Wiki Unsuccessful procedure

[chembree]

Report

INDICATION: Small cell lung cancer and thrombocytopenia.

PROCEDURE: The patient was informed and consented for the procedure then placed in the prone position on the CT scanner table. The patient was prepped and draped in a sterile technique. 1% lidocaine without epinephrine was utilized as a local anesthetic.

Conscious sedation was performed utilizing Versed and fentanyl while monitoring the vital signs.

Under CT guidance, a Kyphon XPress trocar was advanced from a posterior approach and into the left posterior ilium. A bone biopsy device was deployed through the Xpress trocar and into the left ilium. A 2 cm core bone biopsy was obtained. However, a bone marrow aspirate could not be obtained after multiple attempts. Therefore, all trocars and devices were removed. No complications were encountered. 5000 units of thrombin was injected through the trocar and at the bone biopsy site for hemostasis.

IMPRESSION:

1. CT-guided core bone biopsy of the left ilium.
2. Unsuccessful left ilium bone marrow aspiration despite multiple attempts.


How would you code this? I always struggle with coding unsuccessful exams? My thoughts are the doctor did the prep and took the risk of the procedure so I feel like I should bill something but I am not sure what I can bill for.

As far as modifiers this is for an OP hospital. (location 22)

 

[Jmate]

I would use the correct CPT procedure code and append modifier -74 for discontinued procedure , we are told we code the intended procedure not the outcome because resources are used and device and supply codes will be charged by the performing department.
Choose modifier -74 based on the conscious sedation.
I wrote to AHA for their definition of anesthesia with modifier -74 and they wrote me back that they define it as all anesthesia from complete surgical anesthesia to topical, so if a patient is taken to the procedure room and prepped and anesthesia administered the procedure is started but not completed use modifier -74