EM Coding Alert

Question: We have a patient that had surgery with a 90-day global period on July 4. He returned to our office for an infection at the surgery site on July 16 and was admitted that day for a post-op infection at the site of his knee amputation. The surgeon who performed the amputation saw the patient determined that there was no need to return to the OR for treatment. She wants to bill with 99215 with modifier 24. I think this should be a 99024. Which is correct?

Oregon Subscriber

Answer: You are correct. You don’t separately report a related E/M during the global period. The intent of the 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure) is to allow the provider to report a code for tracking purposes without billing for the service. 

Using 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity) with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) wouldn’t be accurate during a global period as the infection was related to the initial surgery.