Question 99223 and modifier 57

[vidraj]

Hi everyone,

I got confused with a denial claim and thought someone can help me out here.

For initial visit (on which decision to perform Pacemaker insertion was made )- coded 99223 - 57 modifier
The second day - patient had PM insertion - coded 99233 - 25 and 33208 - KX with MAC
The third day - follow up visit - coded 99233

The payer just paid for MAC and the third day follow up visit ! Denied the rest of the codes including the procedure code.

With reference to the Global surgical package link
(https://www.cms.gov/outreach-and-ed...oducts/downloads/globallsurgery-icn907166.pdf)

Page 5 & 8 (Physicians Who Furnish the Entire Global Package):
The initial visit 99223 and the second and third day follow up visits - are inclusive as it is a major procedure.

But Page 10 - Pre operative period billing states:
E/M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, these services may be billed and paid separately.


So, My questions are :
- For Major procedures with 90 day global , should we code the consultation and the follow up E/M codes ( 99223 , 99233) or not ?
- Is it correct to append Modifier 25 - on the day of major surgery?

Thank you as always.

Vidhya

 

[AmandaBriggs]

Without seeing the documentation, the first visit is likely coded correctly. The other two visits most likely bundle into the procedure unless the documentation supports treatment above and beyond the pacemaker insertion, i.e. addressing a separate diagnosis(es) or doing more with the underlying condition for the pacemaker other than inserting a pacemaker.

 

[vidraj]

Hi Amanda,

Thank you for your response.
I will appeal for this claim with medical records.


So, I should be coding :

Initial decision making day : 99223 - 57 -
Second day/On the day of surgery: 33208 - KX ( only the major procedure code and no E/M unless seen for a different diagnosis)
Third day : 99233 - 25 and 93280 (Subsequent visit for programming of the device)



(Anyone reading this thread, please do correct me if the information I mentioned above for coding is incorrect).

Vidhya

 

[AmandaBriggs]

I recommend looking at modifier 24 for your day 3 documentation and be sure that it supports adding the modifier along with the programming.

 

[vidraj]

Sure Amanda, noted down the points.

Thank you,
Vidhya Rajesh.