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E/M after decision for surgery

  1. #1
    Default E/M after decision for surgery
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    I have a dilemma, an Ortho Doc did an inpatient consult and wants to bill 99253-57 DOS 1-11, (not a problem), then he saw the patient for subsequent hospital visit 99232 on 1-13 and wants to add another 57 to this. Then did the surgery on 1-15. I don't feel he can charge the subsequent visit, with or without the modifier. He tells me he can. Would like opinions and sources for documentation please. Everything I have found indicates that once the decision for surgery is made, then everything after that is inclusive to the surgery. Anyone? Please?

  2. #2
    Default
    My initial response to this was no, when one of our orthos did this. We did some research and it turns out that they can charge for 1 subsequent care day before surgery after the decision for surgery is made. I've been looking for the back up on this and can't find it.

    It still doesn't seem right to me, but this was just researched a few weeks ago so it is fairly fresh in my mind. If I run across the supporting documentation I will post it.

    Sorry I couldn't be of more help,

    Laura, CPC

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default NO
    I do not believe that there is any charge for the subsequent visit once the decision for surgery is made.

    IF on his first encounter he needed some additional information before making a decision and scheduling, THEN he could code the second visit and use the -57 modifier on that second visit.

    But if the surgeon truly made the decision for surgery and scheduled the procedure as a result of the first visit, then, no additional visits are codeable unless they are for a totally different problem.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Default
    Would one or both E&M still require modifier -57 if the surgery wasn't done until the 15th? This modifier should be used on services the day or the day before a major 90-day global period procedure, no? Please clarify...

  5. #5
    Location
    Duluth, Minnesota
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    1,133
    Default
    well, correct me if I'm wrong - (and I'm not an inpatient coder) BUT - why would you even need the .57 modifier on either visit? Seems to me both dates of service:
    initial 01/11/09
    subsequent 01/13/09

    are 4 and 2 days (respectively) BEFORE the actual surgery date: 01/15/09 - so why would there even be a "global" issue?

    like I said, I'm not an inpatient coder (just learning)...but is there a difference in the global package between inpatient and outpatient?
    if not, then neither visit falls within any global, and doesn't really require any modifier to it. (just the day of (minor) and/or day before (major) surgery would need the modifier)
    Donna, CPC, CPC-H

  6. #6
    Default decision for surgery
    Thanks guys for your response. It's pretty much as I thought also, once that decision for surgery is made. But, I'm also looking into not using the 57 modifier at all since they are more than one day out. As I was reviewing this yesterday (again!!!) it dawned on me that if we remove the 57, then the problem isn't a problem any longer. I appreciate all the feed back. That's what makes this site so great. You get a variety of opinions and then can make an informed decision after research.

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default 57 modifier day before
    I wasn't really focusing ... but you are right. The guidelines say you don't need the -57 modifier unless it's for an E/M the day of or day immediately preceding surgery, at which the decision for surgery was made.

    However ... in practice ... I see carriers lump everything that happens in one hospital stay together even if the visits were 3 or 4 days out from surgery day, and call the visits global.

    F Tessa Bartels, CPC, CEMC

  8. #8
    Default after decisiion for surgery
    Quote Originally Posted by FTessaBartels View Post
    I wasn't really focusing ... but you are right. The guidelines say you don't need the -57 modifier unless it's for an E/M the day of or day immediately preceding surgery, at which the decision for surgery was made.

    However ... in practice ... I see carriers lump everything that happens in one hospital stay together even if the visits were 3 or 4 days out from surgery day, and call the visits global.

    F Tessa Bartels, CPC, CEMC
    I was afraid of that! This is a mess. I don't know what I will do with this one yet. Will still consider consequences. Thanks for your feed back.

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