Wiki Routine postpartum visit with minor illness - time-based.

[RABBIT2020]

A patient visit is a routine post partum. All the related pregnancy related and delivery issues, contraception etc etc are addressed.
Patient had an ultrasound a few hours prior to the postpartum visit. The scan was interpreted and is now being reviewed with the patient.
It shows some abnormality within the uterus which is discussed and management issues are provided.
Md sums up visit as 30 mins total time.

would it be correct to bill for the total time as a complication postpartum?
Please give me your coding ideas.

 

[csperoni]

There are certainly situations where there is an encounter that is part of global, but there are also services provided outside of global and separately billable. You need to separate out the work to bill for the non-global services. The note would need to state something like 16 minutes for postpartum care, 14 minutes for care regarding sonogram abnormality (or whatever the appropriate times were).
Alternately, you could bill based on MDM only (or hx, exam, MDM if 2020). Again, exclude any work that was the postpartum care. For 2021 example, let's assume the uterine abnormality was a thickening of the endometrium, ordered repeat TV and pelvic sono in 3 months (not being done by your office). You get 99213-24 R93.89 for acute uncomplicated illness, 2 points for ordering 2 tests, low risk. If the abnormality was more significant, and you are discussing surgery, ordering PST labs, etc, 99214-24.
What you cannot do is count all time, or all MDM when some of it was included in global. Only the time or MDM outside of global.
I hope that helps.