# Referals to Surgery



## sclontz (Apr 28, 2014)

If a patient has been seen by a family practice physician and that physician refers the patient to a surgeon for an inguinal hernia, cholecystectomy, etc... no workup has been done  by the family practice physician. Can the surgeon bill for the visit before he goes to surgery? 
Thanks for all your knowledge in advance!


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## tcooper@tupelosurgery.com (Apr 29, 2014)

Yes you can bill for the surgeons visit. If it is a Commercial Insurance you can bill a consult code. If patient is a Medicare patient you can bill as a New Patient Code (If patient has not been seen in the last three years by a Physician in your practice). Also, if the patient is having surgery the day of or the next day after office visit you should add a 57 modifier (decision for surgery) to the office visit code. 

Example:  Patient referred to surgeon for a Right Inguinal Hernia. Patient is a Medicare Patient. Patient has never been seen in your practice. Surgeon evaluates patient and make decision for surgery the next day. You would code 99203-57, 49505-RT. 
I hope this helps you. 
Teresa


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## sclontz (Apr 30, 2014)

Teresa,
Thank you for your reply. I am having a hard time finding any written info on this topic and it seems to be a grey area. I have been coding just as you have stated. However, I have been hearing that this would be considered double dipping? Hence, the family practice physician is pd for this visit and the surgeon. 
There are other scenarios, such as the family practice physician does a workup and refers the pt to a surgeon. Can the surgeon bill for an E/M in this situation? This is very similar to an ER physician doing a workup and calling a surgeon in for an appendectomy. If I understand correctly, that is not billable. The article, Report Presurgical H&P With Caution (AAPC, Jan 29,2013) touches on a similar situation.

Any thoughts, comments, or advice on this topic would be greatly appreciated-I really want to be in compliance.
Thanks


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## tcooper@tupelosurgery.com (May 1, 2014)

I have attached three articles that I think might help. 

According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the intraoperative"" portion of the service)" as well as all postoperative care that does not require a return trip to the operating room for a duration of zero 10 or 90 days depending on the procedure. In addition the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made beginning with the day before surgery for major procedures and the day of surgery for minor procedures i.e. procedures with zero- or 10-day global periods.

For example a patient previously scheduled to undergo laparoscopic cholecystectomy (47562 ... cholecystectomy) visits the surgeon the day before surgery for a final exam and to discuss last-minute concerns. In this case the E/M visit is included in the global surgical package for 47562 and you may not report it separately.

On occasion however the decision for surgery which is typically made days or weeks before may be made the day prior to or even the day of the operation. For instance the surgeon is asked to evaluate a patient for acute right-upper quadrant pain and tenderness and upon full evaluation decides the gallbladder must be removed and schedules an immediate laparoscopic cholecystectomy.

In such cases Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM) section 15501.1 instructs carriers to "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure." The modifier must be appended to the E/M service code not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period e.g. an E/M visit five days before surgery.

Therefore in the above example of emergency lap chole the surgeon may report both the surgical procedure and the examination that led to the decision to perform the surgery as long as modifier -57 is appended to the appropriate E/M service code e.g. 99243 (Office consultation for a new or established patient ...). Failure to append modifier -57 to the E/M code will result in the E/M service being bundled into the global surgical package for 47562 leading to a loss in deserved reimbursement. In addition documentation should specifically note that the E/M service resulted in the decision for surgery.
According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the intraoperative"" portion of the service)" as well as all postoperative care that does not require a return trip to the operating room for a duration of zero 10 or 90 days depending on the procedure. In addition the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made beginning with the day before surgery for major procedures and the day of surgery for minor procedures i.e. procedures with zero- or 10-day global periods.

For example a patient previously scheduled to undergo laparoscopic cholecystectomy (47562 ... cholecystectomy) visits the surgeon the day before surgery for a final exam and to discuss last-minute concerns. In this case the E/M visit is included in the global surgical package for 47562 and you may not report it separately.

On occasion however the decision for surgery which is typically made days or weeks before may be made the day prior to or even the day of the operation. For instance the surgeon is asked to evaluate a patient for acute right-upper quadrant pain and tenderness and upon full evaluation decides the gallbladder must be removed and schedules an immediate laparoscopic cholecystectomy.

In such cases Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM) section 15501.1 instructs carriers to "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure." The modifier must be appended to the E/M service code not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period e.g. an E/M visit five days before surgery.

