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Medicare Denial: Visit w/ -57 Modifier

  1. Question Medicare Denial: Visit w/ -57 Modifier
    Medical Coding Books
    We have submitted a rare office visit done on the same date as the doctor performed the patient's colonoscopy. I used modifier -57 on the office visit. Palmetto/Medicare has denied the visit as "Global" to procedure. Is anyone else receiving denials like this?

  2. #2
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    I thought that Medicare wouldn't pay for a visit prior to a colonoscopy unless the patient is having a particular problem. Was the colonoscopy scheduled or was it truely the result of an office visit? If it was an emergent colonoscopy scheduled after the visit, then maybe you could try to appeal the decision.

  3. #3
    Default debrooth - Medicare Denial: Visit w/ -57 Modifier
    Most of the Medicare's do not recognize modifier 57 on a 0 day global procedure. Most colonoscopies do not have a global period. A few questions...
    What E&M code did you use?
    If you used a consult code, Medicare will not pay it.
    If you used a new patient code, and it is a new patient, add a modifier 25 and resubmit.
    If you used an established patient code:
    Was it a new or worsening problem that required evaluation beyond what is normally required prior to performing a colonoscopy?
    If so, is there documentation to help support the medical necessity of the service? If so, does it support adding an additional diagnosis code symptom or condition? If so add a modifier 25 and resubmit. A different diagnosis is not required, but if it is documented it is appropriate to add it.
    In any of the scenarios, make sure that whatever you do, the documentation will support it. Then fight for all your worth!
    Mickie Kummer, CPC, CPMA, CRC, CPC-I, AAPC Fellow

  4. #4
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    Quote Originally Posted by debrooth View Post
    We have submitted a rare office visit done on the same date as the doctor performed the patient's colonoscopy. I used modifier -57 on the office visit. Palmetto/Medicare has denied the visit as "Global" to procedure. Is anyone else receiving denials like this?
    If the E/M is appropriate, you need mod -25 (not -57). Mod -25 applies to 0-10 day global periods (colonoscopies have a zero global); -57 for 90 day globals. However, if this was just a screening colonoscopy you should not code an E/M prior to the scope.
    Lisa Bledsoe, CPC, CPMA

  5. Default
    The patient was quite ill and did need an urgent colo. Turned out there was an opening that day, so the doctor plugged the patient into the slot. Our docs don't perform same-day colos as they truly prefer the patients get cleaned out first with a bowel prep. This was an exception due to the patient's symptoms.
    We initially billed 99214 with modifier -25. It was denied. Next, we applied -57, and they have denied that too.
    I guess it's time to appeal like crazy!

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