General Surgery Coding Alert

Question: Our surgeon performed an ileostomy revision, and the patient was returned five days later complaining of weakness. The surgeon evaluated the stoma, and stated that his impression was Crohn’s and post-surgical inflammation of the stoma. As a coder, how can I decide if an E/M service provided in the global period is separately billable? 

Texas Subscriber

Answer: As a coder, you can’t make the decision for a separate E/M during the global surgical period. The physician must document whether the E/M service is related to the surgery.

Based on the information you’ve given, it’s not clear if the inflammation is typical post-surgical inflammation, unusual inflammation due to Crohn’s or if the patient has a post-op complication. The surgeon’s impression complicates things by listing “post-surgical inflammation,” which is related to the procedure, and Crohn’s, which isn’t.

Best choice: You should ask your surgeon whether this is a post-op complication or a manifestation of the patient’s disease and code accordingly. If it’s a disease manifestation, you can separately bill the E/M service at the appropriate level based on the physician’s documentation.