Neurosurgery Coding Alert

Question: We have case where the patient was admitted back to the hospital during the global period. The patient was having physical therapy and went home. The patient complained of persistent pain and was revaluated for continuing physical therapy (PT). Is the consultation considered part of the post op when the patient was re-admitted to the hospital for an evaluation of continued PT. Urinary tract infection (UTI) was diagnosed during the evaluation.

Ohio Subscriber

Answer: The patient was admitted for "back pain." Since this was post-surgical after treatment of back problem, it seems to be a post-op issue and would not be separately reportable. If, during the course of the evaluation the cause of the pain was a UTI AND if this is unrelated to the surgical procedure (no catheterization was performed), you may separately report this as an unrelated visit with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period...). Make sure that it is well documented and that the diagnosis really is UTI.