Orthopedic Coding Alert

Question: Our surgeon attempted to remove a loose body in the ankle arthroscopically, but it was too large so he had to perform an open removal. Do I bill only for the open procedure, or include the arthroscopic attempt as a discontinued procedure?

Utah Subscriber

Answer: Because your surgeon completed the procedure as an open case, you'll report only 27620 (Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body) Include V64.43 (Arthroscopic surgical procedure converted to open procedure) as a secondary diagnosis.

Arthroscopic answer: If the physician had completed the procedure arthroscopically, you would submit 29894 (Arthroscopy, ankle, [tibiotalar and fibulotalar joints], surgical; with removal of loose body or foreign body) instead.