Internal Medicine Coding Alert

Question: The physician performed incision and drainage on a patient's complicated forearm carbuncle. Four days later, the patient returns with a severe headache and neck pain. The physician examines the patient and sends him home. Can I report both of these services, or is the second encounter considered part of the global surgical package?

Michigan Subscriber

Answer: You'll be able to report the second service with an E/M code because the E/M visit was for a problem unrelated to the earlier incision and drainage.  Because the second visit occurred within the global period of the incision and drainage (10 days), you'll also need to attach modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M code.

On the claims for these visits, you should list the following codes:

• 10061 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple) for the incision and drainage.

• 680.3 (Carbuncle and furuncle; upper arm and forearm) linked to 10061 to represent the patient's carbuncle.

• report the appropriate-level E/M based on the physician's notes for the second visit. If the report indicates a level-two service, for example, report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem- focused history; a problem-focused examination; and straightforward medical decision-making).

• 784.0 (Headache) linked to the E/M code to represent the patient's headache.

• 723.1 (Cervicalgia) also linked to the E/M code to represent the patient's neck pain.

• modifier 24 attached to the E/M code to show that the E/M was unrelated to the incision and drainage.