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Patient |
Physician |
Unbundled |
Missed Procedure |
Billed but
Not Done |
Wrong Code |
Modifiers |
Documentation Deficiency |
DX |
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XXXXXXX |
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XXXXXXX |
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| Patient: lllllllllllllllllll |
Date of Service: 05/22/03 |
Physician: llllllllllllllllllllll
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Original Coding
28045
28285-51 |
The Coding Network Coding
28285-T1
28080-LT
28080-LT-59 |
Discussion
- Billed but Not Done: Excision of tumor from the foot.
- Missed Procedure x 2: Morton’s neuromas were excised from the second and third interspaces of the left foot.
- Modifier: The -51 modifier is not an approved ASC modifier.
- Modifier: Laterality modifier not utilized.
- Modifier: Toe modifier not utilized.
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Diagnoses
215.3
735.4 |
Diagnoses
735.4
355.6 |
Discussion
- Wrong Diagnosis: The term mass, unless otherwise stated, is not to be regarded as a neoplastic growth 215.3 per ICD9 guidelines.
- Missing Diagnosis: Operative report findings state that the masses were consistent with Morton’s neuromas.
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| Patient: llllllllllllllll |
Date of Service: 05/22/03 |
Physician: lllllllllllllllllllllllll |
Original Coding
30520
31276-51
30130-51 |
The Coding Network Coding
30520
31255-50
31287-50
31267-50
31276-50
30130-RT |
Discussion
- Missing Procedure x 7: Bilateral complete ethmoidectomies, bilateral sphenoid antrostomies, bilateral maxillary antrostomies with tissue removal, and the frontal sinus exploration was also performed bilaterally but only one side was coded.
- Modifier x 2: The -51 modifier is not an approved ASC modifier.
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Diagnoses
470
473.9
478.0 |
Diagnoses
470
478.0
471.8
473.8 |
Discussion
- Wrong Diagnosis: Unspecified sinusitis 473.9 would be inappropriate since the documentation states pansinusitis.
- Missing Diagnosis x 2: Pansinusitis and Sinus Polyps.
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| Patient: lllllllllllllllll |
Date of Service: 05/29/03 |
Physician: lllllllllllllllllllll |
Original Coding
58661
58120-51 |
The Coding Network Coding
58558
58662 |
Discussion
- Billed but Not Done: Laparoscopy with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy – tubes and ovaries).
- Wrong Code: The dilation and curettage 58120 was performed hysteroscopically 58558.
- Missed Procedure: Laparoscopic ovarian cystectomy. The cyst was removed only, not the ovary.
- Modifier: The -51 is not an approved ASC modifier.
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Diagnoses
625.9
626.2 |
Diagnoses
620.2
621.2
621.8
626.2
625.3
625.0
626.7 |
Discussion
- Missing diagnosis x 6: Ovarian cyst, Bulky uterus, Boggy uterus, dysmenorrhea, dyspareunia, and post coital bleeding.
- Unsupported Diagnosis: Pelvic pain.
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| Patient: llllllllllllllllllllll |
Date of Service: 05/19/03 |
Physician: llllllllllllllllllllllll |
Original Coding
29880 |
The Coding Network Coding
29880-LT
29877-LT-59 |
Discussion
- Missed Procedure: Chondroplasty was performed in the patellofemoral compartment and is separately reportable.
- Modifier: Laterality modifier not utilized.
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Diagnoses
836.2 |
Diagnoses
836.0
836.1
733.92
717.7
715.96 |
Discussion
- Wrong diagnosis: 836.2 is tear of cartilage or meniscus of knee not specified as medial or lateral. The documentation states medial and lateral.
- Missing Diagnosis x 4: Medial and lateral meniscal tears, chondromalacia of the medial and lateral condyles, chondromalacia of the patella, and early arthritis.
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| Patient: lllllllllllllll |
Date of Service: 05/15/03 |
Physician: lllllllllllllllllllllll |
Original Coding
27403
27331-51
27333-51 |
The Coding Network Coding
29880-RT
29877-RT-59 |
Discussion
- Billed but Not Done: Arthrotomy with meniscus repair 27403.
- Billed but Not Done: Arthrotomy with removal of loose bodies 27331.
- Billed but Not Done: Arthrotomy with medial and lateral meniscectomy 27333.
- Missed Procedure: Arthroscopic medial and lateral meniscectomy.
- Missed Procedure: Arthroscopic chondroplasty.
- Modifier x 2: The -51 modifier is not an approved ASC modifier.
- Modifier x 3: Laterality modifier not utilized.
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Diagnoses
733.92
836.0
836.1 |
Diagnoses
836.0
836.1
844.2
823.00 |
Discussion
- Missing Diagnosis x 2: ACL tear and chondral fracture to the medial tibial plateau.
- Unsupported Diagnosis: Chondromalacia, not patella.
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