General Surgery Coding Alert

Question: Our surgeon provided a consultation to evaluate a patient for acute right-upper quadrant pain and tenderness. Based on the evaluation, the surgeon scheduled the patient for laparoscopic cholecystectomy for the following day.

Georgia Subscriber

Answer: If documentation clearly supported using a consultation code (such as 99243, Office consultation for a new or established patient ...), the payer's rejection of the E/M service probably has to do with the lack of a modifier to distinguish the E/M service from the surgical service (in this case, 47562, Laparoscopy, surgical; cholecystectomy).

CMS guidelines stress that every procedural service includes an -inherent- E/M component. Only if you identify the E/M as a separate, significant service -- and documentation supports this -- will Medicare payers and others that follow CMS rules allow separate reimbursement for an E/M service that takes place the same day as a procedure.

The global surgical period for major surgeries (that is, surgeries with a 90-day global period, of which 47562 is one) under the Medicare fee schedule begins one day prior to the procedure and includes one pre-procedure E/M service for patient evaluation. This means that payers will routinely bundle any E/M service the surgeon provides on the same day as, or -- as in your case -- the day before, a major procedure to the procedure itself.

When the pre-procedure E/M service leads directly to the decision to perform a major surgery, however, you may append modifier 57 (Decision for surgery) to identify the E/M service as separate from and not included in the global surgical package. CMS- Internet Only Manual, section 40.2, directs carriers, -Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier 57 to indicate that the service was for the decision to perform the procedure.-

In this case, the surgeon may claim both the surgical procedure (47562) and the examination that led to the decision to perform the surgery (99243). Because the cholecystectomy is a major procedure, you should append modifier 57 to 99243. The available documentation should specifically note that the E/M service resulted in the decision for surgery.

Caution: As you experienced, failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package for 47562, leading to a loss in reimbursement.