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Denise Posted Tue 22nd of September, 2015 14:18:30 PM

Pt has Alabama Medicaid. Admitted as inpatient 9/14 at 15:22 through Emergency Room to our service. Next morning (9/15) our doc saw and evaluated patient, H&P completed, pt taken to surgery later that same day for cystoscopy and left double J stent placement (52332LT) for left 9 mm ureteral stone with hydronephrosis and obstruction.
My question - do I use the ADMIT/DISCHARGE SAME DAY for EM since Doc evaluated/discharged same day? (Plus modifier 25 on the EM for the procedure he done (0 global days). Doc DID NOT SEE PT on 9/14.
Or will I use the ADMIT E/M DOS:9/15 with mod 25 for the cysto/stent placement (52332LT) later that same day? Cannot charge for discharge.
Thanks for you help.

SuperCoder Answered Wed 23rd of September, 2015 09:55:56 AM

This is very strange that patient was admitted on 9/14 at 15:22 and evaluated on next morning-9/15. It is advisable, kindly make a notice that what services have been performed during the stay for the night, to enhance your billing.
Well, as per given scenario, best option to bill it- same day admit and discharge on 9/15 as doc did not evaluated the patient on 9/14 (make a note that minimum 8 hours are required to bill the service) and code E/M (ED-99281-99285) visit for 9/14 if patient is evaluated in emergency department. Use modifier 25 with E/M service while billing for cystourethroscopy. Hope it helps!

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