Orthopedic Coding Alert
Initial Visit vs. Consult
Virginia McGeorge
West Side Orthopedic Group, OH
Answer: Medicare asks who made the decision for surgery. If the answer is the OS, then the OSs first visit to the patient constitutes an evaluation and management (E/M) service that resulted in the initial decision to perform surgery. And the E/M can be billed separately and identified with the -57 modifier, even though it occurred on the same day as the surgery. The 24-hour preoperative period is included in the global fee for surgery, except as noted here. (The postoperative global period is 90 days.)
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