Report One Approach/Technique per Operation
- By John Verhovshek
- In Billing
- May 27, 2016
- 1 Comment
Occasionally, a surgeon will attempt to perform a procedure using an approach that fails, and must the complete the procedure using a different approach or technique. When this occurs, you should code only for the successful approach.
The National Correct Coding Initiative (chapter 1, “General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services”) confirms, “If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the completed procedure may be reported. For example, if a laparoscopic hysterectomy is converted to an open hysterectomy, only the open hysterectomy procedure code may be reported.”
If the surgeon performs and documents substantial, additional efforts resulting from the change of approach or technique, you may be able to append modifier 22 Increased procedural services to the code describing the definitive procedure (learn more about modifier 22).
John Verhovshek
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What about when one surgery is planed to do arthroscopically for example 29823 but the surgeon also plans to perform an open rotator cuff tear 23410
This is not converted but planned.
Can both be coded?