Wiki Coding Question- Foreign Body Left Finger

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Bridgetln

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Hello All!

I had an op report come through that I'm struggling with whether or not there is enough documentation to bill anything. What are your thoughts?

Pre-Op Diagnosis: Foreign body left ring finger

Post-Op Diagnosis: Normal Exam

Description of Procedure: Patient taken to operative suite, given a digital block as well as some IV sedation. Preoperative x-rays again were noted to have a foreign body in the area of the distal interphalangeal joint. However, intraoperative x-rays revealed absolutely no foreign body present. Multiple projections were taken. There was no foreign body noted. Just for completeness sake, the right upper extremity was re x-rayed. No foreign body was noted in that. Therefore, patient was taken from the operative bed to the postoperative bed, taken to the PACU in stable condition.

I have had another coder in my office review this and we don't feel that there is enough documentation for the surgeon to bill anything. However, the clinic manager thought maybe we could bill a procedure with a 53 modifier. But, there again not sure what I could/ would bill with that.

Your help and opinions would be greatly appreciated.

Thank you!
 
If no incision was made, you would bill an E&M code

You would bill place of service 22 with a new or established E&M.
 
In order to bill for reduced or terminated procedures, the surgeon would have had to begin to perform it (eg, make an incision, scope inserted). It does not appear that's the case here, so I'd say there's nothing to bill as the procedure was never even started.
 
If this was an Out-patient or ASU procedure (as it most likely was), you could look carefully at Modifier 74: Discontinued Out-patient/Ambulatory Surgery Procedure after Administration of Anesthesia. The local anesthesia was in place along with some conscious sedation. Although not a "Life Threatening" extenuating circumstance in this situation, the failure to be able to identify the "foreign body" in the finger (as was thought to be there preoperatively) once in the OR would certainly be a valid reason to cancel the procedure as there is no indication for an open procedure to remove something that is not there. Sending the documentation is a given.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
Adding a modifier isn't really the issue. The problem is finding an appropriate CPT code that describes at least SOME part of the procedure that was intended. If no procedure had begun, there would be no CPT code to bill, hence nowhere to use a modifier.

Looking at a few codes:
20520 Removal of foreign body in muscle or tendon sheath; simple
20525 Removal of foreign body in muscle or tendon sheath; deep or complicated
or even 26080 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each
Each one of these requires an incision as the first step. The remainder of the procedure relies on the incision. The provider did not make any incision per the op note, therefore none of these codes would work. You'd need a CPT code in order to use a "discontinued" modifier.

In another discussion, there was a question as to how to bill for a procedure that was cancelled after the pre-op workup was completed. The agreed upon answer was that you couldn't bill for the pre-op work because it was considered a necessary part of the procedure (even though it didn't happen). Likewise, here we have a situation where the procedure that was planned was not carried out because there was no foreign body present on the X-rays. The X-rays were a necessary part of the procedure (even thought it didn't happen). The same logic applies here.

I agree with the original poster - there's nothing here to bill.
 
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