# modifier 24 - During a global period



## Pillow1 (Feb 9, 2011)

During a global period, can I code a 99213 -24 using an unrelated dx for the primary dx and the reason for surgery as the secondary dx.. or I am not aloud to use the reason for surgery dx on the claim at all when using the 24 modifier during a global period? 
__________________
Denise


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## annakilker (Feb 9, 2011)

*Modifier 24*

I have noticed anytime I use an unrelated DX code and use a DX code used during the surgery, even with the modifier 24 my claim will be denied and I have to appeal the claim with supporting documentation.  So I use the unrelated DX code and V67.09 as the secondary code  and my claims are paid with no problem.


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## mitchellde (Feb 10, 2011)

Pillow1 said:


> During a global period, can I code a 99213 -24 using an unrelated dx for the primary dx and the reason for surgery as the secondary dx.. or I am not aloud to use the reason for surgery dx on the claim at all when using the 24 modifier during a global period?
> __________________
> Denise


There is no reason to ever use the pre procedure dx code since the reason to have the surgery no longer exists after surgery.  After an appendectomy there is no longer an appendix to become inflamed, there is no gall bladder after a choley, the artificial joint after a total knee replacement does not have a degerative condition and so on.  there I agree with the above use the unrelated dx and a V67.09 code secondary.


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## gost (Feb 10, 2011)

This might be a silly question but why would you use any dx that references the surgical procedure or the codition for which it was performed if the current encounter is not related?


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## Pillow1 (Feb 11, 2011)

On 12/9/10 we performed a
cpt  27603 ( i and d leg/ank: ) dx 682.6 (cellulitis of leg) ( 90 day global)

on 01/04/11 we saw the patient for more than one reason
cpt 99214 -24        ... Dx #1 891.1 (open wound knee opposite leg)
                                 dx # 2 682.6 ( cellulitis of leg)
                                 dx # 3  250.00 ( d.m.)
                                 dx # 4 427.31  ( a.f.)
 so if we billed the 686.2(during the 90 day global) it will get denied regardless..no matter which dx # it is?


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## mitchellde (Feb 11, 2011)

Is there any way to see the documentation?  Are these conditions diabetic caused conditions?  It just looks very odd.  It may be your linkage is off and with out the documentation I cannot advise as to how I would bill it, but I will say there is a way to do it if the documentation is written in a specific manner.


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## Pillow1 (Feb 11, 2011)

OK BUT IT IS QUITE EXTENSIVE
WE ALSO  SAW THE PATIENT IN BETWEEN THE ABOVE DATES FOR THE HYPERTENSION, ATRIL FIB AND DM USING 99214-24 AND WE WERE PAID BY MEDICARE

THE NEXT OV  ON 1/4/10 WAS MAINLY FOR THE KNEE WOUND AND NOT THE ABSCESS, BUT NOW I SEE THE DICTATION/ TRANSCRIPTION OF THE  NOTES DO NOT SUPPORT THAT .. IF THE NOTES SUPPORTED THE KNEE WOUND PRIMARILY, MAYBE THE CLAIM WOULD GET PAID....

HERE IS THE 1/4/11 OV NOTE.. THANK YOU FOR YOUR INTEREST... 

PT X is a 79 year Male who comes in today for OFFICE VISIT/RECHECK, Abscess, wound, Diabetes Mellitus, Paroxysmal Atrial Fibrillation (PAF), Cardiomyopathy, Hypertension, dyslipidemia and Venous Insufficiency .								

	Last wednesday he hit his right shin with a sander and now has a large bruise and red spot size of 1/2 dollar...Leg is swollen down to ankle. positive diabetic.


	 History of Present Illness								

	OFFICE VISIT/RECHECK 								
		Patient is here for a 2 week follow-up visit for abscess to the left calf.  Patient is also complaining of a new injury to his Rt. shin and patient's medical history is remarkable for the following:.							
	Abscess 								
		The location of symptoms is in the  left calf  . The duration of symptoms is 1 month(s)  Onset 12/06/10. The Recent medication(s) include Doxycycline and Rocephin 1 Gm IM and Efforts to treat include Incision and Drainage on 12/09/10. The symptoms of condition persists.							
	wound 								
		Associated signs and symptoms include bruising and swollen ankle. The location of symptoms is in the  Right shin  . The duration of symptoms is 7 day(s) .							
	Diabetes Mellitus 								
		The severity is mild to moderate. The symptoms of condition is chronic. The duration of symptoms is 2 year(s) . There are Recent medication(s) include Amaryl and Metformin.							
	Paroxysmal Atrial Fibrillation (PAF) 								
		The severity is mild to moderate. The symptoms of condition is chronic. The duration of symptoms is significant with a long past history (20 years). There are Recent medication(s) include Digoxin and Warfarin.							
	Cardiomyopathy 								
		The symptoms of condition is chronic. The duration of symptoms is significant with a long past history (20 years). There are Recent medication(s) include Coreg.							
	Hypertension 								
		The severity is mild .  Controlled with medication. The symptoms of condition is stable. The duration of symptoms is 5 year(s) . There are Recent medication(s) include Lisinopril; HCTZ.							
	dyslipidemia 								
		The severity is mild .  Controlled with medication. The symptoms of condition is chronic. The Recent medication(s) include Simvastatin. The duration of symptoms is 2 year(s) .							
	Venous Insufficiency 								
		The duration of symptoms is 2 month(s)  Onset 10/21/10. The Efforts to treat include compression stockings.  Patient declines.							

