Wiki Modifier 57 for Renal Transplant H&P

[sarahpoe]

I have transplant surgeons who insist on billing for the H&P for a renal transplant with CPTs 99221-99223 with modifier -57 to indicate a decision for surgery. I have advised them that the H&P is bundled into the major surgery global package, and it should not be separately billed. The patient's have already been evaluated for the renal transplant on a previous day of service in the office setting (billed w/ outpatient E/M) where the decision to move forward with the transplant has initially been made. The surgeon's argument is that they have to reevaluate the patient on the day of the transplant to ensure the patient is healthy enough to undergo this major surgery; therefore they are making the decision to perform major surgery. To me this is standard of care and is also hospital policy to perform the H&P for all surgeries. I am worried that the H&P is inappropriately being unbundled from the global package. CMS does allow the surgeon to bill subsequent hospital visits within the global for immunosuppression therapy using modifier -24, but I cannot find any caveat re: the H&P with modifier -57. Our local Medicare carrier does not provide any specific guidance for this. Has anyone experienced this scenario before? Any information is much appreciated.

 

[thomas7331]

I agree with you, this is not a separate decision for surgery if the patient has already been evaluated and approved for the procedure.

The CMS regulations are very clear about this - for major procedures, a pre-operative visit after the decision has already been made is part of the global package:

"The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery...
• Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures"

You can find the source for this in the Medicare Claims Processing Manual, Chapter 12, Section 40.1 here:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

I believe that billing a second E&M service for another decision for surgery would be difficult to support unless perhaps there was a new problem or major change in the patient's condition that required the physician to re-evaluate the patient and significantly change their plans.

 

[CodingKing]

Decision was made the day before "reevaluate the patient on the day of the transplant to ensure the patient is healthy enough to undergo this major surgery" is just standard pre-op. Its done with every surgery so automatically included in the fee for the surgery. It would only separately reportable if they have to cancel the surgery based on the H&P.

 

[sarahpoe]

Thank you both for your input. The next argument from the surgeons is that the initial evaluation and decision for surgery may have taken place 6 months to a year prior to the date of surgery due to patients being placed on a waiting list for the transplant organ. Therefore it is medically necessary to preform a new evaluation and decision for surgery to ensure the patients health has not significantly changed since the last evaluation. They feel this evaluation for transplants warrants additional reimbursement due to the amount of work that goes into these particular H&Ps. I have never seen a time frame that would allow for the H&P to be unbundled from the surgical package.

 

[thomas7331]

This is a familiar argument - just a couple of thoughts from my perspective:

The medical necessity of the new E&M is not in question, it's just that the reimbursement for that E&M service is included in the package and not paid separately under CMS rules.

The 'decision for surgery', as I understand it, is the evaluation of the patient's presenting problem, with a resulting decision that the surgery is the most appropriate treatment for that problem. Once that decision is made, ensuring on the day of or the day before surgery that the patient is healthy enough to have the surgery is a routine preoperative service done as part of all procedures, and not a new decision for surgery. I think for a transplant, where arrangements and plans have to be made well in advance, it would be hard to argue that the provider is just making this decision on the last day.

Additionally, I'd just make a reminder that physicians' feelings about whether or not they are adequately compensated for the work performed is an issue that should be kept separate from coding discussions. Easier said than done, I know, but compensation should be between the physicians and their employers, not their coders!

Lastly, if all of the above doesn't resolve it, a good solution would be to sample some notes and get an outside auditor's opinion. It's hard to argue in the abstract, but if an independent auditor with experience in thinks the modifier is supported in the documentation, that will often put both coders and providers at ease with the decision you ultimately make on this.