General Surgery Coding Alert

Question: A patient presents to the emergency room with nausea and severe lower-right abdominal pain. Our surgeon examined the patient and ordered labs and radiology services to rule out appendicitis. Based on the test results, the surgeon made the decision for surgery, performed an open appendectomy, and admitted the patient to the hospital. How can we report an E/M plus the surgery, if possible?

Nebraska Subscriber

Answer: Reporting both an E/M service and the surgery, in this case, is both possible and appropriate.

Despite the fact that the first patient encounter was in the emergency room (ER), you should not use one of the codes from the range 99281-99285 (Emergency department visit …). Because the surgeon admitted the patient the same day, you’ll need to report a single E/M code for initial hospital inpatient services for the day.

Do this: Choose the appropriate code from the range 99221-99223 (Initial hospital care …) based on the level of history, examination, and medical decision making (HEM). You should base the HEM level on all the encounters your surgeon had with the patient during the day (except for the surgery), including the ER encounter. You should report the code with modifier 57 (Decision for surgery).

You should additionally report the surgery with the appropriate code such as 44950 (Appendectomy).