# New Patient and decision for surgery



## cpccoder2008 (Dec 10, 2008)

I got all the answers for my previous questions, thanks to everyone who helped, but one more question i'm not sure of. New patient seen in clinic for fracture, patient is to come back in 4 days for pre-op then surgery. Would i bill fracture care for this initial visit and the surgery with - 58 ? Or would i just bill the new patient visit or then the surgery without any modifier's ? Also if anyone can tell me where i can get this in writing also,, those doctor's don't like to be wrong lol, they need to see proof. Please someone help me ?


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## FTessaBartels (Dec 10, 2008)

*It depends on the documentation*

I hate to be less than definitive, but much depends on the documentation of a particular case.

Is fracture care being provided at that first visit? Or is there an absolute certainty that surgery will be needed, but it can't be scheduled for a few days or a week?  

If fracture care is provided at the first visit you'd bill the fracture care (closed treatment) and put a -57 modifier on the new patient visit (decision for surgery).  If NO fracture care is provided you don't need the modifier.

There is NO charge for the pre-op visit ... even if it's done more than 48 hours before the actual surgery. There is no medical necessity for this additional office visit; the decision for surgery was performed at the first visit. 

Date of surgery ... you code the open fracture treatment - IF there was closed treatment performed on 1st office visit, you add -58 modifier to the surgery.  NO E/M code.

I think you probably have a Compliance office that should be able to help you by looking at the actual documentation. 

F Tessa Bartels, CPC, CPC-E/M


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## cpccoder2008 (Dec 10, 2008)

Yes fracture care is being provided at the initial visit, the decision to perform surgery is also decided that visit. Patient is to return to admit and pre-op 2 days later only because of how busy this hospital is. But when the patient does return they don't come back to clinic till after surgery so i won't bill the pre-op, "I know it's included in the initial visit" but all the visit's after the surgery are global so i also don't bill these visits. I was just confused on if it was correct to bill fracture treatment, given that is was performed, which in this case and many case's it usually is. And still be able to bill the surgery with -58. But i agree with what you said completly,i understand it much better now. 

Thanks again !!!


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## dmaec (Dec 10, 2008)

cpccoder2008 - in my opinion, (based on what you posted) - _"New patient seen in clinic for fracture, patient is to come back in 4 days for pre-op then surgery. Would i bill fracture care for this initial visit and the surgery with - 58 ? Or would i just bill the new patient visit or then the surgery without any modifier's ? Also if anyone can tell me where i can get this in writing also,, those doctor's don't like to be wrong lol, they need to see proof. Please someone help me ?"_
First - Modifier 58 - is "staged or related procedure or service, etc" so I think you meant MODIFIER 57 - decision for surgery.  They only time you need to append the modifier 57 "decision for surgery is IF it office visit being charged falls within the "global period" of the surgery.  It's so payment will still be made on the office visit, even though it's falling in a global of surgery, it's to get it out of the global. Since the surgery isn't going to be for at minimun 4 days later there isn't a need for modifier 57 on that office visit at all. you can just charge the procedure (fracture treatment or cast application whatever the case may be)
Also, you *can indeed charge for a preop visit **UNLESS* it is within the global period of the surgery.  So if the preop visit is the day before (major surgery w/ 90 day global) or the day of the surgery (minor surgery)procedure, you can't charge for it UNLESS -it's the decision for surgery (which in your case it isn't). at which point you'd use the 57 decision for surgery modifier on the E/M for the preop.
you can find info pretty much anywhere, just google "global surgical package"...


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## cpccoder2008 (Dec 10, 2008)

dmaec said:


> cpccoder2008 - in my opinion, (based on what you posted) - _"New patient seen in clinic for fracture, patient is to come back in 4 days for pre-op then surgery. Would i bill fracture care for this initial visit and the surgery with - 58 ? Or would i just bill the new patient visit or then the surgery without any modifier's ? Also if anyone can tell me where i can get this in writing also,, those doctor's don't like to be wrong lol, they need to see proof. Please someone help me ?"_
> First - Modifier 58 - is "staged or related procedure or service, etc" so I think you meant MODIFIER 57 - decision for surgery.  They only time you need to append the modifier 57 "decision for surgery is IF it office visit being charged falls within the "global period" of the surgery.  It's so payment will still be made on the office visit, even though it's falling in a global of surgery, it's to get it out of the global. Since the surgery isn't going to be for at minimun 4 days later there isn't a need for modifier 57 on that office visit at all. you can just charge the procedure (fracture treatment or cast application whatever the case may be)
> Also, you *can indeed charge for a preop visit **UNLESS* it is within the global period of the surgery.  So if the preop visit is the day before (major surgery w/ 90 day global) or the day of the surgery (minor surgery)procedure, you can't charge for it UNLESS -it's the decision for surgery (which in your case it isn't). at which point you'd use the 57 decision for surgery modifier on the E/M for the preop.
> you can find info pretty much anywhere, just google "global surgical package"...



