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Included in Surgery?

  1. Default Included in Surgery?
    Medical Coding Books
    Please help! Dr. performed surgery on 10/25/10 latissimus Dorsi Flap from the back to the arm. Patient returned on 11/18/2010, the dictation clearly identifies the patient is being evaluated for postoperative reasons, but a new problem is found. Patient now has seroma fluid aspirated from his back. The Dr. appended modifier 24 to separate the visit from the 10/25 surgery, but it is still included in the seroma aspiration, since this is the decision for this procedure can I append modifier 57 or would it be a write off?

  2. #2
    Columbia, MO
    Is the seroma from the surgery? If so then you can bill for the aspiration with a 78 modifier but not the E&M as complications are related to the surgery.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default Included in Surgery?
    Check the dication and make sure you have enought documentation on the Seroma. Seperate from the post op reasons- if so then you are use modifier 24 on the e&m and 78 on the procedure.

    Hope that helps


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