General Surgery Coding Alert

Question: Our surgeon performed a hospital E/M service for patient presenting with nausea and sharp pain in the right upper quadrant. The surgeon reviewed the imaging tests and provided a clinical evaluation before deciding to admit the patient for surgery to perform a laparo­scopic appendectomy the same day. The appendix showed extensive inflammation, but was intact. Can we code for an E/M and the appendectomy?

Maine Subscriber

Answer: Yes, you can code for both services, but you’ll need to use a modifier to appropriately document this case.

The first service the surgeon provided was an E/M service, which you should report with a code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components …). But because this service resulted in your surgeon admitting the patient for surgery, you need to append modifier 57 (Decision for surgery) to the inpatient E/M code to differentiate it from the usual preoperative exam included in the global package. You can then also bill the appropriate code for the surgery, such as 44970 (Laparoscopy, surgical, appendectomy).

Focus: You can always report an E/M service that results in a decision for surgery. If the E/M is the day before or day of surgery, you should use modifier 57 to note that this is not just the bundled surgical pre-op visit. If the surgery follows later than the day after the E/M, you don’t need modifier 57.

Resource: To learn more about how to interpret situations for modifier 57, dig into the Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, “Payment for Evaluation and Management Services Provided During Global Period of Surgery,” and Section 40.2, “Billing Requirements for Global Surgeries.”