Ob-Gyn Coding Alert

Question: My doctor went to the emergency department (ED) to consult on a patient for a labial abscess. The report reads that while in the ED, he excised and cleaned the labial abscess. Should I include that in the ED visit? And if he continues to follow the patient, which E/M code should I use?

Texas Subscriber

Answer: If the ob-gyn consulted and then performed the abscess incision and drainage (I&D) on the same day, you can bill for both services. You should report the consult with 99241-99245 (Office consultation for a new or established patient ...), depending on the service level provided. Be sure to add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consult code. For the I&D, you should use 56405 (Incision and drainage of vulva or perineal abscess).
 
Code 56405 has 10 global days. Consequently, you would not report any normal follow-up care for the I&D during that time period. If complications arise, however, you could bill separately for any procedures or services performed to treat them.