Gastroenterology Coding Alert

Question: I billed Medicare for an EGD and a hospital inpatient visit using the 57 modifier to indicate the decision for surgery. The provider examined the patient and then determined they needed the procedure. Medicare denied the claim. What am I doing wrong?

AAPC Forum Participant

Answer: Medicare probably has an issue with the evaluation and management (E/M) code. The decision for a minor surgery is included in the surgical package. The decision to do the surgery does not, by itself, warrant a separate E/M service.

For example, coding 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded) with 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) would require significant documentation that proves the provider performed work that was above and beyond the decision to perform the esophagogastroduodenoscopy (EGD). If the E/M was significant and separately identifiable, and there is a separate write-up in the documentation that explains the separate problem, the evaluation of the problem, any discussions that took place, and also a plan for management or treatment, you’d append modifier 25 (Significant, separately identifiable evaluation and management service…) to the E/M code.

Also, modifier 57 (Decision for surgery) is not appropriate in this situation. You would use this modifier to report the decision to perform major surgery, such as one that has a 90-day global period.