Podiatry Coding & Billing Alert

Question: A new patient came to our office with pain in his foot. We performed a complete exam, including xrays, found the patient had a closed fracture. Can we bill a consult code with modifier 57 and a fracture diagnosis?

Illinois Subscriber

Answer: First, verify that the encounter meets all four criteria for a consult:

• a written or verbal request for the consult • the consultant's (podiatrist's) opinion

• any services the consultant provides or orders

• a written report to the requesting physician/provider.

If the visit qualifies as a consult, report the appropriate choice from 99241-99245 (Office consultation for a new or established patient ...); otherwise choose from 99211- 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). CPT states that modifier 57 (Decision for surgery) is for an E/M service "that resulted in the initial decision to perform the surgery." Therefore, you are correct in appending modifier 57 to your claim.