General Surgery Coding Alert

Pay attention to global period.

If your surgeon performs an inpatient procedure that has a global period other than “0,” you need to limit your use of the subsequent hospital care codes 99231- 99233 (Subsequent hospital care, per day…).

Restriction: “You should not use the subsequent hospital care codes for inpatient E/M services related to the surgery on days within the global period,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr. That’s because the global fee for the surgical code includes the immediate post-surgery visits and the patient discharge.

Exception: If another provider performed the surgery, and your surgeon provides an inpatient E/M service unrelated to the initial condition, you can bill your surgeon’s inpatient E/M services with an appropriate code from the range 99231-99233.

Example: A patient underwent emergency appendectomy surgery at the local emergency department (ED) on Wednesday night. The next day, your surgeon was called to the hospital to evaluate the patient for a hiatal hernia identified on a CT scan. Notes indicate that he conducted a problem-focused interval history and examination, and straightforward medical decision making (MDM).

Analysis: Since your surgeon did not perform the appendectomy, and his evaluation is not treating the appendicitis, you should be able to report his services using subsequent hospital evaluation and management (E/M) codes. Based on the encounter description, the best code to report for your surgeon’s service is 99231.