1. Question 1
5/5
Operative Report. Code the following case study.
Preoperative Diagnosis: Torn medial meniscus, left knee
Postoperative Diagnosis: Combination horizontal cleavage tear/flap tear, posterior horn,
medial meniscus, left knee.
Operation: Arthroscopic subtotal medial meniscectomy, left knee
Anesthetic: General endotracheal
Description of Procedure: The patient was placed on the operating table in the supine position
and general endotracheal anesthesia was administered. After an adequate level of anesthesia
was achieved, the patient's left lower extremity was prepped with Betadine scrubbing solution,
then draped in a sterile manner. Several sites were then infiltrated with 1% Xylocaine solution
with Epinephrine to help control bleeding from stab wounds to be made at these sites. These
stab wounds were made anterolaterally at the level of the superior pole of the patella for
insertion of an irrigation catheter into the suprapatellar pouch area, anterolaterally at the level
of the joint line for insertion of the scope and anteromedially at the level of the joint line for
insertion of the various arthroscopic cutting and grasping instruments. The knee was explored,
no abnormalities were noted in the suprapatellar pouch area. A very small, un-inflamed, non-
thickened medial plica was noted. This did not appear to be of any significant problem to the
patient, however. It was elected to leave the area alone. The undersurface of the patella showed
some very minimal signs of chondromalacia in the central portions as well as on the medial
meniscus. With further probing it was noted that he had both a flap tear of the posterior most
portions of the posterior horn of the medial meniscus, along with a horizontal cleavage
involving a fair amount of the remainder of the posterior horn of the medial meniscus. The flap
tear portion of the medial meniscus tear was removed with the 3.5 mm. basket forceps in
combination with the Dyonics intra-articular shaver. The horizontal cleavage tear was probed
and it was felt the upper leaf of the horizontal cleavage was the thinner of the two remaining
components of the horizontal cleavage tear. The upper leaf of the horizontal cleavage tear was
then resected in a piecemeal fashion utilizing combination of the 3 mm. basket forceps and the
Dyonics intra-articular shaver. The rim of the meniscus was then smoothed down and balanced
and the remaining portions of the meniscus were probed and found to be stable and intact. The
intracondylar notch area was visualized and showed some hypertrophic synovitis but the
anterior cruciate ligament could be visualized and was noted to be intact. The scope was then
shifted to the anteromedial port and the lateral compartment was visualized and found to be
free of signs of significant degenerative changes on the joint surfaces and the lateral meniscus
when probed showed no signs of injury.
CPT code(s):
Indexing Path:
CPT code(s): 29881-LT
Indexing Path: may vary-meniscectomy, knee joint, arthroscopic
2. Question 2
5/5
Operative Report. Code the following case study.
Preoperative Diagnosis: Bilateral patellofemoral pain syndrome with patellar malalignment
, Postoperative Diagnosis: Bilateral patellofemoral pain syndrome with patellar malalignment
Operation: Bilateral arthroscopic lateral retinacular releases
Anesthetic: General
Description of Procedure: The patient was placed on the operating table in the supine position
and general anesthesia was administered. After an adequate level of anesthesia was achieved
the patient's right and left lower extremities were prepped with Betadine scrubbing solution
and draped in a sterile manner. Attention was first turned to the patient's left knee. Three sites
were infiltrated with several cc. of 1% Xylocaine solution with Epinephrine to help control
bleeding from stab wounds to be made at these sites. These stab wounds were made
anteromedially at the level of the superior pole of the patella for insertion of an irrigation
catheter into the suprapatellar pouch area, anteromedially a the level of the joint line for
insertion of the various arthroscopic cutting and grasping instruments and anterolaterally at
the level of the joint line for insertion of the scope. The knee was explored arthroscopically. No
abnormalities were noted in the suprapatellar pouch area. The patella appeared to show some
malalignment and slight tilting laterally. There were some mild Grade 1 chondromalacia type
changes involving the central and lateral portions of the patellar undersurface but these really
were very mild. The medial compartment was then visualized and it was noted to be normal. No
abnormalities were noted on either the articular surfaces or on the medial meniscus. The
medial meniscus was probed and was found to be both stable and free of tears. The
intercondylar notch area visualized and the anterior cruciate ligament was well visualized and
was noted as being intact. The lateral compartment was visualized and was also noted to be
within normal
limits. The scope was then switched to the anteromedial port and the inflow cannula was
switched to the anterolateral stab wound site at the level of the joint line. Through the
anteromedial port at the level of the superior pole of the patella a Beaver blade was introduced,
banana type blade being used. With this the lateral retinaculum was released in the
suprapatellar pouch area and down approximately one-third of the way from the superior to
the inferior pole of the patella. After this rent in the lateral retinaculum had been created, the
irrigation catheter was replaced into the superiomedial port and a hook type reverse cutting
Beaver blade was introduced through the anterolateral port at the level of the joint line. The
hooked portion of this blade was then inserted into the defect in the lateral retinaculum and the
lateral retinacular release was completed distally. This provided satisfactory mobilization of the
patella as the tight lateral retinacular fibers were satisfactorily released. A Smiley meniscotome
was used to percutaneously complete the lateral retinacular release distal to the level of the
anterolateral stab wound.
CPT code(s):
Indexing Path:
CPT code(s): 29873-50
Indexing Path: may vary- arthroscopy, surgical, knee
3. Question 3
5/5
Operative Report. Code the following case study.
Preoperative Diagnosis: Abnormal right breast mammogram
Postoperative Diagnosis: Same, probable cyst
Procedure: Right breast biopsy, needle localization
History: The patient is a 68-year-old, white female who was seen by Dr. Quinn for evaluation of
vertigo. During her medical workup, at that time, screening mammography was performed and
5/5
Operative Report. Code the following case study.
