Part B Insider (Multispecialty) Coding Alert

Question: In our office we used to apply modifier 57 to inpatient consult codes. Now that Medicare doesn't accept consult codes, how should we use this modifier?

Answer: The short answer is that you should append modifier 57 (Decision for surgery) to the non-consult inpatient E/M code that the documentation supports. Suppose an ob-gyn performed a 2009 level-three inpatient consult in which the physician determined the patient required an exploratory laparotomy later that same day due to severe abdominal distention and pain as well as some uterine bleeding.

Adding the modifier to the E/M code will help show payers why you're reporting an E/M in addition to the major surgery performed later that day, 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]).

For 2010, the exact E/M code you choose will depend on the circumstances specific to the visit, such as whether the visit is the first or second ob-gyn visit during the admission. But as an example, suppose you're coding the ob-gyn's first visit to an inpatient. Your documentation may support 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity ...), which has requirements similar to 99253 (Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity).

You should append modifier 57 to the E/M code. If, instead, the ob-gyn is the principal physician -- the one overseeing the patient's care and the one who is admitting the patient -- be sure to append modifier AI (Principal physician of record), as well. This would be the case if the ob-gyn admitted the patient for observation for the abdominal pain and bleeding but later made the decision to take her to surgery that same day.