General Surgery Coding Alert

Question: A patient came in for the biopsy report after a 90-day global procedure. The doctor talked to the patient about results and different types of treatment for 55 minutes. How can I capture payment for this visit?

Virginia Subscriber

Answer: Since you are within the surgical global, you should report the appropriate office visit code, such as 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). This visit is not a postoperative follow up examination related to the previous surgical procedure so you can report the E/M service.

You'll be billing based on time, so since the documentation states 55 minutes, 99215 is the best code to use.

Caveat: You need to append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to your E/M code.

Reader Questions and You Be the Coder were prepared with the assistance of Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.