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Discharge after major surgery question

  1. #1
    Default Discharge after major surgery question
    Medical Coding Books
    Thorough confusion! A provider performs a planned major medical procedure and then the patient is discharged the next day. Can a discharge be coded? Or would the facility only be able to charge for this? Thank you.

  2. #2
    Location
    Ellenville, New York
    Posts
    1,176
    Default The surgery was performed, right?
    Assuming that the surgery did occur (and that you are asking about the E/M or discharge services), this would be part of the 90 day follow-up care in the surgical package unless there is documentation that the circumstances/reason for the visit were not related to the surgery. Then modifier -24 would be added.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

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