Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 23, 2009 PDF

Remember: You can't report modifier 57 if the decision for surgery was made long ago.

Question: Our physician planned to perform a radical hysterectomy (58210). The patient's preoperative labs turned up showing that she had diabetes. Her blood sugar was so severely elevated that my physician admitted the patient to the hospital to get her sugar under control before he would do the surgery. The patient was admitted on Feb. 11 for the diabetes, and the surgery took place on Feb. 14. Can we charge the hospital admit and subsequent visits that occurred prior to the surgery date? If so, should I use modifier 59 or 79? And can I still use 57 on the date of the surgery even though it was planned several weeks earlier?

Answer: No modifiers apply to the E/M codes you will report because the diagnosis is uncontrolled diabetes, not the reason for the surgery.

In this case, just bill the hospital admission (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ) on Feb. 11 and the subsequent care (99231-99233, Subsequent hospital care, per day,for the evaluation and management of a patient ...) on February 12 and 13.

The modifiers that you referenced in your question do not apply to this case. You cannot use modifier 59 (Distinct procedural service) with an E/M service, and you would assign modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) only during the postoperative period of a procedure,which, for this scenario, has not occurred yet.

You cannot bill modifier 57 (Decision for surgery) on the date of the surgery because the physician and the patient both made the decision to do the surgery at an earlier time.