Neurosurgery Coding Alert

Question: A neurosurgeon I code for saw a patient in the hospital who presented with severe headache and nausea, and he determined that the patient had a ruptured aneurysm. The physician scheduled immediate surgery (61697). Can I report the hospital visit and the procedure?

South Carolina Subscriber

Answer: Yes. You can, and should, report both the E/M service and the surgical procedure.
 
In this case, you may report both the E/M service (such as a hospital admission, 99223, Initial hospital care, per day, for the evaluation and management of a patient ...) and the intracranial aneurysm surgery (61697, Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) because the E/M service resulted in the decision to perform the surgery.
 
Best practice: Remember to append modifier 57 (Decision for surgery) to the E/M service code to indicate that the E/M service led to the decision to perform a surgery with a 90-day global period on the same day. Always append modifier 57 to the E/M service code, not the surgical procedure code.