ER consult w/procedure then to sx same day

finzy

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i work for a breast surgeon who was called to the ER to consult on breast abscess. she performed and I&D of the abscess in the ER and proceeded to take the same pt to the OR that afternoon for a surgical debridement of the wound. so it would be the consult to the ER with a modifier 25, then the procedure in the ER, then the procedure in the OR later that day. the question that I have is which modifier do I use for the trip to the OR for the debridement,? I am thinking wither 59 or 58? I am rather new to the surgical coding and this is the first time that I have had an encounter such as this one to code. the pt was then admitted to the hospital for 2 days. thanks in advance for any and all advice....it is greatly appreciated!
 
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Mod 78 or Mod 58

Depending on the DOCUMENTED circumstances, I would think you would use either the -58 or -78 modifier with the trip to the OR.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

Grintwig

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Also you need to know if the trip to the OR for debridement was planned. You can only use modifier -78 if the second procedure was not pre-planned.
If the physician planned to go back later in the day and debride then you would use modifier -58.
 
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