Wiki Post op Complications Help

[gd100]

Patient had RT TKR SX on 11/19 with Dr. A. 4 days later (11/23) patient goes to walk-in clinic with bleeding hematoma and sees one of our PAs for consult. The PA cleans up the wound and puts steri strips on it.

I was thinking 99242-58,924.11, 998.59


Then a different PA at the same practice sees the patient in an office setting 1 day later (11/24).

I was thinking 99213-58, (icd-9 may defer)


Please help.

 

[CatchTheWind]

From your question, it is not clear who "Dr. A." is. Does he work for (or own) the walk-in clinic? If so, then these two visits are both included in the global surgical package and are not billable.

If he is unrelated to the clinic, then you can bill these, but I would not use a consult code, as this really is not a consult - and anyway, most payers no longer allow consult codes. You also cannot use modifier 58, as this is used strictly for surgical codes. I also question whether you really have a 99213 level for both visits (particularly the second one); I can't say for sure without seeing the notes, but I would definitely use a worksheet to see how many points you get before assuming it's a 99213.

As for the diagnosis, you cannot use the 998.59 because there is no documentation of infection. And 924.11 is for "hematoma without open wound," so if is is bleeding as you state, you would need to choose a code from the 870-897 (open wound) series.

 

[mitchellde]

From your question, it is not clear who "Dr. A." is. Does he work for (or own) the walk-in clinic? If so, then these two visits are both included in the global surgical package and are not billable.

If he is unrelated to the clinic, then you can bill these, but I would not use a consult code, as this really is not a consult - and anyway, most payers no longer allow consult codes. You also cannot use modifier 58, as this is used strictly for surgical codes. I also question whether you really have a 99213 level for both visits (particularly the second one); I can't say for sure without seeing the notes, but I would definitely use a worksheet to see how many points you get before assuming it's a 99213.

As for the diagnosis, you cannot use the 998.59 because there is no documentation of infection. And 924.11 is for "hematoma without open wound," so if is is bleeding as you state, you would need to choose a code from the 870-897 (open wound) series.

You cannot use an 879-897 code for a post op complication, you do need to pick from the surgical complications section, I would need to see exactly how the provider worded the note to know which one to assign, also you cannot use a 58 modifier on the E&M series of codes. The question is are all of the these providers in the same tax ID? Why did the patient not return to the surgeon? Since post op complications are a part of the global the only way to bill these encounters if by using the procedure code for the surgery and appending the 55 modifier, but only if you have a transfer of care request from the surgeon.

 

[gd100]

Hi CatchTheWind,

Dr. A is one of our doctors from our Ortho office. He performed the total knee at an in network hospital. That same hospital has a walk-in clinic. One of our office PAs did a consult report. I believe you may be right about the PA seeing this patient at the walk-in clinic as a post-op (99024) because it's not really a consult. As far as the second PA who saw them at our Ortho office I would consider that to be a post-op visit. The ICD looks like 891.1 If you can please let me know if this sounds correct.

thank you.

 

[mitchellde]

No you would need to use a 996-998 code for a surgical complication, the 890 code is a trauma code for open wound cause by a trauma event. All of these visits then sound like post op visits by the same provider group so there can be no office visit charge. This is all routine post op until there is a return to the OR.