General Surgery Coding Alert

Question: May I report a hospital admission and procedure on the same day? My payer has been rejecting the admission as not separately reimbursable.

Nevada Subscriber

Answer: Yes, you may bill an E/M service, such as a hospital admission (99221-99223), for the same date of service as a procedure under the appropriate conditions, and if you append modifier -57 (Decision for surgery) to the E/M service code.

The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself, and includes one preprocedure E/M service for patient evaluation. For this reason, payers will normally bundle any E/M service provided on the same day as a major procedure to the procedure itself. But if the E/M service precedes and leads to or results in the initial decision to perform surgery, you may report the service separately, according to CPT rules, by appending modifier -57.

You may not bill for the initial E/M service if the surgery was scheduled prior to the admit, however.

For example, the surgeon sees a patient with extreme pain in the lower abdomen. The surgeon quickly determines that the patient's appendix has burst and schedules immediate surgery. In this case, both the E/M service and the surgery are billable because the E/M service resulted in the decision to perform the surgery (in other words, the surgery was not previously planned at the time of the evaluation).

Some payers are reluctant to pay for an E/M service and procedure on the same day even if you append modifier -57, while others will pay for the service but only if you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). You should ask your payer for its guidelines prior to billing.