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Thread: Admit and Modifier 57

  1. #1
    Join Date
    Apr 2007

    Default Admit and Modifier 57

    AAPC: Back to School
    Need opinion:

    Patient tranferred from rural hospital to urban hospital, diagnosis obstructive hydrocephalus, Patient in semi-coma state. Surgeon is there waiting for patient, admits upon arrival and does a ventricular drain placement.

    Doc billed the admit (99223)with modifier 57 and the procedure. Insurance denies saying admit is part of global. They pay the procedure.

    Is the admit payable?

    Thanks for the input.

  2. #2
    Join Date
    Apr 2007
    Bangor, Maine


    I agree that the admit is global. If the -57 was to be used, wouldn't it have been for during the visit in the rural hospital since that is where the decision was made to transfer the patient to do the surgery? I only ask, because I am not totally sure either, but is makes more sense, I think, don't you?

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default Would need to see documentation to be sure

    I would need to see the actual documentation to be sure, but in most cases the initial hospital visit WOULD be billable with the -57 modifier.

    The patient may have been seen at another hospital but THIS surgeon hadn't seen the patient to make the final decision to perform surgery until the patient arrived at THIS hospital.

    The reason I say that I would need to see the documentation ,however, is that you state the patient was semi-comatose on arrival. This makes me wonder whether there was sufficient documentation for the 99223.

    If you have adequate documentation, I would appeal citing the "decision for surgery" rules.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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