L Posted Tue 29th of March, 2016 17:32:17 PM
How would I code the following:
DIAGNOSIS: Left scaphoid proximal third fracture.
1.Arthrotomy, left wrist, with removal of compression screw.
2.Exam under fluoroscopy, left scaphoid fracture.
3.Posterior interosseous nerve neurectomy, left distal forearm.
SuperCoder Answered Wed 30th of March, 2016 00:01:16 AM
ICD-10 CM Code:
Left scaphoid proximal third fracture: S62.035A.
As it is not mentioned whether, the fracture is displaced or non-displaced or open or closed, so we are considering it as non-displaced and closed.
1.Arthrotomy, left wrist, with removal of compression screw: 20680.
2.Exam under fluoroscopy, left scaphoid fracture: 76000.
3.Posterior interosseous nerve neurectomy, left distal forearm: 64772-LT (You must check the records to see whether the excision/transection is being performed for postoperative pain control. The Centers for Medicare and Medicaid Services has stated that the global surgical package includes postoperative pain management by the surgeon. The documentation must clearly show why the nerve is being excised/transected).
CCI edits shows that, 76000 is considered included in CPT code 20680. But you can report it with -59 modifier (if your documentation support that it was performed for the reason other than 20680).