Primary Care Coding Alert

Question: Three days after having a lesion removed, a patient came in with an infection as a complication of the removal. I know there is a 10-day global period, so do the other seven days now cease to exist? Does the visit now become an E/M visit? Rhode Island Subscriber Answer: From a coding perspective, the postoperative visit for treatment of the infection is not part of the procedure and should be separately reported using an E/M code. CPT states that the "surgical package" associated with surgical codes includes "typical postoperative follow-up care." CPT also states, "follow-up care for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported."

Note that not all payers follow this guidance. For example, Medicare considers "all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room" to be part of the global surgical package and thus not separately reportable for Medicare purposes. (See Medicare Carriers Manual section 4821.A.)