Wiki Hospital rounds w/ procedure

[deonna774@hotmail.com]

A pt was admitted to hospital due to diabetic ketoacidosis. A consultation along with a I&D of an abscess was performed on the same day. The I&D has a 10-day global period. Can you charge for the consultation and I&D on the same day? Do I need to use modifier 25? Due to the global period, I would not charge for the remaining rounds and discharge from hospital? The clinic that I work for is a rural health clinic, will this affect the coding? Any help will be greatly appreciated!!

deonna774

 

[FTessaBartels]

Documentation is key

Without seeing all the documentation it is hard to say whether you can charge for the consult.

Here is what I THNK you are reporting.
Doctor A admits patient for DKA.
Doctor A asks Surgeon B to evaluate for abscess
Sugeon B performs consultation and decides to perform I&D
You could code both the consultation and the I&D (as the consultation resulted in the decision to perform the procedure).

OPTION B - if your documentation, however is ...
Doctor A admits patient for DKA & notes abcess
Doctor A asks Surgeon B to perform I&D
Surgeon B performs eval & I&D.
In this case the eval prior to the I&D is included - the decision / need to perform the procedure was previously identified. I.e. Doctor A wasn't asking for an opinion on how to treat the abscess, but was referring the patient for definitive treatment, so there's no consultation.

As always, it all depends on the documented services.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[deonna774@hotmail.com]

Thanks!

Thanks for your help!!!