Question

PREOPERATIVE DIAGNOSIS: Degenerative joint disease, medial compartment plus old meniscal tear.

POSTOPERATIVE DIAGNOSIS: Posterior horn tear, old, medial meniscus; diffuse grade 3-4 chondromalacia, medial femoral condyle 0-90 degrees; and grade 4 chondromalacia, superior half of the patella.

PROCEDURE PERFORMED: Arthroscopy and partial arthroscopic meniscectomy, right knee.

OPERATIVE PROCEDURE: After suitable general anesthesia had been achieved, the patient’s right knee was prepped and draped in the usual manner. Before prepping, a thigh tourniquet was applied; after draping, it was inflated to 300 mm Hg. No inflow cannula was used. Arthroscope was inserted through an anteromedial portal. The lateral compartment was examined. Everything looked good. Examination of the notch revealed some inflated synovial tissue, which was cauterized with a radiofrequency probe. Examination of the medial compartment revealed a horizontal cleavage tear and flap tear of the posterior horn of the medial meniscus. Using a combination of punch and shaver, the unstable meniscus was excised and contoured. The tibial surfaces revealed a small area of water by the anterior horn of the meniscus. Femoral surfaces showed diffuse wear of grade 3 with occasional areas of grade 4 chondromalacia from 0 to 90 degrees. Examination of the patellofemoral joint revealed very good looking articular surfaces on the inferior half of the patella in the trochlea. However, there was essentially bare bone on the superior half of the articular surface. The knee joint was then thoroughly irrigated, and the arthroscope removed. Stab wounds were closed with 3-0 nylon. A dressing was then applied. Tourniquet was released, after which good circulation was noted to return to the foot. The patient tolerated the procedure well and returned to the recovery room in stable condition.

PATHOLOGY REPORT LATER INDICATED: Benign meniscus tissue and bone chips.

Using the CPT and ICD-10-CM manuals, indicate the modifer that would be reported

Answer 1

Pre operative Diagnosis:
ICD-10-cm
Degenerative joint disease M19.90
Medial compartment plus old meniscal tear M23.2
Post operative period:
Arthroscopy and partial Arthroscopic meniscectomy,right knee CPT code 29881-51-RT
RT-right side
LT- left side
Anesthesia service should be coded separately for the billing purpose 99100
Post operative diagnosis indicate secondary procedure,if a secondary procedure performed more than once use modifier -51(same procedure different site)