tci General Surgery Coding Alert - 2015 Issue 7

Reader questions: Capture Separate E/M in Post-Op Period

Question: Our surgeon performed a rubber band ligation to treat hemorrhoids. Three days later, the patient returned with vomiting and a fever. The doctor diagnosed infectious gastroenteritis (009.1). How do I code the return visit? Texas Subscriber Answer: You should code an appropriate E/M service from the range 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient,…), but you’ll need a modifier, too. Although the hemorrhoid ligation (46221, Hemorrhoidectomy, internal, by rubber band ligation[s]) has a 10-day global period, the return visit is unrelated to that procedure. That’s...

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