Below is an operative report we recently received and I am at a total loss as to what to code.... we are an ASC but the modifier 74 doesn't seem to apply. HELP!! Thanks in advance.
PREOPERATIVE DIAGNOSIS: Painful hardware, left proximal tibia.
POSTOPERATIVE DIAGNOSIS: Left proximal medial leg pain.
OPERATION PERFORMED: Exploration of left proximal tibia with excision of small amount of anterior tibial cortex.
FINDINGS: The screw was buried sufficiently that we were unable to easily locate it. I became convinced beyond all doubt that it was not screw causing her proximal tibial pain. I felt it was not screw causing her proximal tibial pain. I felt it is not worth tearing up the proximal tibia, defined screws that was causing her symptoms. Therefore, I aborted the attempt to remove the screw.0
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in usual fashion supine on the operating room table. We identified where the screw was using the C-arm. I infiltrated this area with Marcaine with epinephrine and minimized bleeding and cut down over this area. We dissected down sharply too this about and could really not palpate the screw. We used our C-arm to help us locate the area and we kept looking and looking and actually moved part of the anterior cortex overlying it, but it became apparent that the screw was buried more deeply and I decided it was not worth tearing up the proximal tibia just to remove a screw when I did not take the screw, it was really causing a problem, now we saw things under direct vision. Therefore, we moved the retractors, flushed the wound with copious antibiotic irrigation, closed the wound in layers using 2-0 Vicryl with the deep tissue, two hooks for the subcu, and skin clips for the skin.
PREOPERATIVE DIAGNOSIS: Painful hardware, left proximal tibia.
POSTOPERATIVE DIAGNOSIS: Left proximal medial leg pain.
OPERATION PERFORMED: Exploration of left proximal tibia with excision of small amount of anterior tibial cortex.
FINDINGS: The screw was buried sufficiently that we were unable to easily locate it. I became convinced beyond all doubt that it was not screw causing her proximal tibial pain. I felt it was not screw causing her proximal tibial pain. I felt it is not worth tearing up the proximal tibia, defined screws that was causing her symptoms. Therefore, I aborted the attempt to remove the screw.0
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in usual fashion supine on the operating room table. We identified where the screw was using the C-arm. I infiltrated this area with Marcaine with epinephrine and minimized bleeding and cut down over this area. We dissected down sharply too this about and could really not palpate the screw. We used our C-arm to help us locate the area and we kept looking and looking and actually moved part of the anterior cortex overlying it, but it became apparent that the screw was buried more deeply and I decided it was not worth tearing up the proximal tibia just to remove a screw when I did not take the screw, it was really causing a problem, now we saw things under direct vision. Therefore, we moved the retractors, flushed the wound with copious antibiotic irrigation, closed the wound in layers using 2-0 Vicryl with the deep tissue, two hooks for the subcu, and skin clips for the skin.