Should You Code This Patient Visit As An E/M Or A Post-Op Visit?

A coding colleague and I recently disagreed on how to code a patient visit. I will share both of our opinions with you and would love to hear what you think in the “comments” section below.

A patient with poorly controlled diabetes had a punch biopsy and returned four days later for evaluation of the biopsy site. There was no complication and the visit lasted five minutes. The doctor evaluated the site, provided recommendations for care and answered two of the patient’s questions.

The disagreement dealt with whether the doctor should code this visit four days after the punch biopsy as an evaluation and management (E/M) versus CPT 99024, which is: Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.

Answer #1. I think this was just a post-op visit and you should code CPT 99024 with a diagnosis of Z09: encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm. Even if the visit occurred after the global period, I would still use CPT 99024 for this unless there was a new and distinct problem for which the patient presented.

Answer #2. I think this is an E/M. If there was a chief complaint and the doctor used her expertise/education to evaluate the issue and manage it, and all of this was medically necessary, this was an E/M. In this case, the doctor evaluated a biopsy site on a patient with poorly controlled diabetes four days after the procedure. In communicating with the patient, the doctor may have said: “This looks good. You should use product X for Y more days and then you should expect to see Z. If anything other than that happens, let me know.” This is an E/M.

Which answer do you agree with? Leave your thoughts in the “comments” section. If you are interested in the which of the above answers was Dr. Lehrman’s, check the comment section below.

Dr. Lehrman is a consultant to the APMA Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Fellow of the American Academy of Podiatric Practice Management (AAPPM). Follow him on Twitter @DrLehrman

References

1. American Medical Association. CPT 2018 Professional Edition.

2. American Podiatric Medical Association Coding Resource Center. Available at https://www.apmacodingrc.org/home.asp .