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Thread: Fx Billed with New Patient visit?

  1. #11
    Join Date
    Apr 2007


    AAPC: Back to School
    This is from Margie Vaught and her take as well as additional documentation that supports E/M with fracture care:

    This Makes me go crazy... and when people tell you this please ask them to provide an official source, below I have supplied all three. Why when there is a fracture diagnosed that all of the sudden we are being told that there are now different rules? So if the patient comes in with check pain and they are diagnosed with a blockage and they are going to place a stent, then can't report the E/M because it was 'known' that they had a blockage? If a patient presents with ruptured appendix and they take to surgery, you can't bill an E/M because it was known what they had? Can you see where this does not make sense? Closed treatment without manipulation under the Table of Risk falls under a Moderate complexity - why are we letting people devalue this service????

    CPT, CMS and AAOS all state that you can bill IF you can support- if you can't support then you can't report that is common sense. There must be documentation to support an E/M service, and then modifier 57 is added per CPT and CMS.
    CPT - check out May 1997 CPT assistant on the use of modifier 57; also check out Surgical Package where it states that you can report the initial decision for the surgery. I even paid the AMA to get an official opinion because I was getting so tired of defending this.
    Orthopedic Coder's Pink Sheet, April 2008, Vol. 9, No. 4

    "Separately, the American Medical Association (AMA) confirmed that if the E/M service is supported (i.e., it meets the required key components/counseling), it could be reported.

    The following example was supplied to both AAOS and CPT/AMA: "Patient presents to office with nondisplaced Colles fracture. Provider does an expanded-focus history and examination, and determines it needs closed treatment without manipulation and a cast is applied."

    Both AMA and AAOS confirmed it would be appropriate in this case for the provider to report 99202-57 or 99213-57 along with 25600, since the initial decision was made during the visit to provide a global service."

    In addition, AAOS reminds physicians of what is included in the global package:

    "Under the global service concept, approximately 10% of a physician's reimbursement for a CPT musculoskeletal procedural service is for the preoperative evaluation and management service(s) performed the day of or day before the procedure, approximately 69% covers the procedural service and the remaining 21% covers the postoperative care, usually 90 days for a "major" procedure."
    E/M code gets the 57 modifier: For the most part, the fracture treatment codes have 90-day global periods attached to them, regardless of whether it's an open or closed treatment, with or without manipulation. For Medicare, that means you'll need to attach a 57 modifier to the E/M code to get it paid, since these are considered ‘major surgery' codes.
    The AMA CPT panel confirms that you should attach the 57: "An E/M service that resulted in the initial decision to perform a surgery may be identified by adding modifier 57, decision for surgery, to the appropriate level of E/M service. Depending on payer guidelines, and the payment policy for global surgery, modifier 57 may or may not affect payment." (CPT Assistant, Dec. 2004).

    On the private payer side, if the insurance company recognizes the 57 modifier, it will generally allow separate pay for the E/M service where the initial decision for surgery was made. Pre-operative visits subsequent to that initial decision are generally included in the global surgery package. But be aware that payer policies vary for this modifier.

    CMS confirms that for Medicare the E/M service where the decision for major surgery is made is always separately billable, too. In its Claims Processing Manual (100-04, Chapter 12, Section 40) CMS states that the following is not included in the global surgery package and is not separately billable: "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."

    AMA on E/M with fracture care and use of modifier 57

    The following clinical example, from the February 1996 CPT Assistant, illustrates the correct billing of an E/M code with fracture care:

    "Patient C presents to the emergency department after falling and fracturing his tibia. The emergency department physician calls an orthopaedic surgeon for a consultation. The orthopaedic physician evaluates the patient and performs a closed reduction of the tibia and applies a long leg cast.

    "In coding this example, it is important to consider that the orthopaedic physician provided a restorative treatment and is responsible for subsequent fracture care, under the surgical package. Therefore, he/she reports the E/M consultation code, provided that the key components have been met, and code 27752 for the closed reduction of the tibia. The cast application cannot be reported separately because the services described in code 27752 includes the first cast."

    Also, here is the AMA position on use of modifier 57 (Decision for surgery), from the May 1997 CPT Assistant:

    Modifier -57, Decision for Surgery

    "An evaluation and management service that resulted in the initial decision to perform the surgery, may be identified by adding the modifier ‘-57' to the appropriate level of E/M service. Modifier -57 provides a means of identifying the E/M service that results in the initial decision to perform the surgery."

    Illustration of Modifier -57

    "A physician is consulted to determine if surgery is necessary for a patient with abdominal pain. The physician services meet the criteria necessary to report a consultation (ie, documents findings, communicates with the requesting physician). The requesting physician agrees with the consultant's findings and requests that the consultant take over the case and discuss his findings with the patient."


    To download Chap. 12 of the Medicare Claims Processing Manual, visit: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf"

    CMS - Check out Claims Processing 100-04 Chapter 12 Sections 30 and 40. There are also local bulletins that make reference.

    AAOS Orthopedic Coding Guide 2008 states on page 47 and 48:
    "Surgical EVALUATION/consultation of a patient, regardless of when it occurs, even if it is on the same day as the surgery, is to be considered a separate encounter as long as the decision to perform the procedure as made in that EVALUATION/consultation....(they go on and talk about the 10% of the global surgical package that is for 'preop' for like planned procedures and then it states)
    However, if a patient is seen for the first time or an established patient is seen for a new problem and the 'decision for surgery' is made the day of the procedure or the day before the procedure is performed then the surgeon can report both the procedure code and an E/M code, using modifier 57 or 25 modifier (payor specific) on the E&M code. The E/M service must meet the documentation guidelines for the level of service reported.
    This is true whether a surgical procedure is performed in the OR or the patient undergoes a 'closed treatment' with or without manipulation in a nonfacility setting (eg. office or ED)."

    "FRACTURE global fees may include the hospital/office encounter in some payment areas. In others, HCFA [CMS] allows you to code an E&M service with a —57 modifier within the global period if the VISIT was the one in which the decision to perform the procedure was made…. The initial cast is applied, and all reVISITs, excluding radiographs that are obtained by the physician, should be included within a 90-day period from the time of the initial FRACTURE. All recastings are on an ‘encounter’ basis and are billed separately."

    Margie Scalley Vaught, CPC, CPC-H, CCS-P, MCS-P, ACS-EM, ACS-OR
    Healthcare Consultant
    Coding Content Specialist for DecisionHealth
    cell 360-880-8304
    fax 413-674-7668
    for workshops and audio http://www.margievaught.com/calendar/index.cfm

    Color emphasis added by me to point out highlights
    Mary, CPC, CANPC, COSC

  2. #12
    Join Date
    Apr 2007


    Yes it is our responsibilty to make sure the documentation supports the charge. When it doesn't you change the charge and educate the provider.

    It is one thing to ask was it right or left or to clarify something in an op report or note. It is completely different to say this doesn't support a level 99203 fix your note so it does.

    Laura, CPC, CEMC

  3. #13
    Join Date
    Apr 2007


    I make the docs responsible for changing their charge, I WILL NOT CHANGE ANYTHING..that is their responsibility....I educate them by making sure that they make sure that their documentation supports what they are charging. I'm not saying that they change every single office note. I did state that on RARE occasion IF i find something, I do take it back to them to either 1) change their code or 2) support the code w/documentation.

    Bottom line to the original poster is:

    YES..you can change for an E/M visit with fracture care according to CMS, AAOS and CPT as posted above.
    Last edited by mbort; 08-19-2009 at 11:51 AM. Reason: typo
    Mary, CPC, CANPC, COSC

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