Wiki Would you code E/M and -57

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Lisa Bledsoe

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If the provider does not state that the decision for surgery has been made the same day as the surgery...is the E/M billable? I think not, but I am being questioned on this. This is a new patient who came in for her first OB visit but was bleeding and found to have a missed AB. The doctor took her to surgery but nowhere in her documentation does she state surgery was recommended, suggested or discussed.
 
I would code the E/M with the 57 if the intent of the visit was truly just for an office visit. It sounds like they discovered the problem during the visit so a decision for surgery had to have been made at that point.

If the procedure was already scheduled before she even presented to be seen then no you wouldn't code for the E/M in addition to the procedure.


It would be interesting to see the note

Laura, CPC
 
Hi Lisa,
I'd go with the E/M and .57 modifier - apparently they came in as you say for the first OB - found to have a missed AB - and went to surgery. The fact that it's not mentioned in the note does not negate the fact that she was brought to surgery (the decision was made). Maybe it was on an emergency type basis... I'd simply ask the provider/doctor amend the documentation to support the decision for surgery. But definately, it was an E/M and it was an unplanned surgery also...
 
Thanks to all for the input. As far as the "note" it was her "first OB" visit, so it's on an OB flow sheet - can't really post that. This gets really complicated because the doctor did not turn in office charges until 2 months later when she received a missing charge report. She turned in the surgery charge two days after the procedure. The patient has no insurance and is now getting another bill. I will leave it up to the doctor and the patient advocate. My opinion was sought and I felt the E/M inappropriate, but I see where it could be based on the "intent". :(
Thanks again!
 
No note?

Lisa,
Maybe I misinterpret your statement, but if there is no note, then definitely there is no E/M service to bill.

If there IS some notation but it's handwritten on a form you can't duplicate here, then I'd code the E/M (level consistent w/ documentation) with the -57 modifier and ask the doc to DICTATE an amendment to the record regarding her decision for surgery.

Of course, if she doesn't want to bill the patient ...

F Tessa Bartels, CPC, CPC-E/M
 
No, there is a note...it is the handwritten OB record. I don't feel comfortable with an addendum to the note 4 months later. I don't want to code/bill it but the "powers that be" want it billed. I have gone on record stating that I disagree. Guess that's all I can do. :(
 
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