Anyone have any thoughts on how best to code this?
The patient was placed on the table, identified by me according to policy. The patient was brought to the Operating Room. Under image intensification, I did an examination of his left hip with no anesthesia. I took it through range-of-motion. He has clicking in the hip. He has heterotopic bone. I wanted to make sure he was not subluxing. It did not look like he was subluxing. His cup is a little vertical, but I think it is more the heterotopic ossification that is causing his pain; however, if we were to excise that, certainly we would look at the cup and the liner and stability intraoperatively. I will see him back in the office and discuss his treatment course with him in further detail.
I can't use 27275 because no anesthesia was used. Any help will be greatly appreciated
The patient was placed on the table, identified by me according to policy. The patient was brought to the Operating Room. Under image intensification, I did an examination of his left hip with no anesthesia. I took it through range-of-motion. He has clicking in the hip. He has heterotopic bone. I wanted to make sure he was not subluxing. It did not look like he was subluxing. His cup is a little vertical, but I think it is more the heterotopic ossification that is causing his pain; however, if we were to excise that, certainly we would look at the cup and the liner and stability intraoperatively. I will see him back in the office and discuss his treatment course with him in further detail.
I can't use 27275 because no anesthesia was used. Any help will be greatly appreciated