Podiatry Coding & Billing Alert

Question: My physician removed lesions from the right foot of a patient 15 days back. The patient reported again in the clinic yesterday for a follow-up visit. How do I code the visit?

Nevada Subscriber

Answer: Whether your practice can bill a follow-up visit depends on the circumstances. Sometimes, a lesion will need to be retreated after four or six weeks. This would be a typical scenario in case of the destruction of a lesion (17000, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgicalcurettement], premalignant lesions [e.g., actinic keratoses]; first lesion). If this is the case, your practice can bill the applicable removal codes again. No modifier would be required. However, unless the patient presented with a separate problem, coders could not assign another E/M code. If the patient has not reported with any new symptoms, you can’t report a new E/M code as the physician would already have evaluated the lesions in the previous visit.

As wart removal codes have a global period of 10 days, you cannot bill the procedure again within the global period. During this time, any normal care would be included in the original service. If the patient has come back, let’s say after five days because of minor itching or irritation, you will not bill an office visit as this would be viewed as regular follow-up care within the global period. Therefore, most follow-up visits are anyway scheduled for 2 weeks after initial visit. According to your information, the patient has reported beyond the global period. So, you can safely report the new treatment codes again. The usual rules regarding the site and the number of lesions will still apply.

If the patient has a revisit within the global period, you will have to use modifiers for follow-up treatments — such as modifier 58 (Staged or related procedure or service by same physician) or modifier 76 (Repeat procedure by same physician).