Wiki Decision For Surgery Modifier (57)

[MelBarclay]

We frequently have a scenario similar to the one below and needing advice to get all visits paid.

09/01/2020 Admit(further workup ordered) CPT: 99222
09/02/2020 Subsequent Visit (Decision for surgery) CPT: 99232
09/03/2020 Surgery CPT: 44140

Modifier 57 would be added to the subsequent visit because that's when the decision for surgery was made BUT then the admit is denied as being included in the procedure. My understanding is if I add it to the initial visit then we can't bill for the subsequent visit when the decision was actually made to operate. Any suggestions???

Thanks in advance!

Melanie

 

[thomas7331]

Your admit shouldn't be denied if it's two days before the surgery - or was the date of surgery above a typo? If so, then yes, per the global surgery policies of CMS and most payers, you are only allowed one preoperative visit for a decision for surgery on the day of or the day before surgery, so you wouldn't be able to bill both an admit and a subsequent visit within that window.

 

[MelBarclay]

Sorry, surgery and subsequent visit on same day. In this scenario I would just code for the initial visit and add modifier 57 even thought the decision for surgery wasn't made until the subsequent visit?