Question: How should I report a scenario in which the emergency department physician helps an obstetrician/gynecologist in the vaginal delivery of an infant in the emergency department? What kinds of documentation should I include to strengthen this claim?
West Virginia Subscriber
Answer: First, you must document medical necessity for the assistance at delivery. However, rather than reporting the delivery code and appending modifier -82 (Assistant surgeon [when qualified resident surgeon not available]), your cleanest coding option may be to report one of the ED E/M codes:
Depending on the circumstances and the documentation provided, you could bill both an ED E/M and the appropriate delivery code.
-- Reader Questions and You Be the Coder were reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of coding at Medical Reimbursement Systems in Stoneham, Mass.
