IndianaAIM Resolutions Manual
ESC 6656.4
AUDIT NAME: POST-OP CARE WITHIN 10 DAYS OF SELECT SURGERY
CLAIM TYPE:
M
HEADER/DETAIL:
Detail
LOCATION:
22
OVERRIDEABLE:
Yes
PROGRAMS:
All
ALLOW DENIAL:
Yes
RECYCLE DAY:
0
DISPOSITION:
Paper Claim
ECS
ECS w/attach
Shadow
POS
Adjustments
Special batch
M
Suspend
Suspend
CCF
Pay
Suspend
Suspend
Suspend
AUDIT DESCRIPTION:
This umbrella audit will fail when the same provider who performed surgery bills for
postoperative care within 0-10 days of the surgery.
AUDIT CRITERIA:
If a provider bills an evaluation and management visit, procedure codes 99201-99205,
99211-99215, 99218-99223, 99231-99233, 99238, 99241-99245, 99293, 99294, 9929599297, 99299, 99301-99303, 99311-99313, 99321-99323, 99331-99333, 99341-99343, or
99351-99353, and payment has been made to the same provider for a surgical procedure
with a value of 010 in the "Global Surgery" field in the Medicare Fee Schedule database,
for the same recipient within 0-10 days of the date of service on the claim, fail this audit.
EOB CODES:
6656 - Postoperative medical visits performed within 10 days of surgery are payable only
for a surgical complication and if documented as medically indicated. Documentation not
present or does not justify the visit billed.
ARC CODE:
B10- Allowed amount has been reduced because a component of the basic procedure/test
was paid. The beneficiary is not liable for more than the charge limit for the basic
procedure/test.
REMARK CODE:
Revised 2/28/03
Revised 06/07/05
Revised 10/26/06
Revised 11/02/06
IndianaAIM Resolutions Manual
ESC 6656.4
N29- Missing documentation/orders/notes/summary/report/chart.
METHOD OF CORRECTION:
Route the claim to the Medical Policy Specialist.
Medical Policy Specialist Instructions:
 Compare claim to suspense screen and correct any keying errors. If no keying errors
check to see:
 If the claim documents the surgical complication necessitating the visit, override the
audit. Surgical complications include but are not limited to:
1. Post operative wound infection requiring specialized treatment.
2. Elevated temperature above 101 degrees F for two or more consecutive
days.
3. Medical complications due to anesthesia, other than nausea/vomiting.
4. Nausea/vomiting that has persisted more than 24 hours.
5. Renal failure.
6. Comatose condition.
7. Cardiovascular complications.



If the procedure paid was billed as surgical care only (modifier 54) by the same
provider and the necessity of the visit is documented and justified, override the audit.
If visit is related to the original surgery deny the service with EOB 6656.
If no documentation provided on or with the claim or documentation does not justify
the visit, deny the service with EOB 6656.
RELATED AUDITS:
ESC 6659.
Revised 2/28/03
Revised 06/07/05
Revised 10/26/06
Revised 11/02/06