Primary Care Coding Alert

Question: The physician performed incision and drainage on a patient's complicated forearm carbuncle. Four days later, the patient returns with a severe headache and neck pain. The physician examines the patient and sends him home. Can I report both of these services, or should I consider the second encounter part of the I&D's global surgical package?


Michigan Subscriber

Answer: You-ll be able to report the second service with an evaluation and management code because the E/M visit was for a problem unrelated to the earlier incision and drainage.    

Because the second visit occurred within the I&D's global period (10 days), you-ll also need to attach modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M code. On the claims for these visits, you should list the following codes:

- 10061 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple) for the I&D.

- 680.3 (Carbuncle and furuncle; upper arm and forearm) linked to 10061 to represent the patient's carbuncle.

- report the appropriate-level E/M based on the physician's notes for the second visit. If the report indicates a level-two service, for example, report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem- focused history; a problem-focused examination; and straightforward medical decision-making).

- 784.0 (Headache) linked to the E/M code to represent the patient's headache.

- 723.1 (Cervicalgia) also linked to the E/M code to represent the patient's neck pain.

- modifier 24 attached to the E/M code to show that the E/M was unrelated to the incision and drainage.