Wiki Knee Arthroscopy during post op period

[amartinez1]

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?

 

[maryanneheath]

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?

I do not believe that you would bill for the H&P, as this is a complication in the postoperative period. I would use 29871 with the 78 modifier, as this was an unplanned return to the OR.

 

[amartinez1]

Thanks for your quick response. One other question is the diagnosis would it be the knee effusion with arthritis or would you also code the septic knee infection since that was the reason the surgery was done. Not sure since he didnt say during open note about there being an infection. It only said there was arthritic changes.

 

[maryanneheath]

I would just use the knee effusion as the diagnosis, because at the time of the procedure, the doctor did not diagnose infection, just the effusion.