How to Answer Indication Procedure Patient Questions (Complete Guide)

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Original Question

Indication for Procedure: The patient is a 46y/o male who was referred to me with complaints of right knee pain. He has had pain for several months and failed nonoperative treatment. I recommended a right knee arthroscopy with partial medial meniscectomy. The risks, benefits and possible complications from the surgery were discussed in detail and the patient wishes to proceed. The potential risks include: Infection, bleeding, neurovascular damage, residual pain and dysfunction, recurrence as well as the surgery possibly not improving the patient’s symptoms. If a meniscectomy is performed the patient understands that there is an increased chance of developing or accelerating any existing arthritis in that knee. The patient also understands the risks of anesthesia which include stroke, heart attack, aspiration, blood clot, pulmonary embolus and death. Description of Procedure: After consent was obtained the patient was taken to the operating room and was administered a general anesthetic and intubated. A well-padded tourniquet was applied to the right upper thigh. The extremity was then prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the right lower extremity and the tourniquet inflated to 325 mmHg. A superomedial portal was made for the introduction of the inflow. An anterolateral portal was made for the introduction of the arthroscope. An anteromedial portal was made for the introduction of arthroscopic instruments. The findings are as follows: Suprapatellar pouch: Normal Medial plica: Frayed Medial gutter: Normal Lateral gutter: Normal Patella: Normal Trochlea: Grade I Chondromalacia – Softening Articular Cartilage Medial Femoral Condyle: Grade IIA Chondromalacia – Fissures/Fragmentation Articular Cartilage <50% and Grade 118 Chondromalacia -Fissures/Fragmentation Articular Cartilage >50% Medial meniscus: Tear, Complex- Root, Posterior Horn, Body Medial Tibial Plateau: Normal ACL: Normal PCL: Normal Lateral Femoral Condyle: Normal Lateral Meniscus: Normal Lateral Tibial Plateau: Normal Popliteus: Normal Popliteal Hiatus: Normal A partial medial meniscectomy was performed. Using a combination of an upbiting basket, straight basket and a 4.2 mm Cuda shaver I removed 50 % of the root, 75 % of the posterior horn, 25 % of the body and 0 % of the anterior horn of the medial meniscus. The rim was smoothed with a 4.2 mm Tiger shaver. A 4.2 mm Cuda shaver was used to remove the medial plica. A chondroplasty was performed of the medial femoral condyle. A 4.2 mm tiger shaver was used to debride the unstable, fibrillated articular cartilage. The portals were closed with 3-0 Prolene suture. The knee was injected with 10 cc of 0.25% Marcaine and 5 mg of Duramorph. A sterile dressing was applied with a Polar Care pad incorporated into the dressing. The tourniquet was deflated at 18 minutes. The patient was awakened and extubated by anesthesia and taken to the recovery room in stable condition. The patient tolerated the procedure well with no immediate complications. Post-op Condition of Patient: Stable What are the 2 ICD 10 codes

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