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Thread: Fracture Care with E/M

  1. #11
    Join Date
    Apr 2007
    Kokomo, IN


    AAPC: Back to School
    I'm wondering if we're not getting hung up on terminology. To me it's procedure vs surgery when using a 57 modifier. My understanding was that it was used for any procedure or surgery with a 90 day global period. I believe most if not all the fracture (procedure) codes are 90 day global so you would append the 57 modifier to the E/M if performed at the same time/day before fracture care. I have seen the 57 described both ways so, I think it's just a matter of how you are using it. Good discussion!
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

  2. #12
    Join Date
    Apr 2007
    Long Island/New York


    Quote Originally Posted by khalid View Post
    hi can u share the Ortho-decision.com link.


  3. #13

    Thumbs up

    Here is an article that will clear things up for people...
    It tells all about what modifier and when it's ok to bill E/M with fracture care.

    Subject AAOS revises coding manual to OK E/M with fracture care
    Source Coder Pink Sheets: Orthopedic
    Publication Orthopedic Coder's Pink Sheet, April 2008, Vol. 9, No. 4
    Effective Date Apr 1, 2008
    Publish Date Apr 1, 2008

    The American Academy of Orthopaedic Surgeons (AAOS) has made it official: You can appropriately bill separately for an E/M visit the same day as a fracture care procedure, as long as that visit is documented to be when the decision for surgery took place.

    The academy confirmed this by adding the following language to the AAOS CPT Coding for Orthopaedic Surgery 2008 manual:"..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 a 57 modifier 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."

    In addition, the AAOS manual now states that the E/M service is separately reportable "whether a surgical procedure is performed in the operating room or the patient undergoes a ‘closed treatment' with or without manipulation in a non-facility setting (e.g. office or emergency department)."

    Separately, the American Medical Association confirmed that if the E/M service is supported (ie, 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 that 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.

    You'll want to remind your physicians to make sure to fully document the E/M visit, in order to support billing the E/M code.

    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

    The information contained herein was current as of the publication date. © Copyright DecisionHealth, all rights reserved. Electronic or print redistribution without prior written permission of DecisionHealth is strictly prohibited by federal copyright law.

  4. #14
    Join Date
    Apr 2007

    Default Shoulder xray

    does an E/M apply if a shoulder xray was done during an office visit? patient was seen for her shoulder pain ONLY.

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