Wiki ED E&M to surgery

[BS&SC]

I have a provider who sends ED consults to me. My understanding is that a consult is not a consult if she is deciding during her E&M that the patient needs surgery, which means she is taking over the care. Is that correct? IF so, my next question is if this is not a consult, do I code an ED E&M for that visit with a 57 appended to the procedure code, or does that procedure then include the E&M visit and decision for surgery?

 

[BS&SC]

Just had a similar one today. At her appt, the woman was found via US to have missed abortion. Patient went to the hospital for a D&C. Provider in same group did an H&P at the hospital and went over risks, etc, and gave the option of D&C vs misoprostol. Patient wanted D&C and was taken to procedure room and released that day. Am I looking at doing an ED E&M with a 57, and coding the procedure, or just the procedure?

 

[natashalage]

Hello, I am still learning but I see that nobody responded to you yet, so let me write my thoughts but again, I am not an expert.
Case #1. The definition of Consult E/M is in CPT book. It must have 3 RRR- MD's Request, recommendation ?, Response sent back. It will be a provider from a Different specialty. If it's the same specialty, then it's not a Consultation. Whoever makes a decision to perform the procedure, that provider can add modifier 25 (if a minor procedure) or -57 for major. All post-op visits will be managed by the MD/specialty who did the surgery. Can you bill for E/M and procedure? Yes, if the decision is made during this visit AND there is above and beyond service provided that is not a part of the procedure. Must have documentation about discussing the disease process, further treatment plan, additional diagnostic studies, orders, or different Dx discussed. IF pt comes specifically for D &C, then code only the procedure.
Case #2. it seems to me that pt went to the hospital with a purpose to have D&C. H&P will be included into the procedure. I feel that you have a good note for ED visit with emergent decision to do D&C and I would bill ED E/M with a modifier.