A surgeon performs a diagnostic shoulder arthroscopy before repairing a patient’s rotator cuff. The surgeon knew ahead of time that he or she would be repairing the rotator cuff. Should a coder or biller append modifier -59 (distinct procedural service) to the CPT® code for the diagnostic shoulder arthroscopy to ensure reimbursement for both procedures?
A physician can debride a wound to remove dead, damaged, or infected tissue so the remaining healthy tissue can better heal. Coders need to look for specific information in the documentation of wound debridement.
Pain is an expected component of injuries, illnesses, and surgical procedures. Let's face it, breaking your leg hurts. In some instances, however, the patient's pain is unexpected or is worse than predicted. Sometimes, the pain can last well beyond the time it should have resolved.
To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report. But simply having the OP report isn't enough. Coders also must be able to read the report and pick out the important information.
Our coding experts answer your questions about correct use of modifier –PD, coding infusions to correct low potassium levels, payment for HCPCS code J2354, appropriate reporting of IV push followed by infusion of the same drug, and the difference between modifiers –AS and -80.
