Wiki Spinal Cord Implant and Removal

[jkolb2018]

Hello... This is my first time posting and any help would be great!!

We had a patient come into our ASC to have a spinal cord implant inserted. Everything seemed to have gone fine. She walked out to her car to leave and started having so much pain she came back in. The physician chose to remove the implant and patient was transported to the hospital. The physician entered charges for the implant being inserted and then entered a second charge for the removal. Wouldn't this be the same encounter? Or can you bill for both on the same day CPT code 63650. He did do a separate operative report for each procedure.

 

[amyjph]

In my opinion, it's not the same encounter, even though it was the same day, it was two separate surgical sessions. The patient left/was D/C and then came back. You would do the insertion as normal. The second surgery to remove would have modifier 78 since it was an unplanned return.
I have seen examples like this where they take a patient in to do a total hip and for some reason it dislocates. They take them back in the same day to fix it. Also, examples where they do a spine case and something goes amiss after causing spinal cord or nerve issues and they have to go back in same day.

 

[jkolb2018]

In my opinion, it's not the same encounter, even though it was the same day, it was two separate surgical sessions. The patient left/was D/C and then came back. You would do the insertion as normal. The second surgery to remove would have modifier 78 since it was an unplanned return.
I have seen examples like this where they take a patient in to do a total hip and for some reason it dislocates. They take them back in the same day to fix it. Also, examples where they do a spine case and something goes amiss after causing spinal cord or nerve issues and they have to go back in same day.

Great thank you so much for you input!