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Please help code this!

  1. Angry Please help code this!
    Medical Coding Books
    Patient is seen in the office today for evaluation of the right ankle. He underwent surgery with Dr. xxxx in Denver approximately 5 weeks ago.


    Patient has a concern over getting his cast wet. He is scheduled to see Dr. xxx later this week in Denver.


    PHYSICAL EXAMINATION: On examination, the cast is removed today in the office. The incisions are benign appearing. There is no sign of infection or rash. The right ankle is in a neutral position. It overall appears to be doing well at this point.


    IMPRESSION: FIVE WEEKS STATUS POST RIGHT ANKLE DEBRIDEMENT WITH ACHILLES TENDON LENGTHENING.


    TREATMENT AND RECOMMENDATIONS: The patient's right ankle was overwrapped with an Ace wrap and placed back into the Cam boot.


    He will follow up as planned with Dr. xxx later this week. He will call or return sooner if there are any problems or concerns.

    My question is what cast removal code would be reported to the Worker Comp carrier?

  2. Default
    Is there a 90 day Global for the Surgery that was done? If yes, then I believe this visit is Post-Op and the cast removal is bundled.

  3. #3
    Default
    Are you billing for a Doctor in the same groupt as Dr. xxxx? If so, it falls under the global period.
    TJ Smith, CPC
    Cheyenne Physicians Group
    Cheyenne, WY

  4. Question
    different surgeon than the one whom preformed the procedure. physician is not performing post -op. Thanks for any help or suggestion.

  5. Default
    Ok, so if you are saying your Doctor is under a different tax ID# than the one that performed the surgery, then yes...you can charge for this visit. I would charge an E&M with 29700. I would also attach the chartnote to claim.

  6. #6
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    you will also need a 25 modifier on the E/M visit
    Mary, CPC, CANPC, COSC

  7. Smile
    Thank you for your help!

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