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  1. #1
    Clearnace Sale
    I have a patient that is being seen in the hospital after a hernia repair. Dr. states: Pt feels much better. AF VSS. tol clears w/o pain/n/v, passing flatus
    abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma
    Will advance diet slowly, add oxycontin to pain regimen for better pain control and overall try to minimize narcotics. Continue in-house care.

    Are there any opinions out there in how this should be coded. My take on it is Brief HPI: Qualityt feels much better, Serverity: w/o pain
    Pertinent ROS: GI: w/o n/v, passing flatus
    Problem focused Exam: Constitution, Abd, Cardiovascular, Skin. 4 systems with 1 bullet each.
    MDM: Prescription drug mgmt, 1 Est prob; stable,improved. No data reveiwed. Straight foward

    I came up with a 99231

    Would appreciate any input:

    Thank you,
    Kristen Richard, CPC

  2. #2
    High Point, NC
    Did your provider perform the hernia repair?
    Cindy Gallimore, CPC, CENTC

  3. #3
    I would think that this is a POV unless the pt is being seen by another physician for another reason.

  4. #4
    And you are correct, but the patient was discharged and re-admitted with abdominal pain and n/v. Our physician did do that surgery and is now f/u up with the patient now that she is back in the hospital. So this would be billed with a modifier 24 and a diagnosis of 789.00 and 787.01.
    Kristen Richard, CPC

  5. #5
    I am pretty sure that something of that nature is not paid unless there is a return to the OR. Not that it can't be billed. Also, if the icd 9 is pain, the note states no pain. Just wondering where the support for that would be. But you are correct w/ modifier choice if you do bill it.

  6. #6
    I wouldn't bill for it. the pain is from the's post op care.
    adrianne, cpc

  7. #7
    whats the global period for the procedure? if its not global, i think 99231 is correct, with modifier -24.
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

  8. #8
    It is global, but my supervisor is telling me that if the pt is re-admitted for a different diag, then it is billable. Not saying that it will be paid, but it is billable. So I posted the question because I was having a hard time trying to distinguish which code to choose, 99231-99233. The documentation is very limited.
    Kristen Richard, CPC

  9. #9
    It may be a different diagnosis but if the pain is directly related from having the surgery, I would consider it post-op. I think about it like this: if the patient was still in the hospital and developed enough pain to stay admitted, I would continue to bill post-op. My rational thats all.
    adrianne, cpc

  10. #10
    Milwaukee WI
    Default 1995 guidelines vs 1997 guidelines
    I agree that this hospitalization is not gonna get paid. More and more commercial carriers are following Medicare's lead on the post-op care - if it doesn't require a return to the OR it's global to the surgery.

    In any case...

    All I see for exam in your note is:
    abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma

    So unless you miss-typed I do not see constitutional or CV.

    Still with 1995 guidelines this would be an expanded problem-focused exam for "limited exam of affected body area or organ system AND other related systems (counting the incision C/D/I and possible seroma as SKIN).

    So with an EPF history and EPF exam you get 99232.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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