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E&M for Admission or Post Op

Stephanie Posted Wed 21st of August, 2019 17:32:47 PM
I would like a second opinion regarding E&M Coding for this case. I have two providers from the same practice and taxonomy code. I billed the following case with post op code 99024. One provider, Dr. XXX, performed a laparoscopic cholecystectomy and 6 days later the patient presented to the hospital and was admitted by Dr. YYY. The patient had several days of blood-tinged yellow fluid draining from his right upper abdominal laparoscopic wound site, accompanied by increasing abdominal pain, mainly on the right side. He also had some nausea w/ decreased appetite. He's had subjective fevers, but hasn't checked his temperatures. His blood sugars have been in the 120s at home. He has some recent loose stools w/o blood, no vomiting. Dr. YYY's Assessment: Patient is a 31 y.o. male w/ history of alcoholic cirrhosis w/ portal hypertension, and type 2 diabetes who had laparoscopic cholecystectomy 6 days ago by Dr. XXX who presents w/ progressively increasing RUQ abdominal pain. Diagnosis: no Dx found Plan: HIDA scan today to rule out bile leak. Dr. YYY admitted the patient but did not proceed to back to the OR for additional treatment.
SuperCoder Answered Thu 22nd of August, 2019 10:25:35 AM

Hi,

Thanks for your question.

Our team is working on this and will get back to you soon.

Thanks.

SuperCoder Answered Fri 23rd of August, 2019 02:49:14 AM

Hi,

Thanks for the patience.

 

As per the CMS guidelines, the global surgical payment includes "All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room".

 

Code 99024 suggests that the provider furnishes an E/M service to a patient for a condition or reason related to a procedure during that procedure’s global period. The service is of the type the global period usually includes. The intent of the code is to allow providers to report a code for tracking purposes without billing for the service. It is zero-charge code.

 

Therefore, code 99024 can be billed to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.

 

Hope this helps.

Thanks. 

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