	 Review Of Systems								

	General (Constitutional) 		 The patient denies any weight changes, changes in the way clothes fit, weakness, fever or fatigue.

	Eyes 		 Patient denies any complaints.

	Ears, Nose, Mouth, Throat 		 The patient has no complaints.

	Respiratory 		 The patient has no complaints.

	Cardiovascular 		 Patient denies any complaints.

	Gastrointestinal 		 Patient denies any complaints.

	Genitourinary - Male 		 Patient denies any complaints.

	Musculoskeletal 		 The patient complains of no complaints.

	Integumentary 		 The patient complains of non-healing wounds left lower extremity   and cellulitis R leg.

	Neurological 		 Patient denies any complaints.


	 Past History								

	Medical History 		 Medical history includes: diabetes mellitus, hypercholesterolemia, essential hypertension  , Cardiomyopathy, paroxysmal atrial fibrillation and dyslipidemia.

	Hospitalizations 		 Hospitalizations include: no recent hospitalizations.

	Immunizations 		 Flu Shot - October 2008 & 09/25/09 & 10/21/10 and Pheumovax - Septemper 2009.
 Examination									

Skin, Hair & Nails 			Left Lower Extremity  with non-healing abscess.  Bandage removed to reveal oozing yellow discharge.  Applied triple antibiotic ointment and rebandaged. Examination reveals Rt. shin distal to knee there is a golf ball size hematoma.  Punctured with 18 guage needle and no pus removed. Lower leg with +severe erythema and warmth, Assessment: Cellulitis of Rt. leg and Non-healing wound of Lt. Leg, Plan: Rocephin 1 Gm IM ordered.  Patient to be referred to Wuesthoff Wound Care and Patient given Rx for Doxycycline 100mg BID.						
Respiratory 			Respirations are regular and unlabored. Lung sounds are clear in all lobes. No abnormalities noted on palpation. Resonance is noted in all fields.						
Cardiovascular 			Auscultation reveals S1 is normal  , S2 is normal  ,  regular  rate,  irregular cardiac rhythm  and no murmurs, rubs, or gallops.						
Constitutional 			The patient is alert and oriented, has normal posture and motor behavior and is appropriately dressed and well-groomed. The facial expressions, manner, affect and relation to people and things are appropriate.						
Extremities 			Examination reveals dependent edema at Rt. ankle.						


 Office Procedures									


Diagnosis				Procedures					
 ICD Code	ICD Name		Rank	CPT Code	CPT Name		Modifiers	ICD Code	Units
6826	 CELLULITIS OF LEG		1	96372	 INJECTION:THERA,PROPH, DIAG			6826,8911	1.00
25000	 DMII WO CMP NT ST UNCNTR		2	99214	 OFFIC/OUTPT E&M ESTAB MODHI 25 MIN			25000,2724,4019,4254,42731,6826,8911	1.00
8911	 OPEN WND KNEE/LEGCOMPL		3	J0696	 Rocephin, Ceftriaxone Sodium 250 mg			6826,8911	4.00
42731	 ATRIAL FIBRILLATION		4						
4254	 PRIM CARDIOMYOPATHY NEC		5						
4019	 HYPERTENSION NOS		6						
2724	 HYPERLIPIDEMIA NEC/NOS		7						

 Prescription									

 Medication			Dosage	Dispensed Qty	Form	Direction	Start On	Refill	DNS
 Doxycycline Tablet			 100 mg	20	Tab	Bid 	12/06/2010	0	No

Provider does have access to a qualified e-prescribing system and some or all prescriptions generated during the encounter were printed or phoned in as required by state or federal law, patient request or pharmacy system being unable to receive electronic transmissions; or because they were for narcotics or other controlled substances.


 Referral	to:__________________________________								


 Recommendation									

6826 - CELLULITIS OF LEG:			 The patient is advised to/ towards : Start new medication , Doxycycline.

25000 - DMII WO CMP NT ST UNCNTR:			 The patient is advised to/ towards : continue current meds.

8911 - OPEN WND KNEE/LEGCOMPL:			 Referrals : wound care center.

42731 - ATRIAL FIBRILLATION:			 The patient is advised to/ towards : continue current meds.

4254 - PRIM CARDIOMYOPATHY NEC:			 The patient is advised to/ towards : continue current meds.

4019 - HYPERTENSION NOS:			 The patient is advised to/ towards : continue current meds.

2724 - HYPERLIPIDEMIA NEC/NOS:			 The patient is advised to/ towards : continue current meds.


 Follow up									

01/12/2011  @3:00									

 Diagnostic Testing and Consults									

Evaluate and treat 		 Diagnosis :  Non-healing wound to lower leg 891.1.


 Instructions									

The patient has had all questions answered and verbalized understanding.  I have relayed that it is the patient's responsibility to return for follow-up visit as scheduled, and patient accepts full responsibility for health care in case of non-compliance with therapy and/or follow-up.
Patient encounter was documented using a CCHIT certified EHR.


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