General Surgery Coding Alert

Question: Our surgeon was called to consult for an inpatient with ascites. The surgeon performed an E/M and decided to carry out a procedure the next day to insert a tunneled intraperitoneal catheter to drain the abdominal fluid. Should I report an E/M, such as 99222 for day one and 99231 for day 2, in addition to the procedure (49418)? Do we need to put modifier 57 on 99222?

Texas Subscriber

Answer: When the surgeon performs an E/M on day 1 and performs a tunneled intraperitoneal catheter insertion the following day, you should not report an E/M on day 2 unless the surgeon also provides care unrelated to the procedure on that date. Assuming you've identified the appropriate E/M code documented by your surgeon, here's how you should code the scenario:

• Day 1: 99222 -- Initial hospital care, per day, for the evaluation and management of a patient ...
• Day 2: 49418 -- Insertion of tunneled intraperitoneal catheter (e.g., dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous.

If your payer follows CMS rules, you should not use modifier 57 (Decision for surgery) with 99222, and you should not report 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) for an E/M on day 2, assuming it was related to the catheter placement.

Here's why: The Medicare Physician Fee Schedule lists a "000" global period for 49418, which gives you two important clues for your question.

First, the 000 designation means that Medicare generally won't pay separately for E/M services performed on the same day as the procedure. Procedures with a 000 period have been priced to include the relative values of expected pre- and post-op services. Applying this rule, you see that you should not report 99231 for an E/M service related to and performed on the same date as the ascites drainage. (You'll find global periods defined in the "National Physician Fee Schedule Relative Value File Calendar Year 2011," available at www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp.)

Second, the 000 designation means you should not append modifier 57 to an E/M service that resulted in the decision for surgery. Medicare Claims Processing Manual, chapter 12, section 40.2.A.4, states that "The '-57' modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure." (The manual is online at www.cms.gov/manuals/downloads/clm104c12.pdf.)