Wiki E/M AND 57 MODF

[Yamy0908@yahoo.com]

Good morning i have a question please.

i have vascular doctor who on his e/m stated pt will be having major surgery, 2 weeks later pt had the surgery however hes also billing e/m w/57 modf on the date of the major surgery. My question is may i bill an E/M also on the date of the procedure since it was performed 2 weeks or a week later. I have done it before and it's been paid however it was brought to my attention that i might be wrong. PLZ CLARIFY...

THANK YOU

 

[jkyles]

Hi there, start with Appendix A of your CPT manual to review the full descriptor of the modifier (emphasis added):

Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

If the doctor made the decision to perform surgery at an earlier visit then reporting an E/M visit modifier 57 on the day of the surgery doesn't make sense.

It's not unusual for Medicare and payers to pay claims in error, but unfortunately practices still have to return the improper payments.

 

[Yamy0908@yahoo.com]

Hi there, start with Appendix A of your CPT manual to review the full descriptor of the modifier (emphasis added):



If the doctor made the decision to perform surgery at an earlier visit then reporting an E/M visit modifier 57 on the day of the surgery doesn't make sense.

It's not unusual for Medicare and payers to pay claims in error, but unfortunately practices still have to return the improper payments.

thank you so much!!!

 

[Nreed]

Good morning i have a question please.

i have vascular doctor who on his e/m stated pt will be having major surgery, 2 weeks later pt had the surgery however hes also billing e/m w/57 modf on the date of the major surgery. My question is may i bill an E/M also on the date of the procedure since it was performed 2 weeks or a week later. I have done it before and it's been paid however it was brought to my attention that i might be wrong. PLZ CLARIFY...

THANK YOU

For Medicare and all insurance companies that follow Medicare guidelines, you might want to review Chapter 1 of the NCCI Manual on the CMS website. Here is the link to that page for you: https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf

On pages I-13 and I-14 it states: Medicare Global Surgery Rules define the rules for reporting Evaluation and Management services with procedures covered by these rules. It then goes on to say: If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M service is performed on the same date of services as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure the E&M service is separately reportable with modifier 57.
---In your situation, it sounds like the provider might have already billed the E&M visit 2 weeks earlier when the decision was made that day to perform a major surgical procedure, so billing it again on the day of surgery would not be correct because the decision had already been made. Payment for the E&M on the day of the procedure would already be included in the payment for the major surgical procedure.

 

[Yamy0908@yahoo.com]

For Medicare and all insurance companies that follow Medicare guidelines, you might want to review Chapter 1 of the NCCI Manual on the CMS website. Here is the link to that page for you: https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf

On pages I-13 and I-14 it states: Medicare Global Surgery Rules define the rules for reporting Evaluation and Management services with procedures covered by these rules. It then goes on to say: If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M service is performed on the same date of services as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure the E&M service is separately reportable with modifier 57.
---In your situation, it sounds like the provider might have already billed the E&M visit 2 weeks earlier when the decision was made that day to perform a major surgical procedure, so billing it again on the day of surgery would not be correct because the decision had already been made. Payment for the E&M on the day of the procedure would already be included in the payment for the major surgical procedure.

thank you so much