Wiki Laceration Repair Global Period?

[rthomas@impcna.com]

Pt has laceration of wrist with no numbness or loss of ROM on initial exam. One week later he returns and reports numbness to the top of hands and fingers of same hand. Would this fall into the global period of the laceration repair since it is probably a result of the laceration or would I be able to charge for this second visit because it was an unforeseen complication and I referred him to hand surgeon?
I keep going back and forth on this. I want to say yes its in global period since more than likely its related but with it being a week later you don’t know if the patient did something else that may have cause the problem.

 

[thomas7331]

It’s not really up to the coder to decide if the new symptoms are related to the procedure or not, it needs to be reflected in the provider’s documentation. If the record is not clear if this is a complication of the procedure or an unrelated problem, then I’d recommend a query to the provider for clarification.

 

[csperoni]

I agree with @thomas7331 that the clinician needs to make it clear if this is a complication or unrelated. Your assumption of "probably a result of the laceration" is not what a coder is trained for.
I will mention that it could also be a third option of "additional treatment of the underlying condition" which is also excluded from the global surgical package. That's my favorite exclusion.

 

[rthomas@impcna.com]

Thanks for the feedback!