Pediatric Coding Alert

Question: Codes 10060 and 10061 have a 10-day global fee, which means you cannot bill an E/M for anything related to that procedure within that time frame. If the patient, however, continues to have follow-up visits outside the global period, would it be appropriate to then report the E/M level that is supported for the services received?

Example: Patient has 10061 billed on 6/15/09 --so any related visits billed through 6/25/09 would be considered global. Patient then has additional follow-up visits on: 6/26, 6/30, 7/3, 7/7, 7/10, and 7/14.

Colorado Subscriber

Answer: Technically, you should code each of the medically necessary office visits (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) that the pediatrician provides outside the 10-day global fee with no modifier.

You need modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) only in a global period for a visit that is separate and distinct from the expected postprocedural follow-up. Payment for the global period per Medicare is based on the number of follow-up visits typically performed for the procedure, such as 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single). If more of these are required -- and performed, you can separately report them.

Be prepared for the insurer to question why so many additional post-I&D visits are necessary. Make sure that the ICD-9 coding reflects any complications, such as infection (for instance, 682.5, cellulitis on buttock; or 250.xx, diabetes), that explain the unusual volume of follow-up visits.

Caution: Before billing the first technically nonincluded E/M service on 6/26, make sure that extenuating circumstances did not push the normally included related visit into a billable period. For instance, was the 25th a Sunday and you didn't have any office hours until the 26th? Or did your office have no visits available on the 25th or before, so the patient was forced to come in after the global period ended? If scheduling gamed the system, do this:

1. Include the visit on the 26th in the global period for 10061 (... complicated or multiple)

2. Code the follow-up visit with 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a  reason[s] related to the original procedure]) billed at a $0 charge.