# Pain Management - proper modifier



## frankmmedbiller (Jan 26, 2011)

I am trying to bill for an inpatient initial visit 99221 from a pain management doctor post operative to manage pain I billed 99221 with mod 55 (post operative management) it was denied saying to rebill with the proper modifier.

Thanks for taking the time to read my question and for any help


----------



## dav4code (Jan 26, 2011)

After the inpatient consolation codes (99251-99255) became obsolete with Medicare, these codes (Initial and subsequent) were to be utilized when billing Medicare. 

My understanding is the Attending would utilize the 99221 on the same day of admission (with a pertinent modifier to indicate they are attending) and then consultations for this patient by other physicians would utilize 99231 for subsequent hospital care.  My intuition tells me the pain doc isn't the attending in this case. The modifier 55 seem odd.  More information would help to be sure the pain do wasn't doing daily hospital management for and epidural catheter (01996). In the case we were paid for in 2k10, 99231 paid the E/M visit for a medicare inpatient seen by our pain doc.


----------



## dwaldman (Jan 26, 2011)

The surgeon who performed the procedure is not asking the anesthesiologist to resume the total post op care. Just provide post op pain management initially following the surgery before the patient is discharged. If the Anesthesiologist met the documentation criteria of HPI detailed. Exam Detailed (extended 2-7 organ systems) (2 bullets from 6 areas/systems or 12 bullets from 2or more area/systems) MDM Low, then 99221 could be reported. This would differ from the attending claim (AI modifier for the attending). Here is another explanation if the documentation does not meet--Det, Det, Low

When the initial hospital care that you used to bill to Medicare using a consultation code does not add up to the lowest-level inpatient care code, what do you do? This has been the million dollar question since the first day of this year when Medicare stopped accepting consultation codes. <br />
CMS offers a solution for when your neurosurgeon's initial hospital care does not meet the requirements of 99221. <br />
Payers should overlook initial/subsequent mismatch <br />
According to CMS, even when the provider documents an initial visit, Medicare contractors should not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately shows that the work and medical record rightly demonstrate that the work and medical necessity requirements are met for reporting a subsequent hospital care code. <br />




Modifier Description 54
 Surgical care only: when 1 physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.

Modifier Description 55
Postoperative management only: when 1 physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.     

ModifierDescription 56

Preoperative management only: when 1 physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.


----------



## mitchellde (Jan 26, 2011)

frankmmedbiller said:


> I am trying to bill for an inpatient initial visit 99221 from a pain management doctor post operative to manage pain I billed 99221 with mod 55 (post operative management) it was denied saying to rebill with the proper modifier.
> 
> Thanks for taking the time to read my question and for any help


modifier 55 cannot be appended to an E&M code it is for procedure codes only.  If the surgeon is passing postoperative care to your physician then you would bill using the surgical code used by the surgeon with the 55 modifier.  However the surgeon's reimbursement will be reduced by the amount you are paid.  If you are not doing all the post operative care then you append the 55 followed by the 52.  You must have a notation in the medical record that shows that the surgeon transferred care of the patient to you either all or part.


----------



## amecey (May 28, 2013)

*01996 & 99231-99233*

What about billing the 01996 and a subsequent hospital care code (99231-99233) on the same day? I cannot seem to find anything that speaks directly about these two codes being billed together. What I found is that you should not bill both of them on the same day but I was just looking for a black and white yes or no answer, if anyone has information regarding this issue I would be so appreciative to hear your thoughts.

Thank You,

AM


----------



## dwaldman (May 29, 2013)

" Management of epidural or subarachnoid drug administration (CPT code 01996) is separately payable on dates of service subsequent to surgery but not on the date of surgery.  If the only service provided is management of epidural/subarachnoid drug administration, then an evaluation and management service should not be reported in addition to CPT code 01996.  Payment for management of epidural/subarachnoid drug administration is limited to one unit of service per postoperative day regardless of the number of visits necessary to manage the catheter per postoperative day (CPT definition).  While an anesthesiologist or non-medically directed CRNA may be able to report this service, only one payment will be made per day."

Above is from the NCCI Policy manual, I have never thought about 01996 and 9923X on the same date of service. Above they do mention in a way that it seems they are recognizing that other evaluation and management service but I would being looking that it  has a documented CC HPI EXAM DX PLAN. Subsequent hospital visit that are typically handwritten in charts sometimes lack the key elements of E/M service. But if the epidural catheter management was not done, can the note stand alone as separately identifiable service that goes above and beyond the pre and post work of 01996. In my personal view point it would have be dictated or typed and the physician would have to understand documentation requirements of 99231-99233 and the service that was provided that was separate would have be easily identifiable.


----------

