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16.   Scenario 2 HISTORY The patient is a 5-year-old female who...

16.  Scenario 2


HISTORY

The patient is a 5-year-old female who was practicing for a ballet recital. As she was completing a pirouette, she twisted her knee and fell to the ground. To ensure that permanent damage had not occurred, the orthopedist felt a diagnostic arthroscopy of her knee should be done.


PROCEDURE

After full explanation of the procedure, the parents signed the consent form. The patient was escorted into the procedure room by her parents where she was sedated. The incision site was prepped and draped. Injection of a saline solution distended the joint. The arthroscope was advanced into the joint through a small skin incision. The exploration revealed a complex lateral meniscus tear of the right knee. A meniscal repair was then scheduled. The arthroscope was removed. Minimal bleeding was noted and the site was covered with sterile dressing. The patient tolerated the procedure well and was taken to the operating room for further care.


Note: External cause code(s) apply, but external cause status is not necessary.

ICD-10-CM:


ICD-10-CM:


CPT:

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