Preoperative Diagnosis: Torn medial meniscus, left knee
Postoperative Diagnosis: Combination horizontal cleavage tear/flap tear, posterior horn,
medial meniscus, left knee.
Operation: Arthroscopic subtotal medial meniscectomy, left knee
Anesthetic: General endotracheal
Description of Procedure: The patient was placed on the operating table in the supine position
and general endotracheal anesthesia was administered. After an adequate level of anesthesia
was achieved, the patient's left lower extremity was prepped with Betadine scrubbing solution,
then draped in a sterile manner. Several sites were then infiltrated with 1% Xylocaine solution
with Epinephrine to help control bleeding from stab wounds to be made at these sites. These
stab wounds were made anterolaterally at the level of the superior pole of the patella for
insertion of an irrigation catheter into the suprapatellar pouch area, anterolaterally at the level
of the joint line for insertion of the scope and anteromedially at the level of the joint line for
insertion of the various arthroscopic cutting and grasping instruments. The knee was explored,
no abnormalities were noted in the suprapatellar pouch area. A very small, un-inflamed, non-
thickened medial plica was noted. This did not appear to be of any significant problem to the
patient, however. It was elected to leave the area alone. The undersurface of the patella showed
some very minimal signs of chondromalacia in the central portions as well as on the medial
meniscus. With further probing it was noted that he had both a flap tear of the posterior most
portions of the posterior horn of the medial meniscus, along with a horizontal cleavage
involving a fair amount of the remainder of the posterior horn of the medial meniscus. The flap
tear portion of the medial meniscus tear was removed with the 3.5 mm. basket forceps in
combination with the Dyonics intra-articular shaver. The horizontal cleavage tear was probed
and it was felt the upper leaf of the horizontal cleavage was the thinner of the two remaining
components of the horizontal cleavage tear. The upper leaf of the horizontal cleavage tear was
then resected in a piecemeal fashion utilizing combination of the 3 mm. basket forceps and the
Dyonics intra-articular shaver. The rim of the meniscus was then smoothed down and balanced
and the remaining portions of the meniscus were probed and found to be stable and intact. The
intracondylar notch area was visualized and showed some hypertrophic synovitis but the
anterior cruciate ligament could be visualized and was noted to be intact. The scope was then
shifted to the anteromedial port and the lateral compartment was visualized and found to be
free of signs of significant degenerative changes on the joint surfaces and the lateral meniscus
when probed showed no signs of injury.
CPT code(s):
Indexing Path:
CPT code(s): 29881-LT
Indexing Path: may vary-meniscectomy, knee joint, arthroscopic
2. Question 2
5/5
Operative Report. Code the following case study.
Preoperative Diagnosis: Bilateral patellofemoral pain syndrome with patellar malalignment
, Postoperative Diagnosis: Bilateral patellofemoral pain syndrome with patellar malalignment
Operation: Bilateral arthroscopic lateral retinacular releases
Anesthetic: General
Description of Procedure: The patient was placed on the operating table in the supine position
and general anesthesia was administered. After an adequate level of anesthesia was achieved
the patient's right and left lower extremities were prepped with Betadine scrubbing solution
and draped in a sterile manner. Attention was first turned to the patient's left knee. Three sites
were infiltrated with several cc. of 1% Xylocaine solution with Epinephrine to help control
bleeding from stab wounds to be made at these sites. These stab wounds were made
anteromedially at the level of the superior pole of the patella for insertion of an irrigation
catheter into the suprapatellar pouch area, anteromedially a the level of the joint line for
insertion of the various arthroscopic cutting and grasping instruments and anterolaterally at
the level of the joint line for insertion of the scope. The knee was explored arthroscopically. No
abnormalities were noted in the suprapatellar pouch area. The patella appeared to show some
malalignment and slight tilting laterally. There were some mild Grade 1 chondromalacia type
changes involving the central and lateral portions of the patellar undersurface but these really
were very mild. The medial compartment was then visualized and it was noted to be normal. No
abnormalities were noted on either the articular surfaces or on the medial meniscus. The
medial meniscus was probed and was found to be both stable and free of tears. The
intercondylar notch area visualized and the anterior cruciate ligament was well visualized and
was noted as being intact. The lateral compartment was visualized and was also noted to be
within normal
limits. The scope was then switched to the anteromedial port and the inflow cannula was
switched to the anterolateral stab wound site at the level of the joint line. Through the
anteromedial port at the level of the superior pole of the patella a Beaver blade was introduced,
banana type blade being used. With this the lateral retinaculum was released in the
suprapatellar pouch area and down approximately one-third of the way from the superior to
the inferior pole of the patella. After this rent in the lateral retinaculum had been created, the
irrigation catheter was replaced into the superiomedial port and a hook type reverse cutting
Beaver blade was introduced through the anterolateral port at the level of the joint line. The
hooked portion of this blade was then inserted into the defect in the lateral retinaculum and the
lateral retinacular release was completed distally. This provided satisfactory mobilization of the
patella as the tight lateral retinacular fibers were satisfactorily released. A Smiley meniscotome
was used to percutaneously complete the lateral retinacular release distal to the level of the
anterolateral stab wound.
CPT code(s):
Indexing Path:
CPT code(s): 29873-50
Indexing Path: may vary- arthroscopy, surgical, knee
3. Question 3
5/5
Operative Report. Code the following case study.
Preoperative Diagnosis: Abnormal right breast mammogram
Postoperative Diagnosis: Same, probable cyst
Procedure: Right breast biopsy, needle localization
History: The patient is a 68-year-old, white female who was seen by Dr. Quinn for evaluation of
vertigo. During her medical workup, at that time, screening mammography was performed and