I don't think i explained the situtaion accurate enough. The pre-op visit is the initial visit.When our patients come back a day or two before surgery for pre-op they don't see the ortho doctor again, they go to lab and admit. So i guess you can say they come back to admit and not really pre-op, that's just how our doc word it on the initial exam. They see the patient and they the tell them to come back to pre-op, admit, lab, etc.. But the ortho doc performs his exam at the first initial visit and that's when he decides to perform surgery. My question was can i bill the closed treatment fracture care at that initial visit knowing he will perform surgery a few days later and would i attach -58 to the surgery. 

Ex: 
99203-57 (new patient visit/pre-op)
27786 (closed treatment of fracture)
Then 4 days later 27792-58 (open treatment)

or 99203 (new patient)
then 27792 (open treatment) 4 days later.


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## cpccoder2008 (Dec 10, 2008)

sorry,, am i making any sence or confusing everyone ? lol... i think i'm starting to understand, it's just new to me. From what i was told, i can bill fracture treatment even though i know the patient will return for surgery as long as i attach -58 to the actual surgery and i can also bill the initial visit with -57 if i also bill fracture care . Is this accurate ?


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## dmaec (Dec 10, 2008)

I think I get it now... and no, you can't bill/code for something that wasn't done.  IF the provider does do fracture treatment that day, I'd code an application code (knowing they were coming back in for surgery in 4 days).  I wouldn't append a 57 mod on the E/M if it wasn't within the global (day before surgery).  I would use a 25 modifier because it's a preop AND they applied a cast/splint (for comfort till surgery).   and since there isn't a global period for the cast application codes, I wouldn't be appending the 58 modifier to the surgery code when it's done (four days later). Again, you don't need the 57 modifier decision for surgery UNLESS it falls within the global period of the surgery.. in the case you're stating, it doesn't.
If they don't do anything to the fracture at the time of the preop, then yes, I'd code and E/M preop only. 
as for your Ex: 
99203-57 (new patient visit/pre-op) I wouldn't put the 57 it's not needed UNLESS surgery is that day or the next day)
27786 (closed treatment of fracture) (would not code this / would code application code and append mod 25 to E/M IF treatment of fx was done)
Then 4 days later 27792-58 (open treatment) Would code this on the day of surgery if that's what's done, would not append 58, because I wouldn't code out a fx treatment code on the visit, I'd code an application code.

or 99203 (new patient) I'd code this if nothing was done to the fracture, no application, nothing... just preop and coming back for surgery.
then 27792 (open treatment) 4 days later. yes, if that's what's done, I'd code this on the day of surgery

by the way- it's tough to get our point across sometimes via typing, isn't it! LOL... am I making sense with my response? LOL.. I think I know what you mean now..


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## cpccoder2008 (Dec 10, 2008)

Yes i understand,, i know, im trying not to post too many thread to confuse myself but i keep coming up with question's that i forget to ask in the previous post. That makes sence, but i know my doctor will ask why i didn't bill fracture care at the initial visit, why i only charged the splint. I just want to make sure i'm getting this right since i know he will be checking up on me since i brought this to his attention. I'm just getting prepared for what i will say !


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## dmaec (Dec 10, 2008)

Well, I wouldn't code fracture care/treatment IF they knew they were taking them into surgery in a day or two (or four) to perform open fracture treatment at that time.  It's apparent that if surgery is the plan, then in reality all they are doing at "this" visit is making the patient comfortable enough to wait for surgery in a few days AND a preop screen.(so I'd do the E/M cast/splint application and modify the E/M with 25)  

Someone else "might" code/bill the fracture treatment code for that day, along with the preop E/M.  You'd still need a .25 (or some do say 57 because it's a 90 day global )on the E/M because of the fracture care procedure code.    AND then, yes, you'd need the 58 modifier on the surgery code once it was done.  

I'm just saying, ....that's what I'd do... IF the plan in the immediate future was definitive surgery open fracture treatment...


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## cpccoder2008 (Dec 10, 2008)

I agree... so far i haven't heard of anyone billing differantly. If so feel free to reply or email me. 

Thanks again


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