Wiki E/M visit during post op

[Diane Eslinger]

Patient comes in for 6 week right hip arthroplasty follow up. During the visit provider realizes that the patient is due for there 2 years follow up for there left hip arthroplasty. Providers performs bilateral hip x-ray and in addition to the right hip exam the provider also performs an exam on the left hip. Can the provider bill out a global visit for the right hip and than an E/M level for the left hip with a modifier 25?

 

[Kaitbohrer]

I believe you would want to attach a 24 to the E&M service. The E&M of the left hip is unrelated to the patients current global period/surgery of the right hip. Also you want to make sure diagnosis shows left & right hip and I would attach z98.890.

Modifier 24 is appended to an evaluation and management service (never to a procedure) to indicate that an unrelated E&M service was provided by the same physician during a postoperative period.