# Same day surgery E/M



## bksaris (Mar 31, 2014)

Hello, I am currently a student who is taking his advanced coding course. I am having some trouble understanding how to code for same day surgery in E/M. Would I code it under initial hospital care? Or is there a specific section for that in the E/M? Any help would be greatly appreciated to help me understand. Thank you.


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## mitchellde (Mar 31, 2014)

if it is an outpatient surgery there will be no E&M on the day of surgery.


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## kellyobenour@yahoo.com (Apr 1, 2014)

yes, apply mod 25 to EM


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## bksaris (Apr 1, 2014)

Thank you so much for your help, its been a long road but I think I'm getting the hang of it.


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## FTessaBartels (Apr 10, 2014)

*Scheduled surgery or emergent surgery?*

There are several options that need to be considered before answering your question.

#1:  Is this scheduled surgery or emergent surgery?
If the decision was made to perform the surgery at a prior visit (either outpatient or inpatient), then this is a scheduled surgery. Any evaluation on the date of surgery is already covered in the surgery, and no additional E/M service is billed.

If the decision for surgery was made at this visit, Then see # 2 BELOW ...


#2)  MAJOR procedure vs MINOR procedure.  
If the procedure is *MINOR (0-10 days global *- e.g. lesion removal), then the evaluation is usually considered a part of the reimbursement for the procedure.  The only difference would be if there was some E/M provided over and above the required evaluation of the condition requiring the procedure.   In that case you would use a *-25 modifier *on the E/M service to show that it was a distinct and separate service from the procedure. You would assign a level of E/M using ONLY that documentation that is not a part of the evaluation of the condition requiring the procedure.  *EXAMPLE:* patient comes in with a sinus infection and a cut on finger requiring repair.  *ONLY* the part of the documentation that deal with the evaluation and management of the sinus infection would be used to determine the level of E/M service.  Any exam/history/MDM related to the cut on finger would be considered part of the laceration repair. 

If it is a *MAJOR surgery (90-day global period *, e.g. appendectomy), and your E/M service was your decision for surgery, then you use a *-57 modifier* to show that this service was the decision for surgery. This can be an outpatient or inpatient visit / outpatient or inpatient surgery.  *EXAMPLE*: patient seen in ER with RLQ pain, determined to be appendicitis and taken directly to OR for emergent appendectomy.   

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Texascoder64 (Apr 13, 2014)

I wanted to add another question to this as well. 
What if, in an out patient(office in my case) where the physician is doing a planned major surgery, for example MOHS that includes the (major) adjacent tissue transfer CPT, but often the physician wants to do a separate  skin exam  and the additional diagnoses may be for something totally unrelated to the  reason the patient is in for the (major) surgery, so the 57 really does not seem to be appropriate because the e/m was not the "decision for surgery" , it was an separate e/m, for something else, like an AK.  I see this often, especially for mohs surgeons, doing additional services on a planned mohs session, (i.e., skin exam, adding on additional minor surgical services such as cryos, PDT's, same day) I would drop the e/m code if a minor surgery was added, but what about when the physician states in note they performed a skin exam or addressed another problem and there is other dx codes to append to e/m - but the e/m is not the decision for that surgery?


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