Inpatient Facility Coding & Compliance Alert

Question: Should modifier 27 be appended on the visit to a second hospital when a patient is transferred from one hospital emergency department to a completely different hospital ED; such as from Hospital system #1 ED to Hospital system #2 ED? I’m asking about facility services with two different ED visits from two separate networks and the emergency departments involved have separate facility tax ID numbers.

Illinois Subscriber

Answer: Given these parameters, two ED visits on the same day in different facilities, the 27 modifier (Multiple outpatient hospital E/M encounters on the same date) should not be required in the scenario you summarized above. 

There are correct coding guidelines which indicate modifier 27 is appropriately appended to subsequent visits on the same date of service if there are multiple outpatient visits provided in the same facility. The intent of the 27 modifier is to flag the second outpatient visit to the same hospital or system to indicate that payment would be appropriate, that the second visit code was not posted in error.  Hospitals generally don’t have accurate tracking of visits to other systems (though you see some hospitals collaborating these days to prevent successful drug seeking behavior); the second hospital may not even be aware that an earlier encounter took place, so it would be unrealistic to expect hospitals to add the 27 modifier in these scenarios.

Since payers have variations in payment policies, I would recommend that if a hospital had this question they should query their Medicare contractor and a few of their high volume payers to determine the payment policy in their local area. Note that for Medicare you should consider using Condition Code G0 in addition to the 27 modifier in order to gain appropriate reimbursement. The G0 indicates that the visits were distinct and independent of each other and, therefore, qualify for separate reimbursement for each visit.