S83.23. In the Tabular List,
S83.23 requires a 6th character to identify left knee and a 7th character for the type of encounter. Code S83.232A identifies a complex
tear of medial meniscus, current injury, left knee.

In ICD-10-CM Alphabetic Index look for Chondromalcia/knee and referring you to M94.26 In the Tabular List, M94.26 requires a
6th character to identify the left knee. The correct code is M94.262.