On day 6, the lymphadenitis had become an abscess, so the otolaryngologist performed an incision and drainage (I&D), which I coded as 21501 (90-day global period). Can I charge a subsequent hospital visit in addition to the I&D?
South Carolina Subscriber
Answer: If the otolaryngologist documented the decision for the surgery based on a history, examination and medical decision-making on day 6, yes, you should bill the follow-up hospital care in addition to the I&D (21501, Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax).
To indicate that the E/M was a decision for surgery, append the subsequent hospital care code, such as 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient -), with modifier 57 (Decision for surgery).