Tissue expander outside of global

[generic808]

If we're outside of global and PT comes in for tissue expanders, what modifier would I append to an E&M? 24, 25?

 

[danskangel313]

A 24 would be applicable when a service is rendered during a post-op period for an unrelated service. A 25 would be appropriate if the E/M was "significant, separately identifiable" from the procedure. If it was know at the time of the original procedure that a tissue expander would be needed at a later date, that would not qualify for a 25. If the tissue expander was unexpected and determined to be necessary after exam and evaluation, then a 25 would be used.

Based on your post, I assume it was previously known that the tissue expander would be necessary and therefore no E/M service should be billed, unless significant extenuating circumstances came about during the encounter.

 

[generic808]

A 24 would be applicable when a service is rendered during a post-op period for an unrelated service. A 25 would be appropriate if the E/M was "significant, separately identifiable" from the procedure. If it was know at the time of the original procedure that a tissue expander would be needed at a later date, that would not qualify for a 25. If the tissue expander was unexpected and determined to be necessary after exam and evaluation, then a 25 would be used.

Based on your post, I assume it was previously known that the tissue expander would be necessary and therefore no E/M service should be billed, unless significant extenuating circumstances came about during the encounter.

Thank you for the response. That is what I was afraid of but my doctor was sure that expanders outside of global would be paid. This particular patient had to stop treatment during global because of chemo, and then she continued 6 months later. So would this just be coded a 99024 global visit even though it's 7 months post-op?

 

[danskangel313]

I would be inclined to go this route:

At some point, I assume, there would need to be an office visit, post chemo, in which the provider evaluates if continuation of the expanders is okay to be resumed. The provider gives the green light and the procedure takes place.
9921X-25 + XXXXX for expander. My thought here is that a "new" decision is made given the extenuating circumstance of the chemo, therefore an office visit should be coded. I would also make sure to tack on a DX for the condition that prompted the chemo and its current status for the office visit.

The subsequent visits would be only the procedure code, UNLESS a new issue arises that influences the continuation of the expanders. The procedure should get paid.

Now, if this is a matter where the patient had a mastectomy, any restoration or reconstruction procedures would never be bundled into the mastectomy by law, even if it's still in the global, but again, no office visit would be billed unless it's unrelated, such as complaint of a fever and cough.