If a Medicare patient is seen in the emergency department and then surgery is performed later that day or night, can the emergency department consult be billed with a modifier -57 along with the surgery? We have been under the impression that, at least in the office, the visit to decide to do the surgery is included in the surgical fee.
Are we correct and does this apply to the encounter in the emergency department too?
So, a patient is seen in the emergency department. An E/M service is performed and one of the following E/M codes is billed based upon a medically appropriate history and/or examination and the appropriate level of medical decision making:
• CPT 99282 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making
• CPT 99283 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making
• CPT 99284 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making
• CPT 99285 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making
The decision is made to perform surgery later that day or that night. The assumption is that the surgery that is going to be performed is a Major surgical procedure, that is one that has a postoperative global period of 90 days. If that is the case, in order to bill the E/M service in addition to the CPT/procedure code, the E/M service will need to be appended by the 57 modifier. The 57 modifier is defined as the following: DECISION FOR SURGERY
The 57 modifier is appended to an E/M service when the E/M service is used in conjunction with a Major surgical procedure code (90 day postoperative global period) for the appropriate reasons:
1. The preoperative visit on the same day or one day prior to the day of surgery is included in the surgery fee.
2. An initial (visit) E/M service may be billed using the -57 Modifier on the E/M code.
3. You may bill a separately identifiable procedure on the same day by using the -57 Modifier on the E/M code.
4. For a major surgery, you may use the -57 Modifier to bill for the service to decide to perform the surgery if it occurs the day before or day of major surgery. If the decision to perform surgery is made at the time of a consultation, you may bill the E/M code with the -57 Modifier.
All of the above applies whether the E/M service was performed in the office or outpatient setting, in the emergency department, or for that matter wherever the E/M service was performed.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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