Blackhorse Posted Thu 08th of March, 2018 12:47:30 PM
Reason for visit: THORACIC/LUMBAR SPINE--OFFICE VISIT
History of Present Illness
Robert comes back for reevaluation from his last visit on 1/31/2018. As you may recall, he was diagnosed at 112 compression fracture which was subacute. He also has thoracic and lumbar degenerative disc disease. My plan at that time was to have aggressive physical therapy and see him back for follow-up. He was getting ready for a 7 mile 12 Hour drive. The plan was to see him back in 4 weeks and get x-rays of the lumbar spine along with a thoracolumbar standard view. The patient states he is doing better. He stopped physical therapy on 2/27/2018. He is still using Norco on occasion
On exam, the patient is A & 0 x 3 with a pleasant affect. He is accompanied by a friend. He is heavyset. Extraocular movements are intact.
Posture is symmetrical and forward lurching. He uses a walker for ambulation and appears slightly unsteady on his feet with forward sagittal balance
Gait is nonantalgic with well coordinated movements of the extremities.
Cranial nerves are grossly intact.
The chest and abdomen are unremarkable to visual inspection. There is no evidence of any obvious dyspnea or masses.
He has no major medical tenderness or cervical tenderness. He has no major gibbus deformities. He has intact sensation and motor function throughout 1+ reflexes.
AP and lateral lumbar spine along with an AP lateral cone down the thoracolumbar region shows no major change in the T12 fracture terms of height but there is sclerosis present consistent with healing.
T12 compression fracture clinically and radiographically healed Improved thoracolumbar pain.
I counseled the patient extensively about his falling risk. He should continue using the walking aid such as a walker. The risk of fracture was discussed. I also discussed proper body mechanics and lifting techniques. The patient was instructed on diagnosis specific therapeutic exercises and stretching to improve strength, ROM, coordination and balance, along with endurance. Face to face manual instruction was provided along with a plan for home exercises. A handout was provided. I stressed the importance of maintaining a strong core and keeping his weight down. I discussed abdominal and back muscle strengthening to keep his core strong and also discussed his positive sagittal balance as a possible fall risk. All questions were answered. I will see him back as needed.
Patient had 22310 on 01/31/2018, diagnosis code was S22.080A. I think the above visit should be post-op but another coder think it should be 99214-24 because in physical exam, doctor states "pt appears slightly unsteady on his feet with forward sagittal balance", which qualifies for diagnosis codes R26.81 and M40.04. However I don't think coder should create diagnosis for doctors. Under Impression, doctor didn't diagnose Unsteadiness of Feet and Postural Kyphosis. Therefore we cannot use R26.81 and M40.04 in order to get paid for modifier 24.
SuperCoder Answered Fri 09th of March, 2018 07:24:12 AM
Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. Post-op care falls into this category of care when the condition that precipitated the surgery no longer exists, but the patient still requires therapy care to return to a healthy level of function.
As per the above documentation, it is suggested not to bill evaluation and management code (99214) separately as this visit falls under post-operative care of CPT code 22310 which has a global day period of 90 days. If the condition was unrelated to the primary condition then you can bill a separate evaluation and management code with an appropriate modifier. The presented documentation is related to the previous condition for which patient was treated. Also, we cannot code any ICD-10 code until and unless it is a definitive diagnosis mentioned in the documentation by treating physician.
Hope this helps!