Wiki 11 days post op

[blondie12]

This is 11 days post op visit for knee surgery but there is also another diagnosis of lumbar disc problems. Can you code this with an e/m and do you need a 24 mod? Also if the same doctor sees the patient that did the surgery is this considered an established patient?

 

[Cyndi113]

Good morning!

Yes, you need to be able to take out your knee surgery information and only code what is left for the lumbar problem. Definitely add a -24. Yes, this patient is established.

 

[dclark7]

If the doctor that did the surgery is seeing the patient, then yes it is established. As for your other question, without the note I can't really tell you if you can bill. However, IF the documentation supports it (i.e. the doc documented an apprpriate HPI, examined the back and made some decision about treating or ordering tests), then yes you can bill the appropriate level E/M and you would use a modifier 24. If there is no documentation that would set it apart from the post op exam and the doc just mentioned an additional diagnosis, then no you cannot bill for it.