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E/M visits for surgery in ED

  1. #1
    Question E/M visits for surgery in ED
    Exam Training Packages
    Hi -

    I have a question…patient went to see his/her PCP about a broken arm and they spoke with an Ortho doctor that would be meeting patient at the Hospital for surgery. Patient was told to go to the ER. Patient arrives at the ER and in the triage the PA evaluated the patient before surgery. (Side note: Patient thought that she was just getting sent straight into surgery). Ok so patient was charged for the PCP E/M visit, an E/R E/M visit from the PA , and the Facility charge for E/M visit in the ER, and the Ortho surgeon for the procedure done. Patient is disputing claims and saying that she wasn't treated in the ER that day so she shouldn't get any "E/M" charges from the PA or the facility.


    Ok so here comes my questions:
    Is the billing for this DOS correct (aside from patient being confused of where she was)?
    Shouldn't the E/M in the ER be the E/M visit that patient ultimately decides for surgery so modifier 57 should be appended?
    If patient decided had surgery after being seen in the E/R, shouldn't the facility charges only be for the operating room and not the E/M visit?

    Any help advice would be great! Thanks in advance!


    Pa Tang Vang, RHIT

  2. Default Intersting Scenario
    Physicians meeting patients in an ER often leads to this type of billing confusion. An argument can be made that all four services are billible. Getting them paid is another story. Often if a PMD meets a patient in the ED prior to surgery, The ED physicians will not bill for the service. So an argument can be made the the professional component of the ED service by the PA shouldn't be billed. But if the PA did a work up and it is documented properly that could be billible. You say the PA only did triage. Usually that is done by a nurse and not billible as professional component. Are you certain the PA didn't do a low level E&M? As to the facility side, that is clearly billible since regarless of who was meeting the patient, facility time and resources were used.
    So I'd say the bill for the PA might be questioned if all he/she did was triage, or if the Ed practice has a policy of not billing when a PMD meets a patient at the ED.

    Jim

  3. #3
    Wink
    Quote Originally Posted by jimbo1231 View Post
    Physicians meeting patients in an ER often leads to this type of billing confusion. An argument can be made that all four services are billible. Getting them paid is another story. Often if a PMD meets a patient in the ED prior to surgery, The ED physicians will not bill for the service. So an argument can be made the the professional component of the ED service by the PA shouldn't be billed. But if the PA did a work up and it is documented properly that could be billible. You say the PA only did triage. Usually that is done by a nurse and not billible as professional component. Are you certain the PA didn't do a low level E&M? As to the facility side, that is clearly billible since regarless of who was meeting the patient, facility time and resources were used.
    So I'd say the bill for the PA might be questioned if all he/she did was triage, or if the Ed practice has a policy of not billing when a PMD meets a patient at the ED.

    Jim
    Thanks Jim for replying! What you said really made sense.
    The triage portion of my question was my mistake...the evaluation of the patient was not done by a nurse but by a PA. He documented that the patient was sent there by the PCP to meet with the Ortho surgeon, however, he stopped in to briefly check on the patient to assure that the patient was stable while waiting for the Ortho surgeon, so yes, you are correct he did do an E/M service but it was at level 4. And also what you said about Facility billing also helped me alot. I never did any billing/coding for the facility so I guess you can say I'm most weakest when it comes to Facility billing/question.
    Thanks so much for making it clearer for me.

  4. #4
    Talking Oops one more question! =)
    Oh and one more question I forgot to ask...which E/M would the modifier 57 be appropriate for? The PCP's E/M service or the PA's E/M service? I'm thinking the PA since there was documentation in the PA's notes (I don't actually have the notes from the PCP's office to compare) where it shows that the procedure was discussesd with the patient who agreed to the surgery.
    Thanks!
    Last edited by pvang; 12-02-2010 at 03:22 PM.

  5. #5
    Default Nvm!
    Never mind! I got my question answered somewhere else.! Modifier 57 would not be needed on neither of these E/M services since these providers didn't perform the surgery. =P

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default 57 modifier
    Actually, if the PA is employed by the Orthopaedic practice, the E/M service by the PA is probably considered the "decision for surgery," and will require a -57 modifier to get paid.

    The PCP, I am assuming, is in a different practice .... or, certainly, of a different specialty, so there is no need for any modifier for the PCP's evaluation.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Wink Thanks!
    Hi FTessaBartels,

    Thanks so much for your feedback! I don't believe the PA was apart of the Orthopaedic office since he was in ER, but hey I could be wrong too. But because of how the information was documented and how it flowed, I didn't think he was. But it's good to know that if the PA was from the same office that his E/M would need the modifier 57. I did not know that and now I do. Thanks again!

    Pvang

  8. #8
    Location
    Milwaukee WI
    Posts
    4,466
    Default 57 modifier
    The 57 modifier is used ONLY for the provider who performs the procedure with a global period. If the PA (or another provider from the same practice/specialty as the PA) did NOT also provide fracture care, then no modifier is required on the E/M.

    From your initial posting (and from my experience with our pediatric orthopaedic specialists), I assumed that the PA was part of the orthopaedic surgeon's specialty practice. IF that is true, then you need a -57 modifier.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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