Pediatric Coding Alert

Question: Our pediatrician performed a frenotomy on a newborn, then discharged the child from the hospital the following day. Do I need to use a modifier on the discharge as it occurred during the global period for the 41010?

AAPC Forum Participant

Answer: You are correct when you say the discharge occurred during the global period for 41010 (Incision of lingual frenum (frenotomy)). Currently, 41010 has a 10-day global period, so a discharge billed with 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (… more than 30 minutes) the following day would be regarded as being within that period.

To bill both the procedure and the discharge, you will need to use modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period). But you must be prepared to document that your pediatrician did not provide postoperative care for the frenotomy as a part of the discharge service. Or, as Medicare puts it, “the physician may need to indicate that an [evaluation and management] E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier ‘-24’ must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure” (www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf).