Wiki Two days one procedure

[Desperate Denise]

Here is a situation that I have never dealt with -

The physician on DAY 1 performs a meniscectomy and begins to start an ACL reconstruction when he realizes he needs additional equipment to complete the ACL. He ends the procedure with starting the ACL and completing only the meniscectomy.

On DAY 2 he has all the equipment to continue and complete the ACL reconstruction.

How do I bill this?

Do I use 29881 for the meniscectomy and then 29888-53 to indicate the procedure was discontinued for DAY 1?

Then for Day 2 do I use 29888-58?

My question is do I even indicate that 29888 was started on DAY 1 and bill for the meniscectomy only. Then on DAY 2 just bill the ACL 29888 - but do I need a modifier. I guess I need Day 1 and Day 2 options. The operative notes are included

THANK YOU GUYS AGAIN !!!!

DAY ONE


POSTOPERATIVE DIAGNOSIS:
1. Right knee pain.
2. Right knee lateral meniscal tear.
3. Right knee recurrent anterior cruciate ligament tear.

OPERATION PERFORMED:
1. Right knee arthroscopy.
2. Right knee partial lateral meniscectomy.
3. Right knee revision anterior cruciate ligament reconstruction.


DESCRIPTION OF PROCEDURE: Patient brought to the preoperative area. Site
and side were identified. He then had spinal anesthesia administered.
Brought in the operating room and placed supine on the operating room
table. Sedation was administered. Right leg had a tourniquet applied set
at 300 mmHg. Right lower extremity was positioned in the Acufex leg
holder with the left leg padded appropriately. The right lower extremity
was prepped and draped in a sterile fashion. Bony landmarks of the
anterior aspect of the knee including anterolateral and anteromedial
portal sites were marked with a marking pen. The areas of the previous
incisions were marked __________ was used. Tourniquet was inflated to
300 mmHg. Incision was made in the area of the anterolateral portal.
Arthroscope was introduced into the knee and into the suprapatellar pouch,
and a diagnostic arthroscopy was begun. There was no evidence of
chondromalacia over the undersurface of the patella or femoral trochlea.
No evidence of chondromalacia over the medial or femoral condyle. An
anterior medial port was made using an outside-in technique. An 18-gauge
spinal needle was inserted above the anterior horn of the medial meniscus.
An 11-blade scalpel was used to incise the skin. An arthroscopic probe
was then sutured to the medial compartment. There was evidence of a
recurrent ACL tear in its midsubstance. Using arthroscopic shavers as
well as arthroscopic biters, the old ACL remnant was removed. There was
no evidence of medial meniscal tear. The meniscus was probed and felt to
be stable. Once the old ACL remnant was removed, the lateral compartment
was entered with the leg in the figure-of-four position. There was no
evidence of a degenerative lateral meniscal tear. Using arthroscopic
shavers as well as arthroscopic biter a partial lateral meniscectomy was
performed. Attention was then turned back to the ACL. The over-the-top
guide was used to extraarticulate to put a guidewire into the proximal
aspect of the tibia. This was then reamed using a 9-reamer and then
dilated using 9, 10 and 10.5 dilators. Once the tibial tunnel was
created, the 7-mm offset over-the-top guide was used to create a femoral
tunnel. As part of the femoral tunnel process, there was a deficient
posterior wall. The deficiency appeared to extend approximately 1 cm into
the proximal femoral tunnel. The decision was made to stop the procedure
since there was not adequate instrumentation to continue the procedure in
the face of a deficient posterior wall. The patient was awoken from
general sedation, brought to the PACU in stable condition. The procedure
was put on hold for 23 hours. The patient was admitted for 23-hour
observation. Patient received 1 gram of Ancef as IV antibiotic
prophylaxis.



DAY 2

POSTOPERATIVE DIAGNOSIS:
1. Right knee pain.
2. Right knee recurrent anterior cruciate ligament tear.
3. Right knee lateral meniscal tear.

OPERATION PERFORMED:
1. Right knee arthroscopy.
2. Right knee revision anterior cruciate ligament reconstruction.


INDICATIONS FOR PROCEDURE: The patient is a 39-year-old male with a
recurrent ACL tear. The procedure was performed on 08/19/2010. As part
of the drilling of the femoral tunnel, there was evidence of a deficient
posterior wall. The decision was made to postpone the surgery until
adequate instrumentation was obtained. The instrumentation was brought in
today for completion of the procedure.

