# Inpatient Consultation in Post op Period



## mbabou (Nov 29, 2011)

I could use another coder's input on the following scenario and how/if to code it:

A Surgeon completes and inpatient consultation on a patient and a cervical laminoplasty within the same admission for Cervical Spinal Stenosis -central, and chose not to address the patient's cervical foraminal stenosis surgically.

The patient does well until 1 week later, the patient is readmitted with the same complaints and an inpatient consultation is requested by another surgeon within the same practice and specialty.  This consulting surgeon diagnoses cervical foraminal stenosis.

 The diagnosis is the same but the symptoms are from a problem that was not surgically addressed but is already established. Would this be coded as a inpatient consultation on an established problem or  would it be a post op complication and unbillable?


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## FTessaBartels (Dec 2, 2011)

*Another decision for surgery?*

Unless he made another decision for surgery, and then took the patient to the OR, I'd say this is global to the first surgery.

Of course, it's hard to say for certain without seeing all the documentation ....

Hope that helps.

F Tessa Bartels, CPC, CEMC


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