E495 – Meniscectomy, partial or total, for symptomatic meniscal tear
OHIP Surgical Assists Code — MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
E495 represents a meniscectomy, which can be either partial or total, performed for a symptomatic meniscal tear. Prior approval may be granted for this procedure in patients with Kellgren-Lawrence grade 3 or 4 osteoarthritis if the clinical record supports: - Significant functional impairment caused by an unstable articular chondral flap or degenerative meniscal tear which has not responded to a minimum of six months active non-surgical treatment; and - The patient is not a current candidate for knee realignment or arthroplasty.
When to Use
- Use for symptomatic meniscal tears where non-surgical management has failed, specifically when the patient does not meet criteria for more extensive procedures like arthroplasty.
- Use in patients with Kellgren-Lawrence grade 3 or 4 osteoarthritis only when there is a documented unstable articular chondral flap or degenerative tear causing significant mechanical symptoms.
Common Pitfalls
- Billing E495 for degenerative meniscal tears in osteoarthritic knees without explicit documentation of six months of failed conservative management will trigger audit flags.
- Failure to document the specific mechanical symptoms or the lack of candidacy for knee realignment/arthroplasty in the clinical record is a frequent cause of claim rejection for high-grade OA patients.
Billing Tips
- Always archive intra-articular photographic evidence of the pathology when billing E495 with R687 to substantiate the necessity of the procedure during post-payment reviews.
Effective: April 1, 2025
N. Musculoskeletal System Surgical Procedures
MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
Surgical
Musculoskeletal System Surgical Procedures
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