Wiki Help coding postop situation

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kpeters88

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I have a patient who had an ESWL (90 Global). Patient came in for Followup, and has had a UPJ obstruction all there life, it has never bothered patient until patient made a small stone and could not pass it. The xrays will always be abnormal and hyronephrosis is only a problem if it is associated with loss of renal function. Dr. stated patient can return if develops pain or recurrent stones.

My question is with this being a post op followup and 90 day global is it ok to charge and E&M or would you consider this part of the global period..

THANKS AGAIN and all help would be really appreciated.
 
Hi Keshia,

Base on the scenario you described, you did not mention if your doctor did additional work up during this post op visit which made him conclude that pt is deemed ok, despite the fact the small stone wouldn't pass and that there is hydronephrosis --- as long as it doesnt affect the renal function. How were the stone and hydronephrosis seen? You mentioned xrays would always show abnormality...

If there was additional work up, then yes you should charge an E & M with modifier 24 plus the radiology test.


Regina McGee,CPC,CPMA
 
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