Orthopedic Coding Alert

Question: How would you handle a hospital admission during the post operative period as far as a charge is concerned?  Patient came in to the office with cellulitis/abscess, and after examination was admitted to the hospital.  What code do we enter for the encounter?

Ohio Subscriber

Answer: You will need to confirm whether or not the cellulitis is located at the pelvic site. If your patient is a Medicare patient or has an insurance that follows CMS Surgical Package guidelines, you cannot bill for the admission, as it would be included in your postoperative care. CMS does not permit billing for postoperative complications.

If however, your patient's insurance follows CPT® Surgical Package guidelines, you might be able to bill for the admission since complications are not included in the surgical package.

The CPT® Surgical Package Definition follows:

"The services provided by the physician to any patient by their very nature are variable. The CPT® codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services "included" in a given CPT® surgical code, the following services are always included in addition to the operation per se:

• Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
• Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)
• Immediate postoperative care, including dictating operative notes, talking with the family and other physicians
• Writing orders
• Evaluating the patient in the post anesthesia recovery area
• Typical postoperative follow-up care