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procedure and e/m by diff physician w/n global

  1. #1
    Default procedure and e/m by diff physician w/n global
    Medical Coding Books
    Patient was originally seen by PCP on initial visit. Billed 99213 and 10060 for axilla abscess. Patient called the next day as the incision had closed and was causing extreme pain. PCP was not available, so pt was scheduled with another physician w/n the practice. The problem was new to this physician and in addition to the e/m, pt had another I & D performed. Physician wants to bill both the E/M and the procedure codes... what modifiers are needed as this is w/n the global period of the intial procedure? Does it make a difference that the doctors bill under the same tax ID #

  2. #2
    Long Beach, CA
    If seen by another doctor in the group this is considered an established patient under the the post op (10 day) of the initial service. Since this is technically a complication an additional E/M charge may not be warranted. If a repeat procedure was done a -76 modifier could be added to the surgery code. A -78 modifier would not apply because the service didn't require a return to the operating room, -58 is a staged procedure which is more for something that is planned. So whether or not to bill for the E/M even with a -25 modifier could be an issue when it comes to payment as is payment for the repeat I&D.

    Denise Paige, CPC-COSC

  3. #3
    I would utilize 77, repeat procedure/service by another physician, on the 10060 and either a 25 or 57, decision for surgery, on the e/m and making sure to indicate by dx that why this was warranted. good luck

  4. #4
    Would I need an additional modifier on the OV as it is w/n the global of the procedure done the day prior? other than the 25 (since we are doing another I & D)?

  5. #5
    Milwaukee WI
    Default Medicare vs Commercial
    Medicare will not cover ANY E/M service for complications (totally different problem would be covered). So, if your patient is covered by Medicare (or, some state's MedicAID) you can forget about charging for the E/M.

    If this is an UNRELATED E/M service during the postoperative period you would use a -24 modifier. (Most commercial insurers will consider a complication separately reportable, so use a -24 for commercial carriers, also.) If the I&D is done the same day (and as a result of the E/M service), you would ALSO use a -25 mod on the E/M.

    You will need a -58 mod on the I&D ... it IS "related" to the first I&D (from your post it sounds as if this is the SAME abscess); even though it's a different person, if both these physicians are the same specialty and the same practice they are considered the same physician.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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