Therefore in the above example of emergency lap chole the surgeon may report both the surgical procedure and the examination that led to the decision to perform the surgery as long as modifier -57 is appended to the appropriate E/M service code e.g. 99243 (Office consultation for a new or established patient ...). Failure to append modifier -57 to the E/M code will result in the E/M service being bundled into the global surgical package for 47562 leading to a loss in deserved reimbursement. In addition documentation should specifically note that the E/M service resulted in the decision for surgery.









Reader Questions: Surgery Consults
- Published on Sat, Jul 01, 2000

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Question: When I am consulted in the hospital about a patient and I recommend surgery the next day, does the consultation fall in the 90-day global period because it was done the day before the surgery?

California Subscriber

Answer: No. Services on the day of a major surgery or on the day before a major surgery that resulted in the initial decision to perform surgery are not included in the global surgery period and may be billed separately, says Tammy Chidester, CPC, billing supervisor with Upshur Medical Management Services, a multi-specialty coding and billing service in Buckannon, W.Va. Whatever appropriate evaluation and management (E/M) code that is used should be appended with modifier -57 (decision for surgery), which indicates that the decision to perform the procedure resulted from this E/M, which therefore should be paid separately. 

The global period does include many services, such as:

 Preoperative visits after the decision for surgery, beginning with the day before the day of major surgery and the day of surgery for minor surgery.

Intraoperative services that are normally a usual and necessary part of a surgical procedure, routine complications, or complications after surgery that do not require a return trip to the operating room.

Postoperative visits related to the surgery.

 Postoperative pain management.

 Miscellaneous services or supplies.

 A history and physical exam would be considered a usual and necessary part of a surgical procedure and would not be coded separately. 

If the patient is not going directly to surgery or having surgery the following day, you may bill whatever level of E/M service you provided.










Reader Question: Decision for Surgery Payable Separately
- Published on Sun, Jul 01, 2001

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Question: One of my physicians attended a seminar in which he was told if he sees a patient in the emergency department (ED), and then performs a procedure (for example, an appendectomy), the E/M is part of the procedures global package and shouldnt be billed. I disagree: He had to do an examination, a history and medical decision-making to decide to perform the procedure. I believe he should bill an E/M with modifier -57, as well as the procedure. Who is correct?


Pennsylvania Subscriber

Answer: You are, says Arlene Morrow, CPC, CMM, a general surgery coding and reimbursement specialist in Tampa, Fla. The global surgery guidelines in the Medicare Carriers Manual, section 4821B, clearly state, the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery is not included in a procedures global surgical package.


Therefore, if the surgeon performed an appendectomy (44950) after evaluating the patient in the ED and determining that surgery was required, the appropriate-level E/M code should be billed with modifier -57 (decision for surgery) appended. 


Note: If a decision is made to perform a procedure with a 0- or 10-day global period, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be used in place of modifier -57.


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## sclontz (May 3, 2014)

Teresa,
Just wanted to say thanks for all the info!


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## OCD_coder (May 3, 2014)

I just wanted to add to the information all ready presented, which was very good.  I have recently audited several surgeons and they failed their audits for deficient information to support that "initial" consult which is definitely reportable.  Even if another provider did all of the workup, the surgeon needs to review that workup to determine what kind of surgery is best for the presenting problem.

The surgeon must have sufficient documentation in the MDM to support reporting this service.  Simply relying on the final diagnosis alone and not documenting their clinical course to get to the decision for surgery is insufficient.  What was found was the surgeon knew the patient was going to surgery from the phone call/referral they received and did not document their reviewing all of the diagnostic work performed to come to that conclusion in their notes as they didn't feel it was important.  It is VERY important to tell the whole picture, not just rotely document the necessary Hx and PE and assume it automatically supports medical necessity for and E&M service.

I am all for surgeons being able to bill for the initial consult prior to surgery, as long as it doesn't appear like a preop visit evaluation.

*Sources:*
Medicare Global Surgery Fact Sheet
CPT Assistant May 2009  "Preop visits are not reportable"


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## wickerfamily@ymail.com (Nov 24, 2015)

*Modifer 57 and 25*

If you charge a visit with 57 or 25 should you have a separate H and P for that visit. And if the patient is scheduled for surgery say 4 days from now and doesn't have a preop visit should you have the H and P on the last visit as well .


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## CodingKing (Nov 24, 2015)

tcooper@tupelosurgery.com said:


> Yes you can bill for the surgeons visit. If it is a Commercial Insurance you can bill a consult code.



I know this comment is from an old thread that someone bumped instead of creating a new now one but i want to comment on this in case anyone else sees this and relies on your answer. The situation in the initial above was a transfer of care not a consultation so it would be a regular old office visit.


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