Pulmonology Coding Alert

Question: Our pulmonologist recently performed an endobronchial biopsy after he made the decision to perform the procedure following an evaluation of the patient. I reported the evaluation with 99232 and reported the biopsy procedure with 31625. I appended modifier 57 to 99232. The claim for 31625 got paid but 99232 was not paid. What should I do to get the claim for the E/M code to be paid?

Texas Subscriber

Answer: E/M services provided on the day of the day before a major surgical procedure are included as part of the pre-operative services valued in the Relative Value Units for that code. If however, the E/M service provided the day of or the day before a major surgical procedure resulted in the decision for surgery, it is separately payable. You will have to append modifier 57 (Decision for surgery) to the E/M service.

Modifier 57 indicates that this was the visit at which the physician decided to perform surgery. However, this modifier is only used on procedures with a 90 day global period, per CMS, although this is not a CPT® rule. It is only used the day of or before a major surgical procedure. For a minor surgical procedure, with 0 or 10 global days, no modifier is needed the day before the service, and a 25 modifier is needed the day of the service, if the E/M service was a distinct, separate procedure.

The CPT® code 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy[s], single or multiple sites) has global period of 0 days, hence modifier 57 does not apply. So in this scenario, the claim for 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components...) cannot be reported separately using modifier 57. However, , you can append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code along with providing proper documentation since the evaluation prompted the decision for the procedure.