Wiki How to bill a post op fever?

[vidraj]

Hello all,

I am debating over a claim where to code it as inpatient consult or a post op follow up. Below is the scenario and I hope one of you can give me your thoughts.

This patient had a major procedure by our general surgeon and is under 90-day global period. Patient called the next day and reported fever and was asked to visit ER.
Pt was admitted by another provider, but the same surgeon was called for consult.

Our surgeon has examined the patient and plan states this:
Patient presents with extensive PSH/PMH presents for groin pain and fevers at home. Patient recently underwent right groin mesh explanation for migrated hernia mesh.
No acute surgical intervention
Expected post op findings on both physical exam and imaging.
Pt agreeable to trying non-narcotic pain regimen including around the clock Tylenol and ibuprofen.
Ok to DC from surgical standpoint with follow up in clinic as scheduled.

Can I code this as 99221 - 24 - R50.9, R10.813, Z98.890? (Because the fever here, is not mentioned as due to recent surgery) or
is this covered under the global package: 99024 - R50.9, R10.813, Z98.890?

 

[thomas7331]

I would not assume that the fever is unrelated just because it isn't stated that the fever was due to the surgery. I would query the physician in this case, as I cannot tell from this documentation whether the physician considered the condition related or unrelated to the surgery, and I feel that the modifier 24 would not be clearly support from what is written here.

 

[lgardner]

Agree with Thomas.

Also, the statement "Expected post op findings on both physical exam and imaging", makes it sound (to me), like the fever could be an expected post-op finding.

 

[vidraj]

Thank you both for this.

I will query the provider.