jdibble
True Blue
Hi Coders,
I am trying to find information on what would be required (if there is a specific requirement of wording) for my provider to document to bill 29879 for a microfracture. He did a Meniscectomy of the lateral and medial meniscus and the microfracture. Diagnoses documented support all codes. The portion of his note for the microfracture states: The articular surface of the medial tibial plateau revealed mild thinning. A microfracture chondroplasty was performed of the chondral defect of the medial femoral condyle. Attention to the intercondylar notch was then made with excision of hypertrophic synovium was carried out. Anterior cruciate ligament was attenuated and marginal osteophytes of the intercondylar notch identified.
The question is, is this enough documentation to support billing the microfracture. If it is not, is there a reference somewhere that would explain what is needed to document to bill this code. Also, if anyone has a supporting reference to support the documentation as is would be helpful too. I have reviewed the lay term description through Codify and there is nothing there that would help verify if more documentation is needed.
The reason I am asking is during an audit of the coding on this providers surgery, it was stated that the documentation does not support billing for the microfracture because the "documentation does not support the debridement of unstable or fragmented cartilage with a motorized suction cutter that would support the 29879 procedure code." I do not see anywhere that a motorized suction cutter is required for a microfracture (rather all descriptions I do see say an awl is used). The auditor does not offer where their information comes from, however states that if the coder "has authoritative information to present to the auditor, the auditor will review and consider."
Any ideas about this supporting or disputing the documentation (with any supporting references) is welcome! If the documentation is not enough, examples of appropriate documentation of a microfracture would be helpful too so I have information if I need to go back to my provider and instruct him that his documentation is insufficient.
Thank you!
Jodi
I am trying to find information on what would be required (if there is a specific requirement of wording) for my provider to document to bill 29879 for a microfracture. He did a Meniscectomy of the lateral and medial meniscus and the microfracture. Diagnoses documented support all codes. The portion of his note for the microfracture states: The articular surface of the medial tibial plateau revealed mild thinning. A microfracture chondroplasty was performed of the chondral defect of the medial femoral condyle. Attention to the intercondylar notch was then made with excision of hypertrophic synovium was carried out. Anterior cruciate ligament was attenuated and marginal osteophytes of the intercondylar notch identified.
The question is, is this enough documentation to support billing the microfracture. If it is not, is there a reference somewhere that would explain what is needed to document to bill this code. Also, if anyone has a supporting reference to support the documentation as is would be helpful too. I have reviewed the lay term description through Codify and there is nothing there that would help verify if more documentation is needed.
The reason I am asking is during an audit of the coding on this providers surgery, it was stated that the documentation does not support billing for the microfracture because the "documentation does not support the debridement of unstable or fragmented cartilage with a motorized suction cutter that would support the 29879 procedure code." I do not see anywhere that a motorized suction cutter is required for a microfracture (rather all descriptions I do see say an awl is used). The auditor does not offer where their information comes from, however states that if the coder "has authoritative information to present to the auditor, the auditor will review and consider."
Any ideas about this supporting or disputing the documentation (with any supporting references) is welcome! If the documentation is not enough, examples of appropriate documentation of a microfracture would be helpful too so I have information if I need to go back to my provider and instruct him that his documentation is insufficient.
Thank you!
Jodi