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Testopel Implants - How would you code this?

David Posted Tue 12th of May, 2015 09:01:28 AM

CHIEF COMPLAINT
Complaining of drainage from his Testopel site that I just put in last week.
PHYSICAL EXAMINATION
Exam reveals that the stab incision is open, draining serosanguineous fluid. This fluid was cultured with a swab. I then prepped the area and dilated the hole and there is a subcutaneous pocket noted. I could not palpate or feel any of the pellets. I placed a small piece of Nu Gauze to wick it open so it would drain. There is some concern because he has a hip prosthesis on this side, so I am putting him on Augmentin for a while and he is to monitor closely. If he gets fever, pain or purulent drainage, he is to call me, otherwise we will see him back at the end of this week to check the wound.
PLAN
As above.

I am thinking the only thing to code is a low level office visit? Is that right?

SuperCoder Answered Wed 13th of May, 2015 03:08:53 AM

Global period of the minor surgical procedures is usually 10 days. Since you have not mentioned the procedure code, considering that your code has a global period of 10 days and the patient has been seen within the global period, you need to append modifier 78 to the procedure code suggesting that this was an unplanned return to the operating room in the post operative period with in the global period. E&M code can be billed only when the patient has been seen for a different problem other than the procedure.

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