Wiki Post Op Exams for Miscarriages

[jlv1980]

We're debating in our office regarding when a patient who is presenting for her postop check following a D&C for a miscarriage. The MD's are stating that they spend quite a bit of time discussing the patient options; tests and labs are ordered so there's medical decision making so they are wanting to charge a level 2 or 3. There is no time documented and the documentation looks like a post op exam obviously because the dx is the same. Any thoughts?

 

[imjsanderson]

It depends on the global days for the CPT billed in the first place. If the visit is within the global period and regarding the dx then it is a post-op visit (post-op visits are built into the RVU's for the CPT billed). If it is outside the global period it may be billable with the level depending on the documentation.

 

[jonvieve]

A treatment of Missed Ab or Incomplete Ab both have a global period of 90 days, althought if the provider discussed options not directly related to post op care the time can be billed.

The post op exam and follow up should be one note. The seporate encounter for procreative managment, genetic counseling or other similar services should be doccumented seporately and billed using -24 with corresponding dx, such as something in the V26 range or whatever applies.

If the only applicable dx for the additional time spent is identical to the dx for the surgical procedure then it would fall within the global period and no additional visit could be charged.

**The question to ask would be: Is this encounter directly related to the surgical procedure billed, or is it an additional service that is not necessary for routine follow-up care?**