Wiki new coder needs help with E/M with surgery

[ggparker14]

I have a patient that was evaluated in the surgeons office on day 1. Day 2 the patient is admitted to observation and has surgery. The doctor is wanting to an observation 99218 plus surgery on Day 2. Is this possible?

Any help is appreciated.

 

[annakilker]

E/m with surgery

Yes you can get paid sometimes. If your documentation supports decision for surgery was made on day 2 you may add mod 57 to the e/m visit; if your documentation indicates the e/m was above and beyond the normal pre-operative preparation you may add mod 25. The procedures subject to the 90 day global period (which of course begins the day before surgery) are sometimes hard to get paid, your documentation will need to be detailed to explain the circumstances requiring the e/m and you will in many cases need to appeal your claim. In either case it can be a challenge getting paid for e/m the day of or day before surgery. (Just an FYI from my experience Medicaid has never paid for an e/m with mod 25 or 57.)

 

[ggparker14]

I found out that the decision for surgery was made in on day 1 in the surgeon's office and then on day 2 the patient was admitted as observation for the surgery.

 

[FTessaBartels]

Code ONLY Day 1 E/M

You can only code the E/M where the decision for surgery was made. So you would code the E/M for Day 1 visit.

Day 2 E/M is really just the hospital/clinic/ASC requirement for H&P for admission (in this case admit for observation). It is global to the surgery performed that day of service.

MODIFIER - if the surgery has a 90-day global you will need a -57 modifier on the Day 1 E/M. If the surgery has a 10-day or less global period you do not need a modifier, but you will probably get a denial and will need to appeal with CPT/NCCI guidelines noted.

Hope that helps.

F Tessa Bartels, CPC, CEMC