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Post-operative dressing change

  1. #1
    Birmingham, Alabama
    Default Post-operative dressing change
    Medical Coding Books
    A patient has surgery done on her toe. The next day, she comes in to see one of our therapists for a dressing change:

    "Wound Care : Removed bulky, Provided skin hygiene, Cleansed wound, pulled packing from wound, redressed with xeroform which was packed lightly into dorsal wound, covered with coban"

    Can this be billed? If so, what might the code(s) to use?


  2. #2
    Check the global period for the cpt code used for the surgery done the day before. If it is 0 global days then you can bill a level 2 established patient visit. If global days are anywhere from 10-90 days then it is considered post operative care and is not separately billable.

  3. #3
    Birmingham, Alabama
    Thank you. A quick question .. if it is a therapist who is doing it, can you still bill an e&m?

  4. #4
    Tacoma, WA
    Quote Originally Posted by paradoxy View Post
    Thank you. A quick question .. if it is a therapist who is doing it, can you still bill an e&m?
    Only a 99211.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  5. #5
    if your therapist is credentialed and contracted with patients' plan and normally bills for services separately from the physician then yes, they can bill for a visit. Otherwise the "incident to" rules may possibly apply.

    Physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, clinical psychologists, clinical social workers, physical therapists and occupational therapists all have their own benefit categories and may provide services without direct physician supervision and bill directly for these services. When their services are provided as auxiliary personnel under direct physician supervision, they may be covered as incident to services, in which case the incident to requirements would apply.

  6. #6
    Birmingham, Alabama
    The therapist is credentialed and we do usually bill for services seperately from the physician (in this case, who did the surgery). The codes the therapist wishes to use are 97597 or 97598. Would those be billable in this case?

  7. Default Dressing
    Can a physician bill dressing change after post op services

  8. #8
    Columbia, MO
    This particular scenario sounds global but depends on the surgical procedure performed. If it is a global surgery then it will not matter therapist or physician it is not a billable service.

    Debra A. Mitchell, MSPH, CPC-H

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