25 & 57 modfiers

BABS37

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If the patient has a same day surgery and it's a 90 day global with a consult- and I use the 57 modifier- will that also allow the CT's, X-Rays or anything else that bumps up with E/M levels go through? I wouldn't code 25, then 57 right? I seriously feel like an idiot with these surgeries and coding lately. So then my next question is- how do I show all of these distinctly? Example, this was coded by the office personal and I don't have an OP note but are looking at these old denials and it's coded like this:

44140-59
44139
45330-57
99223-25

So I start looking at 44140 is a global so wouldn't it get 57 since 99223 was billed? And 44139 is global but 45330 isn't and yet there's a 57 on it? Any advice? Thank you!!
 

btadlock1

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If the patient has a same day surgery and it's a 90 day global with a consult- and I use the 57 modifier- will that also allow the CT's, X-Rays or anything else that bumps up with E/M levels go through? I wouldn't code 25, then 57 right? I seriously feel like an idiot with these surgeries and coding lately. So then my next question is- how do I show all of these distinctly? Example, this was coded by the office personal and I don't have an OP note but are looking at these old denials and it's coded like this:

44140-59
44139
45330-57
99223-25

So I start looking at 44140 is a global so wouldn't it get 57 since 99223 was billed? And 44139 is global but 45330 isn't and yet there's a 57 on it? Any advice? Thank you!!
25 & 57 are for E/M codes only. If the decision for surgery was performed in the visit, use 57 (You'd use 25, when the surgical procedure is minor - 0 or 10 day global). If the decision for surgery was made prior, 99223 may be global. Hope that helps! ;)
 

BABS37

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Thank you Brandi! So how does that work then when I have global and non global procedures being billed together with consultation codes? Like this one, which probably isn't a great example because that was the one that I thought the E/M should get a 57 and not a 25- right? And how's come she put a 57 on 45330 when that isn't a global? I'm confused. :(

44140-59
44139
45330-57
99223-25
 

mhstrauss

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Thank you Brandi! So how does that work then when I have global and non global procedures being billed together with consultation codes? Like this one, which probably isn't a great example because that was the one that I thought the E/M should get a 57 and not a 25- right? And how's come she put a 57 on 45330 when that isn't a global? I'm confused. :(

44140-59
44139
45330-57
99223-25
Was the decision for surgery made at this 99223 visit? If yes, then the 99223 gets the 57 modifier. If not (the decision for surgery was made prior to this visit) then the 99223 should not be billed at all; it is typically included in the global. The remaining codes (surgery codes) cannot get a 25 or 57 because they aren't E/M codes; the only modifiers they can get are the 59, 51, etc, as appropriate. It doesn't matter that only 1 or 2 of the 3 have global periods. If just one does, then there is a global package. And since you're using 99223 for the "consult", then I'm assuming that this is a Medicare patient ? If not, or if the payer still accepts consult codes, then use the 99251-99255 range.

BUT for your original question, about Xrays, etc being included in global... Any diagnostic tests or imaging should be able to be billed separately. However, would need to see more info to say for sure.

Hope this helps to clarify! :)
 

btadlock1

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Thank you Brandi! So how does that work then when I have global and non global procedures being billed together with consultation codes? Like this one, which probably isn't a great example because that was the one that I thought the E/M should get a 57 and not a 25- right? And how's come she put a 57 on 45330 when that isn't a global? I'm confused. :(

44140-59
44139
45330-57
99223-25
Well, I imagine she only put the 57 modifier on there, because she didn't know that she couldn't; if a code doesn't start with 99XXX, you can't use a 57 or a 25 on there - maybe she meant to put a 59 modifier on 45330, since it has a 'separate procedure' designation. Let me ask, though: What happened in this encounter? I'm confused by the codes billed...It looks like the doc was consulted for a patient who was already in the hospital, and (if I'm correct), the doc decided to perform the procedures during that visit.
At some point, they performed a sigmoidoscopy, but it's not clear if that was done before, or after the other procedure.
The other procedures listed, represent an open partial colotomy, with a take-down of the splenic flexure...right? Or was that done by scope, as well? If the colotomy was done laproscopically also, you'd need to use 44204, and 44213, instead.
Assuming that the colotomy was open, and the decision for surgery happened on that date, you'd bill it like this:
99223-57
45330-59
44140
44139...This code doesn't need a modifier, because it's an add-on code, meant to be used in conjunction with 44140.

If the colotomy was done by scope, then it will look like this:
99223-57
44204
44213
45330...this time, it doesn't look like it needs a 59 modifier, because it's not on the NCCI tables with 44204 or 44213 - but I might be wrong about that.
If the decision for surgery wasn't done that day, don't bill 99223 at all.

FYI: The 'Decision for surgery' modifier (57), means that, during that E/M encounter, the provider made the decision to perform a major surgery (eg, one with a 90 day global). Normally you see it on a day that comes before the surgery date, but it's also correct to use, if it's on the same date. Sometimes, you'll see it on a DOS prior to the surgery for minor procedures (0, 10 day globals) - and that's okay, too. You can use a 25 modifier on the same DOS as the surgery instead of the 57 modifier for major surgeries - it will probably pay if it's billed that way, but it's technically not correct.

*Note - The term "Global" comes from the 'global surgical package'...CPT defines some services as being incidental to surgical procedures, and they're described in the CPT under the surgery guidelines. The global days are a set period of time before and after the surgery, where any services related to the surgery (E/M - like the follow up visits), are considered 'bundled' into the surgery. Basically, they're saying "We already paid you a large amount of money to perform this surgery, and that includes any routine aftercare, for the next 90 days."

