Wiki Initial consult inclusive to 41520

[karen1123]

Some insurance companies are not reimbursing the initial visit when a subsequent frenuloplasty is performed for newborns when done for issues with poor latching due to ankyloglossia. The child is seen for evaluation and the surgery performed a day or two later in the office. It seems the physician should be reimbursed for the evaluation of a new patient as well as the surgery. Would modifier 57 be appropriate for the intial visit?

 

[JenniferB7]

There are many carriers that will bundle an E/M visit 24 hours and sometimes up to 1 week before a procedure, regardless of whether the visit was initial or established. Medicare bundles all E/M services same day into a procedure with a 0 or 10 day global, even if the patient was new.

From the Medicare Claims Processing Manual, Chapter 12, Section 40.1 (B) - first bullet

The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure.
​

From Medicare Global Surgery Fact Sheet - page 3:

Initial consultation or evaluation of the problem by the surgeon to determine the need for major [90 day global] surgeries. This is billed separately using the modifier -57 (Decision for Surgery). This visit may be billed separately only for major [90 day global] surgical procedures.​

Since most carriers (not all) follow CMS guidelines and CPT 41520 has a 90 day global, it would be appropriate to append modifier 57 to the initial E/M visit.

Hope that helps!