Knee Arthroscopy with Meniscectomy / Meniscus Repair
Right [left] [medial / lateral] meniscus tear, [bucket-handle / horizontal / radial / complex degenerative]
Same
Right [left] knee arthroscopy with [partial medial meniscectomy / medial meniscus repair / partial lateral meniscectomy / lateral meniscus repair / bilateral meniscectomy / bilateral meniscus repair]
[***, MD/DO]
[Resident/PA name]
Spinal [/ general endotracheal] [/ laryngeal mask airway]
The patient is a [age]-year-old [male / female] with right [left] [medial / lateral] meniscus tear confirmed on MRI, presenting with [medial / lateral] joint line pain, [locking / catching / giving way], not responsive to conservative management. The risks, benefits, and alternatives were discussed and informed consent was obtained.
Arthroscopic examination confirmed a [bucket-handle / posterior horn / radial / horizontal cleavage] tear of the [medial / lateral] meniscus. The tear extended from the [anterior / middle / posterior] horn and measured approximately [X] cm. The tear was [in the red-red zone / red-white zone / white-white zone (avascular, not repairable)]. [The ACL was intact. The PCL was intact.] Articular cartilage was [intact / Outerbridge Grade [I–IV] at the medial/lateral femoral condyle / tibial plateau]. [The contralateral compartment was normal.]
The patient was positioned supine with a thigh tourniquet and a leg holder. Standard anterolateral and anteromedial portals were established. A systematic diagnostic arthroscopy was performed, examining all compartments including the patellofemoral joint, medial and lateral compartments, and the intercondylar notch.
[PARTIAL MENISCECTOMY:]
The [medial / lateral] meniscus tear was visualized. A [basket forceps / motorized shaver] was used to remove the unstable torn fragment, preserving as much healthy meniscal tissue as possible. Meniscal probing confirmed a stable residual rim. The articular surface was inspected and any loose chondral fragments removed.
[MENISCUS REPAIR (ALL-INSIDE):]
The tear was in the vascular red-red [/ red-white] zone and was amenable to repair. The tear edges were freshened with a [rasp / motorized shaver] to stimulate healing. An [all-inside repair device (e.g., FasT-Fix, CrossFix)] was used to place [X] sutures across the tear from posterior to anterior. Each stitch was tensioned and locked. The repair was tested with a probe confirming reduction without gapping. [Outside-in supplemental sutures were placed for the anterior horn.]
Final arthroscopic inspection confirmed adequate resection [/ secure repair] and no loose bodies. The tourniquet was deflated. Portals were closed with [3-0 Monocryl]. A sterile dressing was applied.
None
[Meniscal fragment sent to pathology if removed]
Minimal
None
The patient was taken to the PACU in stable condition. [Partial meniscectomy: weight-bearing as tolerated with crutches; discontinue when comfortable.] [Meniscus repair: non-weight-bearing for [4–6 weeks]; protected ROM on crutches.] Physical therapy was prescribed.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left *** meniscus tear
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left knee arthroscopy with *** meniscectomy/repair
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Spinal/LMA
INDICATIONS: .PTAGE-year-old .PTSEX with *** meniscus tear, failed conservative management. Consent obtained.
FINDINGS: *** tear, *** horn, *** cm. Zone: ***. ACL/PCL intact. Articular cartilage: Outerbridge *** at ***.
PROCEDURE:
Supine, tourniquet, leg holder. AL/AM portals. Systematic diagnostic scope; findings above. [Partial meniscectomy: unstable fragment removed, basket/shaver, stable rim confirmed.] [Repair: edges freshened, *** all-inside devices placed posterior to anterior, tensioned and locked, probe confirmed reduction without gapping.] Final scope: adequate resection/repair, no loose bodies. Tourniquet deflated. Portals closed. Dressing.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: [WBAT / NWB *** weeks]. PT prescribed.
Signed: .ME, .MYDEGREE
.TODAYVariants
Concomitant Chondroplasty / Microfracture
A [Grade III–IV] full-thickness chondral defect was identified at the [medial femoral condyle / trochlea / patella], measuring [X × X] mm. [Chondroplasty: the unstable cartilage margins were debrided to stable vertical walls with a curette and shaver. The lesion surface was smoothed.] [Microfracture: the calcified cartilage layer was debrided to expose subchondral bone. An awl was used to create microfracture holes 3–4 mm deep at 3–4 mm intervals until fat droplets confirmed adequate marrow penetration. Post-operatively, the patient will remain non-weight-bearing for 6–8 weeks.] Microfracture is appropriate for lesions <2 cm²; larger lesions may benefit from osteochondral transplantation or cartilage restoration procedures.
Charting Tips
- Document meniscal zone. Red-red zone tears (peripheral, vascular) are repairable; white-white zone tears (central, avascular) are not. Document the zone and the rationale for repair vs. resection. In young patients, err toward repair even in borderline zones.
- Document ACL status. A concomitant ACL tear significantly changes the surgical plan — an unstable knee with ACL deficiency and a repaired meniscus has poor outcomes without ACL reconstruction. Document that the ACL was evaluated and its status.
- For meniscus repair, document repair technique, number of implants placed, and post-repair probe test. Document 'probe confirmed reduction without gapping' to confirm the repair held and support the repair code over meniscectomy.
- Document mechanism and chronicity explicitly. Acute traumatic and chronic degenerative tears are coded in mutually exclusive diagnosis families, and mixing them is a payer-flagged coding error.
Documentation & Reimbursement Considerations
- Primary service: Report Knee Arthroscopy with Meniscectomy / Meniscus Repair as the primary service when it is the definitive operation performed.
- Meniscectomy (one compartment 6.85 wRVU, both compartments 7.21 wRVU) and meniscus repair (one compartment 9.36 wRVU, both 11.48 wRVU) are standalone primary codes with 90-day global periods. They are mutually exclusive alternatives, not add-ons, so report repair or meniscectomy for each compartment, not both. Repair carries higher wRVU than meniscectomy, so document the repair decision explicitly.
- Chondroplasty is included in the meniscectomy codes whether performed in the same or a different compartment, and the NCCI edit (modifier indicator 0) cannot be overridden. With meniscus repair, chondroplasty in a different compartment may be separately reportable depending on payer policy, so confirm before billing.
- Repeat knee arthroscopy within the 90-day global period is usually reported as an unplanned return to the operating room for a related complication. The staged-procedure modifier applies only when the second arthroscopy was planned and documented as staged at the index surgery, not for symptom recurrence or re-tear.
- Diagnostic arthroscopy is bundled into any surgical arthroscopy of the same knee on the same date and is not separately reportable.
- Acute traumatic meniscus tears and chronic degenerative tears are coded in different, mutually exclusive diagnosis families. Document the mechanism, chronicity, and side to support the correct one.