Post-op Follow-up

[jnevil]

I have a patient who was treated in another state on 8/28/2010 for an ORIF. She presented to our office for her very first visit ever on 10/1/2010 at the visit she was placed in a Cam Walker and we obtained x-rays. Should you charge a fracture charge or an office visit for the services provided on 10/1/2010? We have no information from the operating physician.

 

[FTessaBartels]

Modifier 55

Will you be performing ALL her postoperative care ... or is this a one-time visit?

If you will be performing all her postoperative care, you will need to contact the operating surgeon. You will use the exact same CPT code(s) that operating surgeon used, but with a -55 modifier; the operating surgeon will use the codes with the -54 modifier.

If this is a one-time visit, just code the appropriate E/M as per the documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[debwoods65]

I have a follow up question to this - in a case like this is it best to bill with the same DOS as the original surgery? We rarely ever do this but on the occasion that it happens would like to make sure we are coding correctly. Thanks.

 

[FTessaBartels]

Dos

No, your DOS is the date you provide the service.

Hope that helps.

F Tessa Bartels, CPC, CEMC