# Struggling with Inpatient Visits E/M



## BABS37 (Mar 27, 2014)

Hi. I am needing some help on a Medicare denial. Can anyone help?

02/03/14 inpatient consult- abdominal pain- CPT 99231 (Medicare denied due to bundled- they want a modifier- the only one I can think to bill would be with 25 or 57, however the 57 wasn't the initial decision for surgery- HELP)

02/04/14 inpatient consult- CPT 99232- initially 25 but then reverted to 57 (still denied as Medicare wants a different modifier- I have no clue)
02/04/14 2nd consult- takes patient to surgery- CPT 45378
02/04/14 after 45378 was done- goes to emergency surgery- CPT 44320

02/05/14 inpatient consult- CPT 99232 Medicare denied wanting a modifier as it is also bundled- 25? Again, no clue

Can anyone help me with the modifiers that Medicare would possibly want with this scenario?? 

Thank you so much!


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## OCD_coder (Mar 27, 2014)

First, you can only have one consultation per admission per provider.  Your posting is a little confusing as you mention a 2nd consult, but you are not billing a 2nd E&M on the same DOS, which is really a continuation of the consult if performed by the same provider.  

The initial consultation/evaluation is allowed prior to a decision to perform a major surgery (44320), so you will need a modifier 57 and a modifier 25 when a minor procedure is performed on the same day (45378).  

The modifier 57 does not trump and cover for the need of a modifier 25.


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## MnTwins29 (Mar 28, 2014)

Also, the E/M on 2/5 would be considered post-op care after a major procedure and is not payable unless it is for a different condition.  If that is the case, you would need modifier -24 attached.


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## BABS37 (Mar 28, 2014)

OCD: I tried to put it together a little bit more so it makes sense: 
First, you can only have one consultation per admission per provider. Your posting is a little confusing as you mention a 2nd consult, but you are not billing a 2nd E&M on the same DOS, which is really a continuation of the consult if performed by the same provider. On 02/04/14- my surgeon saw the patient again resulting in another billable subsequent visit which is why I billed 99232 and I would have used the 25 modifier initially as my physician decided to take the patient down for a colonoscopy- hence billing 99232-25 and 45378. However it happened, my physician consulted the patient with a second visit that same day following labs that came back suspicious. I know only one visit per day can be billed so that?s why I didn?t bill for two. My surgeon decided to take the patient to surgery for a diagnostic laparoscopy to see if he could find anything. As a result, he ended up performing a colostomy which is a 90 day global procedure, hence making the 99232-25 that was done earlier in the day being switched to 99232-57. 
The initial consultation/evaluation is allowed prior to a decision to perform a major surgery (44320), so you will need a modifier 57 and a modifier 25 when a minor procedure is performed on the same day (45378). 02/03/04 wasn?t the initial admitting date of service and my surgeon took over services for the admitting physician starting on 02/03/14. His first consult with the patient in regards to any type of surgery was 02/03/14- which is considered a subsequent visit and so 99231 would be appropriate. The insurance wants a modifier for that visit. The only modifier I could think that the insurance would want is 57 to kick it out of global billing for the 90 day global surgery performed- 44320. The reason why I don?t think that is appropriate is because the surgeon did not decide the need for surgery until 02/04/14. So are you saying I should not bill out for any subsequent visit on 02/04/14 and put a 57 on 02/03/14 bc it doesn?t sound like insurance is going to pay for a subsequent visit each day? Or are you saying to put modifier 25-57 on the subsequent visit for 02/03/14 to kick it out of both the major and minor surgery? Kind of like the 24-25 modifier rule unrelated same day procedure?
MnTwins29: I was told I could bill for one visit per day. So how does that work then if a patient is admitted then, let?s say 01/25/14 my surgeon is the admitting physician, he sees the patient everyday billing for subsequent visits after he bills for the initial inpatient visit. Ten days later, he decides to perform a 90 day surgery. Based on the above situation, it sounds like the insurance would deny one visit before considering that pre-op. And, in the case of Medicaid, they would deny all visits saying they are related to pre and post op care. 
I know for a scheduled surgery, if the surgeon admits the patient for observation, it?s considered post-op care and not billable but that same rule applies for the above situation as well? So the fact that my surgeon has seen this patient every day since surgery and is still in the hospital, he cannot bill for any of these subsequent visits unless they are all unrelated to his surgery? My surgeon is also not tied to the hospital. He is self-employed under his own tax id and his own clinic so he will not get anything the hospital will bill for outside of the actual surgery and inpatient visits. Am I to tell him his services are free at that point? 

Thanks for both of your help!!!! Sorry for the massive email. I'm just trying to wrap my head around the inpatient side.


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## mitchellde (Mar 28, 2014)

It is possible that the modifier needed on the first encounter was not for your provider visit but for the admitting provider.  For inpatient consults to work  the admitting provider must use an AI modifier or the consulting provider cannot get paid.  Also when you are performing an inpatient consult you should use initial visit levels not subsequent.  The second day then looks like it should be the 57 modifier, you do not double up on the 25 and 57, you append one or the other but never both.  You can bill for a visit every day , except for surgical, once the decision for surgery has been made then that visit gets the 57 and post op visits are inclusive just like in the office setting.  If the post op encounter is for a condition that does not relate to the surgery then you append the 24 modifier.


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