Coding, Classification & Reimbursement

Post-Op Encounters

  • 1.  Post-Op Encounters

    Posted 10-12-2018 08:29
    Hello!
    I have multiple situations where a neurosurgeon, or his/her PA/NP goes into the room to see the patient after a surgery​ and in his/her assessment states patient doing well after the procedure, but then goes on to state a condition not related to the surgery that another specialist is managing that particular problem. This is still a 99024, post-op encounter correct? Also, would I just use the Z codes for the post-op encounter, or do I add in the diagnosis(es) that the other specialist is managing? For instance, the patient had an anterior arthrodesis but has an ulcer near the sacrum that is being treated by a different doctor. The day after surgery the PA goes in to check on the patient, and mentions that the ID team grew staph from the wound and is managing that problem. Do I also add that diagnosis on top of the Z codes for the post-op visit, or is this considered incidental and not to be coded because the ID specialists are handling it? Thanks in advance for the advice!

    Rich

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    Richard Dinaso
    Coder\Abstractor
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  • 2.  RE: Post-Op Encounters

    Posted 10-15-2018 10:59
    ​If you are using 99024 to capture the hospital visit, I would not bother to report the ulcer diagnosis.  Your 99024 claim would be $0 and isn't going anywhere, so it really doesn't matter.  I would only code that diagnosis if the neurosurgeon was evaluating/managing/treating the ulcer, otherwise it will be captured by the infectious disease provider.

    You could report the condition for which the surgery was performed and/or the postop code.

    In my past life, we did not complete charge tickets for postop hospital visits from the surgeon.  Only for their postop office visits did we complete charge tickets using 99024 with the postop diagnosis code.



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    Greta Ryan, RHIA, CCS, CCS-P
    Coding & Compliance Analyst
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  • 3.  RE: Post-Op Encounters

    Posted 10-16-2018 06:43
    ​Thank you very much Greta!

    Rich

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    Richard Dinaso
    Coder\Abstractor
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