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H & P during Post Op Period

  1. Default H & P during Post Op Period
    Medical Coding Books
    I have a question..

    Pt had a CABG on January 15, 2009.
    He presents to us today (2/3/09) and a history and Physical is performed.

    He will be having an exploration of the right leg due to the Saphenous Vein Graft.

    How would we code or can we code the H&P?

    And what Modifier would we use?

    What modifier for the Exploration?

    Is any of this considered part of the surgery bundle?

    Thanks for your help!

  2. Smile post op patient
    Since the patient just had cabg done, assuming that the leg you are checking was part of the cabg, i think the visit should fall under the global this is a post op issue
    if its not related to the previous surgery you probably could use a E&M code with the 24 modifer for a new problem

    the exploration code would have78 or 79 modifer
    and look at cpt codes range 35701-35761 it is based on the veins that are involved. I hope this helps

    Margaret Dodd, CPC

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