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Retained Surgical Clamp

  1. #1
    Default Retained Surgical Clamp
    Medical Coding Books
    I have a situation that I'm not sure how to handle. Our cardiovascular surgeon performed an AAA repair and then a different doc (not with our practice) performed a ventral hernia repair. Three weeks later the patient presented to the ER with nausea and vomitting. Abdominal films revealed a retained clamp. At the end of the original AAA case, our doc states that "sponge, instrument, & needle count done". There is no such documentation for the ventral hernia repair.

    Our doc was consulted after the patient was admitted for the retained clamp, nausea, & vomitting. My question is am I able to bill for this consult or would it be bundled into the original AAA repair? Thanks for any help you could offer.

  2. #2
    Milwaukee WI
    Default Maybe
    Can you bill for the consult? ... It depends .. what was the reason for the consult?

    But there's a different question you should ask ... Should you bill for the consult? Sometimes the best course is to do nothing.

    F tessa Bartels, CPC, CPC-E/M

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