Don’t Overcode This Arthroplasty Procedure
Question: The practitioner’s notes show that a diagnostic arthroscopy of the right hip was performed. During the procedure, loose bodies were found and removed within the joint. Can both the diagnostic arthroscopy and loose body removal be reported separately? AAPC Forum Participant Answer: No, you are only able to report one code for this encounter. When the diagnostic arthroscopy led directly to a surgical intervention, the diagnostic work is then bundled into the surgical procedure and cannot be coded separately. On your claim, you’ll report 29861 (Arthroscopy, hip, surgical; with removal of loose body or foreign body) for the arthroscopy appended with modifier RT (Right side) to indicate laterality. Make note: According to Chapter 4 of the Medicare National Correct Coding Initiative (NCCI) Policy Manual, if an arthroscopic attempt is converted to an open surgical procedure, you may only bill the open procedure. Reporting both the failed arthroscopy and the successful open surgery is considered unbundling. However, if the physician performs a diagnostic arthroscopy and those findings lead to the decision to perform an open procedure, you can report the diagnostic arthroscopy separately. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
