Minor Procedure while in Post-Op

cpccoder2008

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A patient has a Arthroscopy of the knee due to chondromalacia. Patient returns for follow up after surgery with no complications. Patient comes back while still in post op for discharge. While being examined patient is found to have OA and requiers an injection of the knee. I know i would bill 20610 but what about the E/M.
 
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Qualified Yes

In the absence of full documentation, I'd say ...

Yes, you could code the E/M (with modifiers -24 and -25) -- that's assuming documentation supports this.

F Tessa Bartels, CPC, CPC-E/M
 

cpccoder2008

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I would say -24 because it's an unrelated E/M during post-op but would that be appropriate because a minor procedure was performed ?
 

mbort

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I would do an office visit with a 24-25 combo make sure that the chondromalacia diagnosis is NOT attached to either line item.
 
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