General Surgery Coding Alert

Question: Recently, Ive noticed more and more insurance carriers either denying or bundling the procedures with modifier -57 attached. Our office uses a hospital admit procedure code (99221-99223) or consultation code (99241-99245 or 99251-99255) with modifier -57. Some insurance companies bundle the two codes and pay only for the surgery. For example, we would bill 99244-57 and 49505 (repair, initial inguinal hernia, age 5 years or over; reducible). The explanation of benefits (EOB) will come back as 56341 (now 47563, cholecystectomy with cholangiography) with a message that the services were bundled together, and the evaluation and management (E/M) is included in the surgical fee.

Another insurance company informs us it will not pay for modifier -57 because it considers this within the pre-op days of the surgery. Sometimes the surgery is performed the same day and sometimes the next day. What is a provider to do, other than appeal every claim? How do I explain to the insurance companies that they should pay for these procedures?

Colorado Subscriber

Answer: Barbara Cobuzzi, CPC, CPC-H, CHBME, an independent coding and reimbursement specialist in Lakewood, N.J., responds: First of all I would like to know if the doctor did a laparoscopic repair of the hernia, or an open one. The coding submitted to the insurance company says it was an open procedure, and it looks like they recoded it to the laparoscopic approach. They do not have authority to change the doctors coding, and if the op note does support the open coding, I would accuse the payer of fraudulently recoding doctors the services. Fight them at all levels on this.

The next step is to determine whether the evaluation and management (E/M) prior to the surgery was the history and physical for a scheduled surgery, or actually the decision for surgery, says Cobuzzi. Modifier -57 (decision for surgery) should be used only when the E/M resulted in the decision for surgery. If surgery is scheduled, E/M prior is not billable if it is the day before or day of the surgery. Services on major procedures are considered part of the global period the day before or day of surgery and the -57 modifier was created to pay for E/M services that resulted in the decision to do surgery previously unscheduled, Cobuzzi explains. Assuming modifier
-57 is being used appropriately, many payers are trying to save money by not paying for E/M services that resulted in the decision for surgery, and you have to appeal and fight it.

An appeals letter should indicate that the RVUs for major procedures do not include the work component of E/M services that resulted in a decision for surgery, Cobuzzi continues.

In some instances, depending on their carriers, coders may be able to circumvent the appeals process by filing manually and including the necessary documents with the claim, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. You should check with your carrier to determine if they will consider the claim at the time of the initial filing if documentation is submitted, Callaway-Stradley says, noting that doing so may considerably reduce the delay of payment that is created when practices wait for claims to be denied and then appeal them.