Unrelated E/M's after the date of the surgery, but within the global period (by the same doctor), need a 24 modifier attached, to process. For other surgical procedures (eg, CPT's that don't start with 99XXX) on the same date as the surgery may need a modifier, and they may not. It depends on CPT guidelines, and NCCI edits. Procedures after the surgery, but during the global period, will need either a 58, 78, or 79 modifier, depending on the circumstances. Does that clear up some of it for you? :)
 

BABS37

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I am only billing consultation codes as the same day for surgery if there was one so I will almost always use the 57 for same day global surgery. Otherwise, his I & D's and non-global surgeries I bill without E/M's- his office personal will either bill one or not, depending on the info she gets. I don't see that part or code it. I still can't figure out why she was using 57 on procedure codes though and then billing out 25 too. And you're right! I hadn't even noticed you don't bill a 57 on procedure codes! lol! I feel like an idiot. I have a huge stack of denials to work through and the 25 she used would almost always be a 57 for the global surgeries on the E/M. I guess the good thing is it threw out the whole entire claim instead of paying on part of it. I have a lot to fix. Thank you sooooo much Meagan!!!!
 

btadlock1

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I still think the 57 was probably supposed to be a 59...

Just curious...was the colotomy done as an open procedure, or was it laproscopic?
 

BABS37

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Sorry Brandi! I didn't see your previous post before I posted my other reply. I can see if I can get copies of what was done that day. I'm guessing it wasn't coded correctly as with everything else I keep running into. The problem is, I am coding for a physician who works out of state so my access is only limited to his surgeries- and yes, mostly all I see are his consult, either in the ER setting, inpatient, or um...possibly an office visit- anytime those are done, he seems to be doing same day surgeries. I don't bill out any Post-Op visits either and I won't see or code those either. The hospital or his clinic will depending on where the patient goes. This all was a lot easier when I worked at the hospital and everything was pretty much cut and dry but this has been very difficult for me. I know the E/M is included in some surgeries but his documentation supports it and he's also doing a separate paragraph declaring the reason for the decision for surgery so I assumed since I had this, it was ok to bill but maybe not? I can't even tell if the patient is in inpatient status. I can only go by the admitting physician doctor and hope the date on my note is correct. Really difficult.
 

btadlock1

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Sorry Brandi! I didn't see your previous post before I posted my other reply. I can see if I can get copies of what was done that day. I'm guessing it wasn't coded correctly as with everything else I keep running into. The problem is, I am coding for a physician who works out of state so my access is only limited to his surgeries- and yes, mostly all I see are his consult, either in the ER setting, inpatient, or um...possibly an office visit- anytime those are done, he seems to be doing same day surgeries. I don't bill out any Post-Op visits either and I won't see or code those either. The hospital or his clinic will depending on where the patient goes. This all was a lot easier when I worked at the hospital and everything was pretty much cut and dry but this has been very difficult for me. I know the E/M is included in some surgeries but his documentation supports it and he's also doing a separate paragraph declaring the reason for the decision for surgery so I assumed since I had this, it was ok to bill but maybe not? I can't even tell if the patient is in inpatient status. I can only go by the admitting physician doctor and hope the date on my note is correct. Really difficult.
Ouch...doesn't sound like they're sending you enough of what you need to do your job effectively. You should really have access to the entire chart, as it pertains to this encounter. You need an operative note, summary, and the place of service should definitely be documented on the H&P.

If he declared that he made the decision for surgery right then, then you can bill it. More than likely, since they went with 99223, the patient is inpatient, but errors do happen. I assumed that they were already inpatient, only because GI specialists don't usually admit patients - they're usually consulted, after someone's already admitted. But that's not always the case either, so if you have evidence that this was the initial encounter, and that the GI doc did admit the patient, remember to append the AI modifier to 99223, as well, to show that he's the admitting MD of record. (If he mentions another doctor in his note, though, he was probably just a consultant.)

I'd definitely speak with the office, to let them know that you can't accurately code, without all of the relevant encounter info to verify. Yeah, you can tell them when modifiers are on the wrong codes, but if they want you to tell them how it's supposed to be billed, you really need to be able to verify all of the codes selected, by comparing them to what's documented. Otherwise, you might be advising them to bill a service that's not actually "there" (from an auditing standpoint). Plus, many times, you'll catch additional charges that they didn't think to bill, so it works out better that way.
 

BABS37

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Yea, the ones that I am using the initial inpatient consultation codes for with the same day surgery are the ones that have a date of service prior to the consultation date and since there's nothing else in the EMR under my physician, then I can assume he's still inpatient and its the first time my physician has seen the patient. Otherwise, my physician is the 'admitting physician' on what looks like just regular new/established visits to me. Some consult visits that have same day surgery sometimes have a different admitting physician. But all in all, I don't think I get the right stuff either.
 
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Why did the original coder use -57 on a procedure?

It really doesn't matter why the original coder used the wrong modifier, as long as you fix it - once you have all the documentation so you can support the correct codes.

But I'm going to take a wild guess at the scenario.
Patient seen in clinic for a consultation, which resulted in a sigmoidoscopy. The result of the scope was that the doctor knew he needed to perform surgery - TODAY.
Patient was immediately admitted for the open colectomy, and take down of splenic flexure.
CPT tells us that any/all E/M services performed outside the hospital are coded using the initial hospital visit when they result in admission. So the code used would be the 99223.
The coder, however, was thinking chronologically. Visit had the -25 to distinguish it from the scope. The coder then was thinking that the SCOPE resulted in the decision for surgery, so that's why the -57 was added to that code.
It's wrong, but like I said, I'm just guessing as to how it happened.

The important thing is to get the documentation and submit a corrected claim/appeal with correct coding.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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