General Surgery Coding Alert

Question: Our surgeon scheduled an initial repair of an incarcerated inguinal hernia for a 35-year-old male patient. The pre-op lab work revealed severely elevated blood sugar, so our surgeon admitted the patient early (June 3) to control the diabetes before performing surgery on June 6. Can we charge for the E/M for the hospital admission and subsequent visits that occurred prior to the surgery using a modifier such as 59, 79, or 24? Also, can we list modifier 57 on the date of surgery even though it was planned several weeks earlier?

Virginia Subscriber

Answer: Yes, you can charge for the E/M service involved in the hospital admission and subsequent hospital visits your surgeon made prior to surgery. Modifiers don't apply to the E/M codes that you report prior to surgery, because the diagnosis for those services is uncontrolled diabetes, not the inguinal hernia surgery.

Do this: Bill the hospital admission (99221- 99223, Initial hospital care, per day, for the evaluation and management of a patient ...) on June 3 and the subsequent care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) on June 4 and 5. Bill the surgery on June 6 (49507, Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated).

The modifiers that you referenced in your question do not apply to this case. You cannot use modifier 59 (Distinct procedural service) or 79 (Unrelated procedure or service by the same physician during the postoperative period) with an E/M service, and you would assign modifier 24 (Unrelated evaluation and management service by the same physician during the postoperative period) only during the postoperative period of a procedure, which, for this scenario, has not yet occurred.

You shouldn't bill modifier 57 (Decision for surgery) on the date of the surgery because the physician and the patient both made the decision to do the surgery at an earlier time.

Note: The surgeon might bill an E/M service for the diabetes on the day of surgery, and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be appropriate.