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initial inpatient with surgery

  1. #1
    Default initial inpatient with surgery
    Medical Coding Books
    Hi all,

    Can someone tell me, can a physician code a initial inpatient with a modifier 57 and do a surgery on the same day or is the initial included with the surgery? Patient was admited through the ER.

  2. #2
    North Carolina
    If it was for the decision of surgery...yes you can bill.

    Modifier 57: Decision for Surgery
    An E/M examination coded with modifier 57 indicates a visit that resulted in the initial decision to perform a major surgery. It is used the day before or the day of major surgery. Surgeries that have a 90-day follow-up period are considered major surgeries. When coding modifier 57, ensure that the patient's records clearly indicate when the initial decision to perform the surgery was made. Do not use modifier 57 with an E/M service performed on the same day as minor surgery.

    Page 8
    Rebecca CPC, CPMA, CEMC

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