Wiki 29880 vs 29881


Brandon, FL
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Provider dictates in operative report that he did both a medial and lateral arthroscopic meniscectomy. MRI shows only medial meniscus tear. States lateral meniscus is intact. All supporting documentation in patient chart states medial and lateral meniscectomies were performed. Would you bill for both?
I would bill what the surgeon performed. Sometimes abnormalities are not found on imaging. I would query the physician if s/he did not include a postoperative diagnosis that would support the lateral side.
I agree with hblakeman above in that the MRI could have been normal as to the Lateral Meniscus, but found to be abnormal at the time of arthroscopy. But, you seem to have conflicting documentation in that he states that the "Lateral Meniscus is in tact," but then proceeds to perform a Partial Lateral Meniscectomy. It can't be both normal and abnormal at the same time. His Operative Report details would have to describe/document abnormalities of the Lateral Meniscus warranting/justifying the Partial Lateral Meniscectomy which he claims to have done. If that documentation isn't there, then you can only charge for the medial side. ("If it isn't there in black and white, then it didn't happen.")

I hope this helps some.

Respectfully submitted, Alan Pechacek, M.D.