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Marla Posted Tue 07th of November, 2017 10:34:21 AM
If a patient gets admitted following a tonsillectomy for dehydration and dysphagia, can you bill an E & M service since the dehydration is secondary to the surgery? If we use a dehydration and dysphagia diagnosis codes?
SuperCoder Answered Wed 08th of November, 2017 01:19:31 AM

Hi Maria,

Scenario first:

If a patient gets admitted following a tonsillectomy for dehydration, we can bill an E/M service, since this condition is unrelated to the surgery performed. However, dysphagia may be related to tonsillectomy due to spasm or some other complication of surgery so we may not consider it seperately in global period.

Scenario second:

If your documentation says dehydration due to dysphagia, patient is not able to take food or liquids after surgery which resulted in dehydration then we may not bill E/M in following visit as it becomes related condition.

Also,

Routine postoperative care includes the following services:

  •  Treatment for complications following a procedure that does not involve a return trip to the operating room
  • Critical care services for seriously injured or burned patients
  • Follow-up E/M visits related to the patient’s recovery following surgery
  •  Pain management related to the surgical procedure

You may also refer to below link for further query.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

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