Wiki H & P during Post Op Period

[twilson2]

I have a question..

Pt had a CABG on January 15, 2009.
He presents to us today (2/3/09) and a history and Physical is performed.

He will be having an exploration of the right leg due to the Saphenous Vein Graft.

How would we code or can we code the H&P?

And what Modifier would we use?

What modifier for the Exploration?

Is any of this considered part of the surgery bundle?

Thanks for your help!
-Tori

 

[maggiedodd]

post op patient

Since the patient just had cabg done, assuming that the leg you are checking was part of the cabg, i think the visit should fall under the global this is a post op issue
if its not related to the previous surgery you probably could use a E&M code with the 24 modifer for a new problem

the exploration code would have78 or 79 modifer
and look at cpt codes range 35701-35761 it is based on the veins that are involved. I hope this helps

Margaret Dodd, CPC