Ob-Gyn Coding Alert

Question: A new patient was admitted through the emergency department (ED) with abdominal pain. The workup was extensive with four to five hours of on floor care and evaluation on the first day. Several more days of workup culminated with a TAH BSO (total abdominal hysterectomy with bilateral salpingo-oophorectomy) for endometriosis with endometrioma and extensive lysis of adhesions. What, in addition to the TAH BSO, can we code for?

Washington Subscriber

Answer: You can code for the initial and subsequent inpatient care because this extensive a workup would not normally be included in the global surgical package and the care was given before the decision to perform surgery was made. It would be appropriate to code for the initial inpatient care (99221-99223) but not the ED care because all care for a given service date is rolled into the single code billed, and that code will reflect all E/M services rendered to the patient that day.

Also, you may be able to bill for prolonged physician services (99356-99357 for inpatient prolonged service).

For example, if your physician has documented a level-three initial hospital visit (99223) and the unit floor time was four hours, you can bill for 170 minutes of prolonged service using 99356 for the 60 minutes, and 99357 X 4 (for three 30-minute periods and one 20-minute period). You may also be able to bill for prolonged services for the day before surgery.

However, once the decision to perform surgery has been made, many payers consider any E/M services to be included as part of the global package, so your documentation will be important to getting paid. For instance, Medicare will always include E/M visits the day before surgery as part of the global package for a major procedure (which a TAH BSO is), but they allow billing for E/M care up to and including the care that involved making the decision to perform surgery. You would add a modifier -57 (decision for surgery) to that E/M visit.