Outpatient Facility Coding Alert - 2015 Issue 7
Reader questions: Capture Separate E/M in Post-Op Period
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Article Overview
This reader Q&A addresses coding for an established-patient follow-up visit that occurs during a postoperative period but is unrelated to the original surgery. It is aimed at coders and billing staff who handle evaluation and management documentation, postoperative scenarios, and diagnosis coding across ICD-9 and ICD-10 references. The article covers the general relationship between the follow-up visit, the surgical global period, and the supporting documentation needed to assign the visit appropriately.
Why This Topic Matters
Postoperative encounters can be coded differently depending on whether the visit is related to the prior procedure. Understanding the article helps readers identify when an unrelated evaluation and management service and the accompanying diagnosis coding context are discussed in the source material.
What You Will Learn
- How postoperative return visits are categorized at a general level
- How evaluation and management documentation is considered in a follow-up setting
- How diagnosis coding context is presented across ICD-9 and ICD-10 references
- How modifier use is discussed in relation to unrelated postoperative services
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physician practice staff
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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