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.
- ICD-10 specificity: traumatic/acute tears use S83.2xx with laterality and encounter type. Chronic/degenerative tears use M23.2xx. These families are mutually exclusive — document mechanism and chronicity explicitly. Mixing the families is a payer-flagged coding error.
Documentation & Reimbursement Considerations
- Report Knee Arthroscopy with Meniscectomy / Meniscus Repair as the primary service when it is the definitive operation performed.
- All four carry 90-day global periods and are mutually exclusive alternatives — not add-on services. A surgeon bills repair OR meniscectomy for each compartment, not both. Repair codes carry higher wRVU than meniscectomy; document the repair decision explicitly.
- These meniscectomy codes already account for chondroplasty performed in the same or a different compartment. The NCCI modifier indicator is 0, so the edit cannot be overridden.
- Repeat knee arthroscopy within the 90-day global period: related unplanned return-to-the-operating-room reporting (unplanned return to the OR for a related complication) is correct in most scenarios. Staged-or-related-procedure reporting (staged procedure) is only appropriate when the second arthroscopy was planned and documented as staged at the time of the index surgery. Do not use staged-or-related-procedure reporting routinely for symptom recurrence or re-tear.
- ICD-10: Traumatic/acute meniscus tear = S83.2xx (laterality required; 7th character A=initial encounter for closed injury, D=subsequent, S=sequela). Degenerative/old tear = M23.2xx (derangement of meniscus due to old tear or injury). These are mutually exclusive — do not use S83.2- for a chronic degenerative tear or M23.2- for an acute traumatic tear. Document mechanism and chronicity to support reporting selection.