amartinez1
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Patient is 1week post op left knee arthroscopy with Menisectomy, Synovectomy, and Chondroplasty. Patient returned to office for post op visit and dressings were changed. Next day patient called physician regarding fever and worsening knee pain he was sent to ER for evaulation for possible knee infection. In ER physician documented History and Physical and then was admitted to have left knee arthroscopy with debridement.
Main details of Op report states: Tourniquet applied, findings showed significant arthritic changes throughout left knee. Knee joint was debrided. Knee was irrigated with antibiotic solution. No evidence of pus within knee joint. Cultures were sent. Post operative diagnosis left knee effusion.Patient was admitted for observation.
Question: Can the H&P be billable and will it be an E&M category? Also if patient returned to operating room for same knee and debridement was done can that be billed again with modifier of 78 or 79. Unsure which to use.And for the procedure would that be the 29871(Arthroscopy knee, surgical for infection, lavage and drainage) or the 29877(Chondroplasty)? Physician states that the diagnosis is chondromalacia, knee infection, septic joint but I don't read any of that in the op report only arthritic changes. Any suggestions on how to code the case?
Main details of Op report states: Tourniquet applied, findings showed significant arthritic changes throughout left knee. Knee joint was debrided. Knee was irrigated with antibiotic solution. No evidence of pus within knee joint. Cultures were sent. Post operative diagnosis left knee effusion.Patient was admitted for observation.
Question: Can the H&P be billable and will it be an E&M category? Also if patient returned to operating room for same knee and debridement was done can that be billed again with modifier of 78 or 79. Unsure which to use.And for the procedure would that be the 29871(Arthroscopy knee, surgical for infection, lavage and drainage) or the 29877(Chondroplasty)? Physician states that the diagnosis is chondromalacia, knee infection, septic joint but I don't read any of that in the op report only arthritic changes. Any suggestions on how to code the case?