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Follow up during global surgical period

  1. #1
    Default Follow up during global surgical period
    Medical Coding Books
    Patient came in for mole removal. Pathology report came back actinic keratosis. So, I wanted to charge a 11402 with a 702.0 dx. For the first visit.

    Patient came back 10 days later for what was originally scheduled as a suture removal, however, during the visit, the doctor documented the cc: as tooth ache and wrote the patient an rx for PCN. He also gave the patient the pathology results from teh lesion removal and evaluated the excision site.

    For original visit global surgical period is 10 days. Would you charge an office visit for the second visit listed above, or include it in the global surgical package?
    Heather Winters, CPC, CFPC

  2. #2
    As long as your tooth ache problem meets the documentation requirements, I would bill it!

  3. #3
    Default Global Surgical Period
    I have CC: tooth ache
    HPI: Duration, location
    Exam: 7 Bullets
    Assessment: Dental Fracture with abscess and actinic keratosis
    Plan: PCN, Remove sutures, F/U with dentist

    I cant really say it is totally unrelated to surgery, but a separate problem was addressed. Would you still use a modifier 24?
    Heather Winters, CPC, CFPC

  4. #4
    I would send the records with it. You might get it, you might not, but I personally would still bill it and try.

  5. #5
    I would bill it with the toothache dx.

    I would carve out the post op info into its own no charge 99024 visit with the p/o dx.

  6. #6
    Modesto California
    24 modifier for seperate dx. However, toothache can fall under dental and not medical.

  7. #7
    Hartford, CT
    I would bill the second visit with a 24 modifier and the dental abscess dx (I wouldn't use toothache since he did dx an abscess and treated it). The toothache is totally unrelated to the surgery. I agree with 1073358 and would carve out the f/u into a separate no charge visit.

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