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Our orthopedic was asked to see a patient in the ER, did a review of the patient’s chart and xrays, but never saw the patient as the patient left the hospital against medical advice. Is there any level of E&M that would be billable for the time he took to review the patients record and radiology results prior to seeing the patient?
Thank you
Operative Note
Pre Op Diagnosis: Incarcerated Umbilical hernia
Post op Diagnosis: same
Procedure: Umbilical hernia repair with mesh
Surgeon:
Anesthesia Staff:
Anesthesia Type:.
ASA Class:
Estimated Blood Loss: 50
IV fluids: 600
Report of operation
With the patient supine under general anesthetic, after an appropriate time-out and a hloraPrep prep, a curvilinear incision was made at the inferior aspect of the umbilicus. The umbilical skin was raised as a flap and the hernia sac was separated from the umbilical skin. This was Opened and a portion of the incarcerated omentum was resected The remainder was reduced. A preperitoneal space was created to accommodate the mesh and then the Ventralex mesh was placed in the preperitoneal position, tacking the mesh to the fascia circumferentially with 2-0 PDS.
Being satisfied with the mesh placement, the soft tissue was able to be closed over the mesh with a running 2-0 PDS, separating the mesh from the subcutaneous space. The umbilical
skin was partially resected to remove redundant skin then tacked to the underlying fascia with 3-0 Vicryl and the skin was closed with Skin staples The estimated blood loss was less
than 50 mL. The sponge, instrument, and needle counts were correct. The patient tolerated the procedure well and was prepared for transport to the recovery room in satisfactory
condition.
Two years ago, this patient had a primary sigmoid CA removed by sigmoid colectomy with a permanent colostomy.
The correct CPT code for this, as documented, would be 45110 with -52 since the colostomy was not performed.
So, my quandary is – is it appropriate to use both modifier -52 and -22 on one line item? They effectively cancel each other out – for payment purposes.
TYIA,
Karen
Thanks