Get Paid For E/M Services Billed With Trauma Calls
Published on Sat Jan 01, 2000
Insurance carriers often bundle evaluation and management (E/M) services that result in a decision to perform surgery into the payment for the procedure itself. But, by using the proper modifier, neurosurgeons can be reimbursed for both services.
For example, a neurosurgeon is called into the emergency room to examine a patient with a closed in head injury. The neurosurgeon evaluates the patient (99222, inpatient hospital care, per day, for the evaluation and management of a patient), which includes taking a full history and performing a comprehensive examination. He or she decides the patient needs surgery for the head injury, admits her to the hospital and operates to evacuate a subdural hematoma (61108).
When an E/M service such as 99222 is billed with a trauma surgery code, carriers may disallow the E/M portion. They maintain that the surgerys global period begins the day before surgery. Consequently, the decision to operate and all attendant E/M procedures performed are included in that period and are not separately reimbursable.
Modifier Makes Difference
But carriers dont seem to agree on which modifier should be attached to the E/M code to show it was a separate procedure. In Wisconsin, for example, Susan L. Turney, MD, FACP, medical director of reimbursement for the Marshfield Clinic, in Marshfield, Wis., and a representative to the AMA CPT Advisory Committee for the American Medical Group Association, recommends using modifier -57 (decision for surgery). Whichever evaluation and management service the neurosurgeon provides, they would append with a -57 modifier indicating that the E/M service was provided to make the decision to perform the surgery.
In North Dakota, however, Tanya Moszer, RN, an independent neurosurgery reimbursement specialist from Bismarck, reports that modifier -57 does not always lead to reimbursement for E/M codes submitted with trauma cases.
The insurance companies we deal with consistently reject E/M code 99222-57 when it is submitted with a trauma code. The grounds for rejection is bundling, same date of service. Payment is included in the basic allowance for the procedure.
According to Nancy Timmons, CPC, president of the Neuroscience Administrative Assembly (NAA) and a coding specialist at the Front Range Center in Ft. Collins, Colo., modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be used in such trauma cases as long as the E/M service and the surgery are performed on the same day.
According to Medicare guidelines, modifier -57 should only be used when there is a major surgery performed within a 90-day global package; modifier -25 is used for procedures with zero and 10-day global packages, she says.
According to CPT 2000, modifier -25 should not [...]
