Neurosurgery Coding Alert

Question: One of our patients had surgery for a decompression. The patient returned to the office within the global period for a consult with our other surgeon who specializes in fusions and it was decided the patient needed to return to the operating room for a fusion along with a re-do decompression. I'm questioning if we can charge for the office visit or would the consulting surgeon's services be part of the global even though he's addressing a continued issue. Any help would be appreciated.

California Subscriber

Answer: You would not report the E/M because the evaluation service was related to the original reason for surgery. However, if the subsequent surgery is performed within the global period of the first decompression, modifier 58 may apply to the subsequent procedure.