tci General Surgery Coding Alert - 2017 Issue 5

Reader Question: 'Decision for Surgery' Allows E/M

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...

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