Wiki Post Operative Visit with Decision for Surgery

[LEE ANN]

Patient presents initially as new pt & biopsy is performed. Patient returns 7-10 days for follow up and to discuss biopsy results. Decision for surgery is made. Is the second visit billable with 24 & 57 modifiers since decision for surgery was made and has different dx from initial visit?

 

[csperoni]

I believe the 2nd visit only needs -57 if you are doing major surgery the same day/following day.
I am assuming the biopsy has a 10 day global and you are within global.
-24 seems appropriate for your situation.
You cannot count time or activities performing routine postop care (like removing sutures) in leveling the visit. But since the provider will be performing an additional procedure, I say this falls under "added course of treatment which is not part of normal recovery from surgery."
Reference the CMS global surgery booklet, page 7 (click for link).