Wiki Subsequent day's following surgery ?

[cpccoder2008]

I do the billing for surgery inpatient. Most of the time they are in 90 global and the day's following surgery are bundled. I understand if they have complication's or a new problem i can bill these days. I have a patient who had surgery on say 2-26 and that night developed a 103.00 fever. The doctor did not make his rounds and dictate till 2-27. In his note he put
" POD #1 pt developed 103.00 fever last night, was given tylenol, fever is stable. No other complaints"

Can i still code this as fever even though he doesn't state the patient still has a fever ? Wouldn't this be a complication of surgery ? Dx 780.62 ?

 

[LTibbetts]

That is what I would do. I do inpatients as well.

 

[cpccoder2008]

That is what I would do. I do inpatients as well.

Thanks !!

So would i bill all the day's he stated patient had fever or night ?

 

[kbarron]

So, you consider a post op fever not in the global time frame?

 

[LLovett]

Interesting, but based on the note you posted he wasn't involved with the treatment of the fever anyway. It took place before he even rounded.

I think it would be part of the global period as well.

Laura, CPC

 

[cpccoder2008]

Interesting, but based on the note you posted he wasn't involved with the treatment of the fever anyway. It took place before he even rounded.

I think it would be part of the global period as well.

Laura, CPC

Correct. He didn't have any involment of the fever. The nurse gave tylenol at night and he made his round's the next morning. By that time the fever was either gone or stable. Sometime's patients will spike a 103 but won't be able to stabilize it and end's up being a post op infection. Which i bill the days starting with the fever, if still present. But if the patient's fever went down before he made his round's then i usually don't bill it due to global. Since the patient didn't have fever at the time the physician examined him/her.