Report One Approach/Technique per Operation

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).

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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