tci Outpatient Facility Coding Alert - 2018 Issue 1

Reader Question: Use Modifier 78 for Related, Unplanned Procedures

Question: A patient had surgery for an elongated second metatarsal at the ASC where the physician performed an oblique distal osteotomy with single screw fixation. The patient is seen at weekly intervals with no complication after two weeks. At the third visit, the physician takes an X-ray and notices that the osteotomy is displaced and the screw has pulled out. When questioned, the patient says that he slipped on a step two nights ago. The physician decides to take the patient back to the operating room at the ASC to remove the screw, realign the osteotomy, fixate the bone...

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