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ER consult w/procedure then to sx same day

  1. Default ER consult w/procedure then to sx same day
    Medical Coding Books
    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 is greatly appreciated!

  2. #2
    Milwaukee WI
    Default 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

  3. #3
    Albuquerque, NM
    I agree with Tessa I would use 78 for the trip to the OR.

  4. Default
    is wound related to breast abscess or is it separate wound?

  5. #5
    Fayetteville, NC
    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.
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

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