Diane Posted Mon 24th of February, 2020 16:07:11 PM
Surgery was originally posted as excision lumbar bursa as read by a radiologist. When Dr. got in he found no bursa only subfascial scar. Procedure listed was: 1. Exploration lumbar wound 2. Routine C &S 3. Excision of subfascial scar with paraspinal muscle release. 4. Partial takedown of posterior bone graft. She had a previous fusion in 2016. There is no code for partial takedown of bone graft or bony overgrowth lumbar spine that I can see. The only code that I see is 11044. But the reimbursement for 11044 is so low ! i was hoping you could come up with a better code(s) for these procedures. Thank you.
SuperCoder Answered Tue 25th of February, 2020 08:28:37 AM
In CPT code 11044, the provider performs prolonged cleansing of the wound. The provider uses a scalpel, scissors, or other appropriate instruments to remove necrotic or foreign material from the site of injured bone, also including work on the epidermis, dermis, subcutaneous tissue, muscle and/or fascia when needed. The provider either closes the wound immediately or can delay the wound closure depending on the wound size. Use this code for debridement of up to the first 20 cm2 when debridement occurs down to bone, and also include debridement of the epidermis, dermis, subcutaneous tissue, muscle and/or fascia in this code. As you said, there is no specific code for partial takedown of bone graft, also for lumbar wound exploration and lumbar sub-facial scar. In this scenario, you can bill CPT 11044 with modifier 22 (Increased procedural services) or it is suggested to bill the unlisted code for the spine i.e. 22899.
When reporting a procedure with an unlisted code, submit a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Also include the operative notes or other relevant documentation to strengthen the claim for good reimbursement and to avoid a possible denial.
Also, in order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:
- Increased intensity
- Additional time
- Technical difficulty
- Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician
An unusual procedure is not when the physician took only a few extra minutes on the patient’s case or when the physician documents that the procedure was only slightly more difficult. There is an average range of difficulty for every procedure. A procedure could be slightly more difficult and still meet the definition of the procedure and not warrant appending modifier 22.
Hope this helps!