DESCRIPTION OF PROCEDURE: The patient was brought into the preoperative
area. Site and side were identified. Spinal anesthesia was administered.
He was placed supine on the operating room table. The right leg was
placed in the Acufex leg holder with a tourniquet at the right thigh. The
left leg was padded appropriately. The right lower extremity was prepped
and draped in a sterile fashion. The leg was Esmarched and the tourniquet
was inflated. The previous incisions were opened. The arthroscope was
introduced through an anterolateral portal. A hematoma was removed.
Attention was then turned to the posterior wall. Using the 7-mm offset
guide, a guide pin was advanced through the distal aspect of the femur.
Sequential reaming was performed using an 8-mm reamer. Periodically, the
reaming process was stopped to ensure that a back wall was present. After
approximately 1 cm of deficient back wall, the wall was seen to be present
at greater depth. After reaming with an 8, this was dilated to 9 and 9.5.
Care was taken during the dilating process to ensure that there was no
evidence of additional posterior wall blowout. A 9-mm RIGIDFix guide was
advanced then transtibial and seated within the femoral tunnel, and the
cannulas for the RIGIDFix guide were inserted into the lateral aspect of
the femur. The position was checked via arthroscopy. They seemed to
intersect the bony aspects of the femoral tunnel. The outrigger was
removed. A Beath pin was advanced transtibial into the femoral tunnel and
out the anterior aspect of the thigh. On the back table, a bone-patellar-
bone graft was prepared. It consisted of a 25-mm femoral bon plug 9 mm in
diameter and a 30-mm tibial bone plug 10 mm in diameter. A Beath pin was
used to pass the graft in a standard fashion which was well seated within
the femoral tunnel. It was secured using the RIGIDFix bioabsorbable pins.
Longitudinal traction on the grade ensured that it was well affixed. The
leg was brought through a range of motion of 0-120 degrees x15. The graft
was once again felt to be rigidly fixed. The leg was brought into full
extension with external rotation of the foot and a posterior drawer. An
11 x 30-mm Smith and Nephew BioRCI screw was used to affix the tibial
graft in place. Once all hardware was in position, Lachman and anterior
drawer were performed and was felt to be stable. Arthroscopic pictures
revealed the graft to be in good condition and stable. Copious irrigation
and incisions were performed. The subcutaneous tissues were closed with 2-
0 Vicryl in interrupted fashion. The skin edges were approximated with 3-
0 Prolene in a subcuticular manner. A sterile dressing was applied. A
cooling unit was applied. A brace was applied. The patient was brought
to the PACU in stable condition. He tolerated the procedure well.

 

[Bella Cullen]

I would probably bill day 1 29881, 29888-53
then day 2 29888-58.

 

[mitchellde]

I remember reading in a CPT assistant that you cannot code a discontinued procedure with a completed one. As you need a V64.x dx code as a secondary dx to should the discontinued reason and that will negate then the completed procedure.
So I lean toward
29881-22 for the day 1
29888-58 or 78 for day 2

 

[mitchellde]

I remember reading in a CPT assistant that you cannot code a discontinued procedure with a completed one. As you need a V64.x dx code as a secondary dx to should the discontinued reason and that will negate then the completed procedure.
So I lean toward
29881-22 for the day 1
29888-58 or 78 for day 2

 

[Bella Cullen]

I remember reading in a CPT assistant that you cannot code a discontinued procedure with a completed one. As you need a V64.x dx code as a secondary dx to should the discontinued reason and that will negate then the completed procedure.
So I lean toward
29881-22 for the day 1
29888-58 or 78 for day 2

My only thinking on that though is it would seem like you had to do additional work for the 29881 procedure and that is not the case here.
modifier 22 reads:
When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work.

So if you couldn't code for the discontinued procedure, (I'm not sure on that), I would just bill 29881 without 22 modifier.

 

[capricew]

Im going to agree with bella,
when you bill a d/c proc modifier, it is still payable but often times only payable at a percentage of your normal contracted rate.
If the proc was d/c'd due to lack of preparation by phys or facility, then this should not be billed to insurance because if it is, whatever the insurance pays, the patient may also be responsible for a portion of that bill. Then when you go back the next day and bill aga in, the patient will be responsible again for the same proc that was actually completed.
I am leaning towards 29881 day one
and 29888 on day two with appropriate modifier for return to or