We billed the following report as a 76000 and 77002 and was rejected for the 77002 by Medicare. I'm new to radiology coding so I have no idea if I can attach a 59 modifier to this claim. Can anyone take a look at this op note and explain this to me? ANY help would be greatly appreciated!!
RIGHT HIP THERAPEUTIC INJECTION
HISTORY: Right hip pain for several months. No trauma or
fracture of the right hip.
COMPARISON: MRI right hip 11/21/2011.
FLUORO TIME: 8 seconds.
FINDINGS: The risks, benefits, and potential complications were
discussed with the patient including pain, infection, and
bleeding. All questions were answered. Written and oral informed
consent were obtained.
The patient was positioned in the supine position. The femoral
artery was palpated and marked. Fluoroscopy was used to identify
the superolateral portion of the femoral neck. The overlying skin
was marked and prepped and draped in sterile fashion. The patient
was given subcutaneous 1% lidocaine with bicarbonate for local
anesthesia.
A 25 gauge spinal needle was advanced to the surface of the
femoral neck and placement was confirmed with intra articular
injection of 1 cc of contrast. A mixture of 3 cc Optiray 240, 3
cc Marcaine, and 1 cc of 40 mg Depo-Medrol was injected into the
hip joint.
The spinal needle was removed and a bandage was applied. The
patient tolerated the procedure without difficulty. There were no
immediate postprocedure complications.
The spot arthrographic images demonstrate degenerative change of
the hip.
PAIN LEVEL PRIOR TO INJECTION: 8
PAIN LEVEL POST INJECTION: 0.5
A 14 x 9 mm ossific density fragment is noted adjacent to the
right acetabulum, which could represent a small fracture fragment
or os acetabuli.
IMPRESSION:
1. IMPROVEMENT IN PATIENT'S RIGHT HIP PAIN FOLLOW INJECTION
OF MARCAINE, DEPO-MEDROL SOLUTION.
2. 15 X 9 MM OSSIFIC DENSITY FRAGMENT ADJACENT TO THE RIGHT
ACETABULUM, WHICH COULD REPRESENT SMALL FRACTURE FRAGMENT VERSUS
OS ACETABULI.
RIGHT HIP THERAPEUTIC INJECTION
HISTORY: Right hip pain for several months. No trauma or
fracture of the right hip.
COMPARISON: MRI right hip 11/21/2011.
FLUORO TIME: 8 seconds.
FINDINGS: The risks, benefits, and potential complications were
discussed with the patient including pain, infection, and
bleeding. All questions were answered. Written and oral informed
consent were obtained.
The patient was positioned in the supine position. The femoral
artery was palpated and marked. Fluoroscopy was used to identify
the superolateral portion of the femoral neck. The overlying skin
was marked and prepped and draped in sterile fashion. The patient
was given subcutaneous 1% lidocaine with bicarbonate for local
anesthesia.
A 25 gauge spinal needle was advanced to the surface of the
femoral neck and placement was confirmed with intra articular
injection of 1 cc of contrast. A mixture of 3 cc Optiray 240, 3
cc Marcaine, and 1 cc of 40 mg Depo-Medrol was injected into the
hip joint.
The spinal needle was removed and a bandage was applied. The
patient tolerated the procedure without difficulty. There were no
immediate postprocedure complications.
The spot arthrographic images demonstrate degenerative change of
the hip.
PAIN LEVEL PRIOR TO INJECTION: 8
PAIN LEVEL POST INJECTION: 0.5
A 14 x 9 mm ossific density fragment is noted adjacent to the
right acetabulum, which could represent a small fracture fragment
or os acetabuli.
IMPRESSION:
1. IMPROVEMENT IN PATIENT'S RIGHT HIP PAIN FOLLOW INJECTION
OF MARCAINE, DEPO-MEDROL SOLUTION.
2. 15 X 9 MM OSSIFIC DENSITY FRAGMENT ADJACENT TO THE RIGHT
ACETABULUM, WHICH COULD REPRESENT SMALL FRACTURE FRAGMENT VERSUS
OS ACETABULI.
