Your question doesn't give me enough detail to answer you accurately.
Is this the same physician who performed the surgery? If YES, then the visit will be considered global to the surgery.
If NO ... i.e. a different physician of a different specialty / practice ... the code will depend on whether or not a consult was requested, whether or not the patient is covered by Medicare, and whether or not this is the first visit this physician has had with this patient during this hospitalization.
Depending on documentation you MAY be able to ALSO use prolonged service codes.
You will code the diagnosis the physician DOCUMENTED for THIS visit.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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