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Pain Management Coding Alert

Reader Question:

Code Non-Surgical Services for Recovering Surgery Patients

Question: One of our patients underwent emergency appendectomy surgery at the local emergency department (ED) at 11 p.m. on Thursday night. The next day, our physician was called to the hospital to treat the patient for a migraine headache. Notes indicate that he conducted a problem-focused interval history and examination, and straight­forward medical decision making (MDM). Can we report this service, even though it occurred during the global period for the appendectomy?

Montana Subscriber

Answer: Since the physician did not perform the surgery, you should be able to report her services using subsequent hospital evaluation and management (E/M) codes.

Based on your encounter description, the best code to report for your physician’s service is 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …).

Remember: This is only correct coding if your provider did not perform the procedure. The immediate post-surgery visits and the patient discharge are part of the global fee for the appendectomy. Since the physician did not perform the appendectomy, and is not treating appendicitis during the E/M, you can report an E/M for the visit.