# I&D Abscess with complicated post-op course



## mshapiro (Apr 23, 2014)

We have some patients that come in with an abscess and extensive cellulitis or other complicating factor (e.g. location near a joint) .  In addition to an incision and drainage procedure they require care in the global period which I believe is not part of the routine postoperative care following incision and drainage ( which typically would include packing changes, wound check, culture followup) in the 10-day global period.  These complex patients require IV antibiotic therapy (daptomycin)  which also includes monitoring for toxicity of the drug  (lab tests every 3 days).  I believe that (presuming the documentation supports the above services) that  it would be appropriate to code a separate E&M.   Do you agree?  Would it be correct to use a -24 modifier on the E&M service?


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## OCD_coder (Apr 24, 2014)

For Medicare, all care performed in the global period is inclusive except care that occurs in the OR.  I refer to the Global Fact Sheet for information.  

The key to documentation for the provider is to specifiy the underlying condition or an added course of treatment as Medicare does not consider this a "normal" part of recovery from surgery and would be billable with a modifier 24 on the E&M and 58 on any procedures to capture 100% of the fees would be appropriate.

http://www.cms.gov/Outreach-and-Edu...oducts/downloads/GloballSurgery-ICN907166.pdf


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## Tonyj (Apr 24, 2014)

OCD_coder said:


> For Medicare, all care performed in the global period is inclusive except care that occurs in the OR.  I refer to the Global Fact Sheet for information.
> 
> The key to documentation for the provider is to specifiy the underlying condition or an added course of treatment as Medicare does not consider this a "normal" part of recovery from surgery and would be billable with a modifier 24 on the E&M and 58 on any procedures to capture 100% of the fees would be appropriate.
> 
> http://www.cms.gov/Outreach-and-Edu...oducts/downloads/GloballSurgery-ICN907166.pdf


Using a modifier 24 doesn't seem appropriate to me in this scenario. Due to the fact that it is related to the post op care. I'm interested to hear other coders opinions.


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## KRivers26 (Apr 25, 2014)

mshapiro said:


> We have some patients that come in with an abscess and extensive cellulitis or other complicating factor (e.g. location near a joint) .  In addition to an incision and drainage procedure they require care in the global period which I believe is not part of the routine postoperative care following incision and drainage ( which typically would include packing changes, wound check, culture followup) in the 10-day global period.  These complex patients require IV antibiotic therapy (daptomycin)  which also includes monitoring for toxicity of the drug  (lab tests every 3 days).  I believe that (presuming the documentation supports the above services) that  it would be appropriate to code a separate E&M.   Do you agree?  Would it be correct to use a -24 modifier on the E&M service?


I agree with billing a separate evaluation and managament service with modifier 24 appended due to the services you described (IV antibiotic therapy (daptomycin) which also includes monitoring for toxicity of the drug (lab tests every 3 days), not typical post-op care for the procedure (incision and drainage) rendered. To further support my reasoning, I need to know what is the underlying condition of these "complex" patients that necessitate the above additional services in the post-op period.  CMS states *"Treatment for the underlying condition or an
added course of treatment which is not part of
normal recovery from surgery;" *is separately billable.   
*http://www.cms.gov/Outreach-and-Edu...oducts/downloads/GloballSurgery-ICN907166.pdf*


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## mshapiro (May 12, 2014)

*Treatment for the underlying condition...*

The reason for the more extensive treatment is the extensive nature of the surrounding cellulitis, associated symptoms (e.g. fever), or proximity to an important structure (joint, spine, face (brain) ).  
Unfortunately the ICD-9 code for cellulitis and abscess is the same  (682.x series), so in many cases there is not a second diagnosis code available.
Obviously intravenous antibiotics  are not part of the typical postoperative management. Most cases do not require this treatment.   On the other hand the treatment is not "unrelated" to the original diagnosis.
In the CMS document you attached  it states (under "Which services are NOT included in the global surgery payment"): "Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery".

Therefore I think that we would be justified in coding an "unrelated"  E&M service in the global period.


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