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Operative Note Coding Proficiency Test with Rationale
Question 1:
Operative Report:
Patient: John Doe
Date of Procedure: 08/01/2024
Preoperative Diagnosis: Torn meniscus, left knee
Postoperative Diagnosis: Torn meniscus, left knee
Procedure Performed: Arthroscopic partial meniscectomy
Surgeon: Dr. A. Smith
Anesthesia: General endotracheal anesthesia
Description of Procedure:
The patient was placed supine on the operating table. After induction of
general anesthesia, the left knee was prepped and draped in the usual sterile
fashion. Arthroscopic instruments were inserted through small incisions, and
the torn portion of the meniscus was visualized and excised. The joint was
irrigated, and the instruments were removed. The incisions were closed with
sutures, and sterile dressings were applied. The patient was transferred to
the recovery room in stable condition.
What is the correct CPT code for this procedure?
A. 29881
B. 29880
C. 29877
D. 29875
What is the correct ICD-10-CM code for this diagnosis?
A. M23.2X1
B. S83.241A
C. S83.231A
D. M23.8X1
Answer Key with Rationale
Question 1:
CPT Code: A. 29881 (Arthroscopy, knee, surgical; with meniscectomy
(medial OR lateral, including any meniscal shaving))
, 2
o Rationale: The procedure described involves arthroscopic
excision of a torn meniscus, which aligns with CPT code 29881.
ICD-10-CM Code: B. S83.241A (Tear of medial meniscus, current
injury, left knee, initial encounter)
o Rationale: The diagnosis of a torn meniscus in the left knee is
accurately captured by S83.241A.
Operative Note Coding Proficiency Test with Rationale
Question 1:
Operative Report:
Patient: John Doe
Date of Procedure: 08/01/2024
Preoperative Diagnosis: Torn meniscus, left knee
Postoperative Diagnosis: Torn meniscus, left knee
Procedure Performed: Arthroscopic partial meniscectomy
Surgeon: Dr. A. Smith
Anesthesia: General endotracheal anesthesia
Description of Procedure:
The patient was placed supine on the operating table. After induction of
general anesthesia, the left knee was prepped and draped in the usual sterile
fashion. Arthroscopic instruments were inserted through small incisions, and
the torn portion of the meniscus was visualized and excised. The joint was
irrigated, and the instruments were removed. The incisions were closed with
sutures, and sterile dressings were applied. The patient was transferred to
the recovery room in stable condition.
What is the correct CPT code for this procedure?
A. 29881
B. 29880
C. 29877
D. 29875
What is the correct ICD-10-CM code for this diagnosis?
A. M23.2X1
B. S83.241A
C. S83.231A
D. M23.8X1
Answer Key with Rationale
Question 1:
CPT Code: A. 29881 (Arthroscopy, knee, surgical; with meniscectomy
(medial OR lateral, including any meniscal shaving))
, 2
o Rationale: The procedure described involves arthroscopic
excision of a torn meniscus, which aligns with CPT code 29881.
ICD-10-CM Code: B. S83.241A (Tear of medial meniscus, current
injury, left knee, initial encounter)
o Rationale: The diagnosis of a torn meniscus in the left knee is
accurately captured by S83.241A.
