tci General Surgery Coding Alert - 2018 Issue 9

Reader Question: Marshal E/M Plus Surgery Pay

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...

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