“I attempted to remove a screw under local anesthesia in the office setting that was placed during a bunion correction about 10 yrs ago. I was unsuccessful and the patient will need to undergo the procedure in the operating room. How would I bill this visit? It was a new patient to the office.”
So, the surgeon attempted to remove a screw that was inserted during a hallux valgus correction under local anesthesia. The original procedure was performed years ago. Unfortunately, the removal of the screw was unsuccessful and now the patient will have to go to the OR for a follow up procedure.
Since this was an initial encounter for the surgeon with this patient, here is my suggestion on how to bill this Initial encounter:
CPT 99203 – 57
CPT 20680 (Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate) – RT/LT, 53
The definition of the 53 modifier is the following: DISCONTINUED PROCEDURE: Use this modifier is you decide to terminate a surgical or diagnostic procedure because of extenuating circumstances or because of a threat to the patient. It is used only if the procedure was cancelled after anesthesia induction or after surgical preparation in the surgical suite. Use the modifier with the code that was terminated.
Well, let’s face it, local anesthesia was administered and I am assuming that the surgical site was prepped and the hardware removal could not be completed. I sure would consider this to be an “extenuating circumstance” based upon the fact that the procedure will have to be continued in an operating room.
Let’s also talk about the follow up procedure in the operating room. How should that be coded? Assuming that the procedure is successful and the screw is successfully removed, here is the appropriate coding scenario:
CPT 20680 – RT/LT, 76
The definition of the 76 modifier is the following: REPEATED PROCEDURE BY THE SAME PHYSICIAN: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.
Isn’t what is being performed a “second bite of the apple,” or a repeat of the procedure that had to be discontinued? I believe that it is.
This is my opinion.
Dr. Michael G. Warshaw
DPM, CPC
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