Stephanie Posted Tue 17th of March, 2020 11:44:17 AM
Hello, the patient is S/P THA. She had a atraumatic dislocation of the rt hip. The provider performed a closed reduction(27266) and open reduction of the right hip(?) However neither technique was stable enough. In the end a revision of the right femoral stem (27138) was completed. CCI bundles the closed reduction and I would assume the open reduction would be bundled as well. Would it be appropriate to report a 22 modifier on the 27138 instead of trying to bill each attempt at reduction and the revision?
SuperCoder Answered Wed 18th of March, 2020 05:09:57 AM
As per the general guidelines, if a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the completed procedure may be reported. So, the final successful procedure code will be coded only i.e. 27138.
Yes, you can report 22 modifiers with CPT 27138, if there is proper documentation on operative report that give a precise explanation and quantification – in clear language – how much, and why, additional time and/or effort was necessary.
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:
–Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician.
Hope this helps!