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Minor Procedure while in Post-Op

  1. #1
    Default Minor Procedure while in Post-Op
    Medical Coding Books
    A patient has a Arthroscopy of the knee due to chondromalacia. Patient returns for follow up after surgery with no complications. Patient comes back while still in post op for discharge. While being examined patient is found to have OA and requiers an injection of the knee. I know i would bill 20610 but what about the E/M.

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Qualified Yes
    In the absence of full documentation, I'd say ...

    Yes, you could code the E/M (with modifiers -24 and -25) -- that's assuming documentation supports this.

    F Tessa Bartels, CPC, CPC-E/M

  3. #3
    Default
    I would say -24 because it's an unrelated E/M during post-op but would that be appropriate because a minor procedure was performed ?

  4. #4
    Default
    or would you use both -24 & -25 ?

  5. #5
    Location
    Columbus Ohio
    Posts
    44
    Default
    I would use both. 24 because it is during the global period and 25 because you are also billing the injection 20610.

  6. #6
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    I would do an office visit with a 24-25 combo make sure that the chondromalacia diagnosis is NOT attached to either line item.

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