Wiki :confused: HELP! FRACTURE SURGERY DENIAL AETNA

[MBOS]

I billed
1 ~ 823.81 closed fracture of unspecified part of fibula

2 ~ 824.4 bimalleolar fracture closed


1, 2 <- 27810 :53:lt treat ankle fracture
1, 2 <- 27826 :lt treat lower leg fracture
1, 2 <- 10140 :lt drain hematoma/fluid
1, 2 <- 76942 :lt echo guide for biopsy


this was denied by aetna any sugestions

notes :
1 attempted closed reduction of left ankle
2 evacuation of hemtoma at thre fracture site
3 open reduction internal fixation left ankle
4 flouroscopy greater than 1 hour
5 layered closure

 

[mitchellde]

You have a discontinued closed reduction, and an open treatment of a fibular fx. You have an unspecifed code for the fibula fx dx and a code for the ankle fx. you have coded a biopsy but no dx to go with it and a hematoma evac with no dx for it either. Also you have no dx code for the discontinued procedure.
Your notes however look to support only and open reduction of the ankle and a hematoma evac.
I agree with the denial by Aetna.
Think of your claim as a cliff note for the documentation of the provider. The claim needs to tell the same story the note tells.
When you have a discontinued procedure and a completed procedure asyou have here you do not report the discontinued.
I can offer no more without a complete note, I am assume you post abbreviated.. If your note from the provider is exactly what you posted then in my opinion it is not a codeable encounter, you need detailed operative notes.

 

[dclark7]

Another problem in addition to what Debra has pointed out is you have used a CPT code for treatment of weight bearing articular surface, but have a diagnosis code of bimalleolar fracture. As Debra stated, without seeing what was actually documented, as opposed to an abbreviated version, we can't offer much more help.