Wiki Wound Check

[saagar]

We saw a patient in our clinic in the morning for wound check. We billed for 99204. Patient came back in the afternoon as there was bleeding and physician rechecked the wound and applied dressing. Can we bill the second visit as F/U?

 

[JessH2618]

The first thing I would ask is if there is a global period associated with the procedure the patient had done. If there is no global period, then you can bill the second visit with the physician based on his/her documentation.

If there is a global period associated with the patient's procedure and the patient is still within that period, I would review the physician's documentation to see what, if any, complications exacerbations, or recurrence is reported as that is not included in the global surgery package under CPT rules.

The exception to this is if the patient has Medicare, this would still be considered a post-op as Medicare includes complications, dressing changes, etc in the global surgery package.

(btw, this information can be found in May 2010 Coding Edge. Pg. 29 does an Excellent job of breaking down the defination of the global surgery package per CMS vs. CPT guidelines.)