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General Surgery Coding Alert

Reader Question:

46418: Global Days Give E/M and Modifier Clues

Published on Wed Sep 14, 2011

Question: Our surgeon was called to consult for an inpatient with ascites. The surgeon performed an E/M and decided to carry out a procedure the next day to insert a tunneled intraperitoneal catheter to drain the abdominal fluid. Should I report an E/M, such as 99222 for day one and 99231 for day 2, in addition to the procedure (49418)? Do we need to put modifier 57 on 99222? Texas Subscriber Answer: When the surgeon performs an E/M on day 1 and performs a tunneled intraperitoneal catheter insertion the following day, you should not report an E/M on day 2 unless the surgeon also provides care unrelated to the procedure on that date. Assuming you've identified the appropriate E/M code documented by your surgeon, here's how you should code the scenario:Day 1: 99222 -- Initial hospital care, per day, for the evaluation and management of a patient ...Day 2: 49418 -- Insertion [...]
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